545 Herz 34 · 2009 · Nr. 7 © Urban & Vogel 2009 Herz Percutaneous Cardiopulmonary Support for Catheter Ablation of Unstable Ventricular Arrhythmias in High-Risk Patients Corrado Carbucicchio, Paolo Della Bella, Gaetano Fassini, Nicola Trevisi, Stefania Riva, Francesco Giraldi, Francesca Baratto, Giancarlo Marenzi, Erminio Sisillo, Antonio Bartorelli, Francesco Alamanni 1 Abstract Background and Purpose: In patients with severe car- diomyopathy, recurrent episodes of nontolerated ven- tricular tachycardia (VT) or electrical storm (ES) fre- quently cause acute heart failure and cardiac death; the suppression of the arrhythmia is therefore lifesav- ing, but feasibility of catheter ablation (CA) is preclud- ed by the adverse hemodynamic conditions together with the characteristics of the arrhythmia that inter- dicts efficacious mapping. The use of the percutaneous cardiopulmonary support (CPS) for circulatory assis- tance may allow patient’s stabilization and enhance efficacy and safety of CA in this emergency setting. Patients and Methods: 19 patients (19 males; mean age 61 ± 6 years; chronic ischemic cardiomyopathy, eleven patients; primary dilated cardiomyopathy, six patients; arrhythmogenic right ventricular dysplasia/ cardiomyopathy, two patients) with recurrent nontol- erated VT episodes undergoing CPS-assisted CA were retrospectively evaluated. Twelve patients had acute hemodynamic failure refractory to inotropic agents and ventilatory assistance, seven patients had under- gone a failing nonconventional CA procedure. 14 pa- tients presented with ES, and in twelve the procedure was undertaken under emergency conditions within 24 h from admission. Patients were ventilated under general anesthesia and assisted by a multidisciplinary team. The CPS system consisted in a Medtronic Bio-Me- dicus centrifugal pump and in a Maxima Plus oxygen- ator, a 15-F arterial cannula, and a 17-F venous cannula. Results: Flows between 2 and 3 l/min were activated after induction of 56/62 forms of nontolerated VT, achieving hemodynamic stabilization in all patients. CA was mainly guided by conventional activation map- ping and was effective in abolishing 45/56 supported VTs; in 10/19 patients all clinical VTs were suppressed by CA. Mean procedural time was 4 h and 20 min. Com- plete stabilization was achieved in 13 patients (68%) without VT recurrence during a 7-day in-hospital mon- itoring. A significant clinical improvement was ob- served in two patients (11%); one patient (5%) with per- sistent VT episodes acutely died after heart transplant. At a mean follow-up of 42 months (range 15–60 months), 5/18 patients (28%) were free from VT recur- rence, 7/18 (39%) had a clear clinical improvement with reduced implantable cardioverter defibrillator inter- ventions. 5/14 patients (36%) had ES recurrence; among them, three died because of acute heart failure. No se- rious CPS-related complications were observed. Conclusion: The CPS warrants acceptable hemody- namic stabilization and efficacious mapping in high- risk patients undergoing CA for unstable VT in the emergency setting. Safety and efficacy of this tech- nique translate into significant clinical improvement in the majority of patients. Even if only relatively inva- sive, CPS should be reserved to patients with ES or in- tractable arrhythmia causing acute heart failure; moreover, the need for an experienced team of multi- disciplinary operators implies that its use is restricted to selected high-competency institutions. (Perkutaner kardiopulmonaler Support für die Katheterablation instabiler ventrikulärer Arrhythmien bei Hochrisikopatienten Zusammenfassung Hintergrund und Fragestellung: Bei Patienten mit schwerer Kardiomyopathie verursachen rezidivie- rende Episoden nicht tolerierter ventrikulärer Tachy- kardie (VT) oder eines elektrischen Sturms (ES) häu- fig akutes Herzversagen und plötzlichen Herztod; die Suppression der Arrhythmie ist daher lebensret- tend, jedoch stehen der Durchführbarkeit der Kathe- terablation (KA) ungünstige hämodynamische Ver- hältnisse sowie die Charakteristika der Arrhythmie, die ein effizientes Mapping verhindert, entgegen. Der Einsatz des perkutanen kardiopulmonalen Sup- ports (KPS) zur Kreislaufunterstützung kann zur Sta- bilisierung des Patienten beitragen und die Effizienz Schlüsselwörter: Ventrikuläre Tachykardie · Katheterablation · Herz- versagen · Hämodyna- mische Unterstützung Key Words: Ventricular Tachycar- dia · Catheter ablation · Heart failure · Hemo- dynamic support 1 Centro Cardiologico Fondazione Monzino – IRCCS, Institute of Car- diology, University of Milan, Italy. Herz 2009;34:545–52 DOI 10.1007/ s00059-009-3289-3