CASE ANECDOTES, COMMENTS AND OPINIONS Percutaneous thoracic paravertebral block reduces refractory ventricular tachyarrhythmias after left ventricular assist device implantation Forum Kamdar, MD,a Jacob Hutchins, MD,b and Emil Missov, MD, PhDa From the aCardiovascular Division; and the b Department of Anesthesiology, University of Minnesota Medical Center, Minneapolis, Minnesota
Refractory ventricular tachycardia (VT) and fibrillation (VF) occur in a sub-set of patients after continuous-flow left ventricular assist device (CF-LVAD) implantation and are associated with significant morbidity and mortality due to compromised right ventricular (RV) function. Antiarrhythmic therapy and catheter ablation have limited efficacy in this setting. We describe 3 patients with CFLVAD who had a significant reduction in the burden of refractory ventricular tachyarrhythmias after a percutaneous bilateral paravertebral block (BPVB). Patient 1 is a 66-year-old man with ischemic cardiomyopathy and prior endocardial VT ablation. After HeartWare LVAD (HeartWare, Framingham, MA) implantation, he experienced symptomatic VT despite therapy with amiodarone, mexiletine, and metoprolol. Endocardial VT ablation was marginally successful. Unstable, symptomatic VT developed 10 months after CF-LVAD implantation. Thirteen episodes of anti-tachycardia pacing (ATP) and repeated external defibrillatory shocks failed to terminate the VT and eventually resulted in RV failure. Percutaneous BPVB allowed the VT to be terminated by overdrive pacing. In the 4 months before undergoing orthotopic heart transplantation, he did not have any sustained VT requiring ATP, shocks, or hospitalization. Patient 2 is a 32-year-old man with non-ischemic cardiomyopathy and prior automatic implantable cardioverter defibrillator placement. He presented in cardiogenic shock with refractory VT/VF necessitating 19 episodes of ATP and 18 internal shocks, despite therapy with lidocaine and amiodarone. He underwent emergency implantation of a HeartMate II LVAD (Thoratec Corp, Pleasanton, CA). Postoperatively, he continued to have hemodynamically unstable VT/VF despite maximal therapy with amiodarone, lidocaine, and esmolol. Endocardial VT ablation resulted in a modest reduction of the VT/VF burden. The patient developed severe metabolic encephalopathy due to lidocaine
toxicity and profound hypotension caused by esmolol. He underwent percutaneous BPVB and had no further sustained VT for more than 1 month. Patient 3 is a 60-year-old man with an out-of-hospital cardiac arrest and newly diagnosed ischemic cardiomyopathy. He was placed on extracorporeal membrane oxygenation support as a bridge to HeartMate II LVAD. He had recurrent VT/VF requiring 150 defibrillatory shocks leading to rapidly progressing RV failure. On the second postoperative day, he underwent percutaneous BPVB and had a significant reduction of VT/VF burden. He underwent automatic implantable cardioverter defibrillator implantation before discharge to home and has not required further defibrillation in the last 12 months. We describe a novel management for sympathetically mediated ventricular tachyarrhythmias after placement of CF-LVAD with percutaneous BPVB. The association of sympathetic activity and ventricular tachyarrhythmias is well established. Surgical and percutaneous sympathetic denervation has been described in long QT syndrome,
Figure 1 Still ultrasound image at the level of the second and third thoracic vertebral bodies with the patient in a lateral decubitus position. The paravertebral space (PVS) is identified using the transverse process (TP) and pleura (n) as landmarks for an injection of liposomal bupivacaine. A 22-gauge block needle (arrowheads) is advanced until its tip rests beneath the lateral edge of the transverse process, then 0.5% bupivacaine (3 ml) with epinephrine (1:200,000) is injected to confirm correct placement, followed by 10 ml liposomal bupivacaine once the correct needle placement is determined. The procedure is repeated on the contralateral side.
1053-2498/$ - see front matter r 2015 International Society for Heart and Lung Transplantation. All rights reserved. http://dx.doi.org/10.1016/j.healun.2015.01.988
Case Anecdotes, Comments and Opinions
867
catecholaminergic polymorphic VT, and VT storm.1–4 These techniques are known to reduce VT but are invasive, permanent, and can have significant adverse effects. BPVB is widely used as a regional anesthesia technique. It results in sympathetic and somatic blockade in the dermatomes above and below the injection site. In the 3 reported patients, BVPB resulted in a significant reduction of VT/VF burden. BPVB was performed in the cardiac intensive care unit with ultrasound guidance in hemodynamically unstable patients who were fully anti-coagulated (Figure 1). No procedure-related complications or adverse hemodynamic effects occurred in our case series. BPVB avoids the toxicity and pro-arrhythmogenicity of anti-arrhythmic therapy. Its effects last 3 to 7 days, thus avoiding the long-term effect of sympathetic denervation while inducing sympathetic inhibition to quiet refractory VT/VF. BPVB is an efficacious technique for reducing sympathetically mediated refractory ventricular tachyarrhythmias after CF-LVAD placement.
