2019 SCAI SHOCK

Title
End-stage Heart Failure Exacerbated by Recurrent Ventricular Tachycardia

Introduction
Cardiac arrhythmia can complicate existing heart failure. We present a case of end-stage heart failure and refractory ventricular tachycardia necessitating mechanical circulatory support.

Clinical Case
Patient is a 54-year-old male with history of coronary artery bypass grafting x3 and long-standing heart failure complicated by ventricular tachycardia. He presented to the emergency room with sustained ventricular tachycardia (VT) refractory to cardioversion. Left heart catheterization and transesophageal echocardiography demonstrated left ventricular ejection fraction of 10-15% with two occluded vein grafts and patent left internal mammary graft to the left anterior descending coronary with no distal reperfusion targets. He was taken to the operating room for mechanical circulatory support due to recurrent VT and hemodynamic compromise. A trans-axillary Impella 5.0® device was attempted but unsuccessful due to arterial size and veno-arterial extracorporeal membranous oxygenation (ECMO) was initiated through the left femoral vessels. His VT continued despite adequate ECMO therapy and an Impella CP® device was placed via the right femoral artery to vent the left ventricle. Distal perfusion limbs connected to the ECMO circuit were placed in bilateral femoral arteries. His VT abated but he was not able to wean from ECMO. Being deemed unsuitable for transplantation, he was taken back to the operating room for redo sternotomy, placement of a left ventricular assist device, and ventricular ablation. He progressed well and was discharged on postoperative day 14.

Discussion
Consideration of early tissue ablation may be considered in the setting of severe heart failure with concomitant refractory arrhythmias.