Disclosure statement
Effect of racial and ethnic differences in heart transplantation with ABO incompatibility
may affect the post-transplant outcomes.4 Moreover, longer ischemic time have been stated to be a significant factor leading to a graft failure.5 In this study, the authors did not report any information about the importance of racial/ethnic differences and graft ischemic time. Their study would have been strengthened if they had added the data of the abovementioned suggestions. Finally, we would conclude by congratulating Bergenfeldt et al1 on their outstanding study.
Ahmet Dolapoglu, MD,a and Ilimbek Beketaev, MDb From the aCardiovascular Surgery Department; and the bCenter for Stem Cell Engineering, Texas Heart Institute, Houston, Texas
We deeply appreciate the authors Bergenfeldt et al1 for their recently published article in The Journal of Heart and Lung Transplantation (January 2015), ‘‘Outcomes after ABO-incompatible heart transplantation in adults: A registry study’’. The authors prepared a high-quality research on the topic of ABO-incompatible heart transplantation. As far as we saw in literature, this is one of the largest ABOincompatible studies in heart transplant patients; however, we would like to make a few important suggestions regarding this study. It is essential to keep in mind that racial and ethnic differences influence the graft outcome after heart transplantation.2,3 Several studies have demonstrated that recipients of a racial/ethnic minority background are more likely to have donor-recipient human leukocyte antigen mismatch and are more likely to have an episode of rejection during the first year after transplantation. According to panel reactive antibody screening, black recipients were more susceptible to graft failure than other ethnic groups due to higher levels of panel reactive antibody. These differences
None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.
References 1. Collura CA, Johnson JN, Moir C, Ackerman MJ. Left cardiac sympathetic denervation for the treatment of long QT syndrome and catecholaminergic polymorphic ventricular tachycardia using videoassisted thoracic surgery. Heart Rhythm 2009;6:752-9. 2. Wilde AA, Bhuiyan ZA, Crotti L, et al. Left cardiac sympathetic denervation for catecholaminergic polymorphic ventricular tachycardia. N Engl J Med 2008;358:2024-9. 3. Bourke T, Vaseghi M, Michowitz Y, et al. Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation. Circulation 2010;121:2255-62. 4. Ajijola OA, Lellouche N, Bourke T, et al. Bilateral cardiac sympathetic denervation for the management of electrical storm. J Am Coll Cardiol 2012;59:91-2.
Disclosure statement None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.
References 1. Bergenfeldt H, Andersson B, Bućin D, et al. Outcomes after ABOincompatible heart transplantation in adults: a registry study. J Heart Lung Transplant 2015, http://dx.doi.org/10.1016/j.healun.2015.01.008. [E-pub ahead of print]. 2. Allen JG, Weiss ES, Arnaoutakis GJ, et al. The impact of race on survival after heart transplantation: an analysis of more than 20,000 patients. Ann Thorac Surg 2010;89:1956-63: [discussion 1963-4]. 3. Cohen O, De La Zerda D, Beygui RE, Hekmat D, Laks H. Ethnicity as a predictor of graft longevity and recipient mortality in heart transplantation. Transplant Proc 2007;39:3297-302. 4. Morris AA, Cole RT, Veledar E, et al. Influence of race/ethnic differences in pre-transplantation panel reactive antibody on outcomes in heart transplant recipients. J Am Coll Cardiol 2013;62:2308-15. 5. Marasco SF, Esmore DS, Negri J, et al. Early institution of mechanical support improves outcomes in primary cardiac allograft failure. J Heart Lung Transplant 2005;24:2037-42.
Refractory ventricular tachycardia (VT) and fibrillation (VF) occur in a sub-set of patients after continuous-flow left ventricular assist device (CF-LVAD) implantation and are associated with significant morbidity and mortality due to compromised right ventricular (RV) function. Antiarrhythmic therapy and catheter ablation have limited efficacy in this setting. We describe 3 patients with CFLVAD who had a significant reduction in the burden of refractory ventricular tachyarrhythmias after a percutaneous bilateral paravertebral block (BPVB). Patient 1 is a 66-year-old man with ischemic cardiomyopathy and prior endocardial VT ablation. After HeartWare LVAD (HeartWare, Framingham, MA) implantation, he experienced symptomatic VT despite therapy with amiodarone, mexiletine, and metoprolol. Endocardial VT ablation was marginally successful. Unstable, symptomatic VT developed 10 months after CF-LVAD implantation. Thirteen episodes of anti-tachycardia pacing (ATP) and repeated external defibrillatory shocks failed to terminate the VT and eventually resulted in RV failure. Percutaneous BPVB allowed the VT to be terminated by overdrive pacing. In the 4 months before undergoing orthotopic heart transplantation, he did not have any sustained VT requiring ATP, shocks, or hospitalization. Patient 2 is a 32-year-old man with non-ischemic cardiomyopathy and prior automatic implantable cardioverter defibrillator placement. He presented in cardiogenic shock with refractory VT/VF necessitating 19 episodes of ATP and 18 internal shocks, despite therapy with lidocaine and amiodarone. He underwent emergency implantation of a HeartMate II LVAD (Thoratec Corp, Pleasanton, CA). Postoperatively, he continued to have hemodynamically unstable VT/VF despite maximal therapy with amiodarone, lidocaine, and esmolol. Endocardial VT ablation resulted in a modest reduction of the VT/VF burden. The patient developed severe metabolic encephalopathy due to lidocaine
toxicity and profound hypotension caused by esmolol. He underwent percutaneous BPVB and had no further sustained VT for more than 1 month. Patient 3 is a 60-year-old man with an out-of-hospital cardiac arrest and newly diagnosed ischemic cardiomyopathy. He was placed on extracorporeal membrane oxygenation support as a bridge to HeartMate II LVAD. He had recurrent VT/VF requiring 150 defibrillatory shocks leading to rapidly progressing RV failure. On the second postoperative day, he underwent percutaneous BPVB and had a significant reduction of VT/VF burden. He underwent automatic implantable cardioverter defibrillator implantation before discharge to home and has not required further defibrillation in the last 12 months. We describe a novel management for sympathetically mediated ventricular tachyarrhythmias after placement of CF-LVAD with percutaneous BPVB. The association of sympathetic activity and ventricular tachyarrhythmias is well established. Surgical and percutaneous sympathetic denervation has been described in long QT syndrome,
Figure 1 Still ultrasound image at the level of the second and third thoracic vertebral bodies with the patient in a lateral decubitus position. The paravertebral space (PVS) is identified using the transverse process (TP) and pleura (n) as landmarks for an injection of liposomal bupivacaine. A 22-gauge block needle (arrowheads) is advanced until its tip rests beneath the lateral edge of the transverse process, then 0.5% bupivacaine (3 ml) with epinephrine (1:200,000) is injected to confirm correct placement, followed by 10 ml liposomal bupivacaine once the correct needle placement is determined. The procedure is repeated on the contralateral side.
1053-2498/$ - see front matter r 2015 International Society for Heart and Lung Transplantation. All rights reserved. http://dx.doi.org/10.1016/j.healun.2015.01.988
Case Anecdotes, Comments and Opinions
867
catecholaminergic polymorphic VT, and VT storm.1–4 These techniques are known to reduce VT but are invasive, permanent, and can have significant adverse effects. BPVB is widely used as a regional anesthesia technique. It results in sympathetic and somatic blockade in the dermatomes above and below the injection site. In the 3 reported patients, BVPB resulted in a significant reduction of VT/VF burden. BPVB was performed in the cardiac intensive care unit with ultrasound guidance in hemodynamically unstable patients who were fully anti-coagulated (Figure 1). No procedure-related complications or adverse hemodynamic effects occurred in our case series. BPVB avoids the toxicity and pro-arrhythmogenicity of anti-arrhythmic therapy. Its effects last 3 to 7 days, thus avoiding the long-term effect of sympathetic denervation while inducing sympathetic inhibition to quiet refractory VT/VF. BPVB is an efficacious technique for reducing sympathetically mediated refractory ventricular tachyarrhythmias after CF-LVAD placement.
Disclosure statement
Effect of racial and ethnic differences in heart transplantation with ABO incompatibility
may affect the post-transplant outcomes.4 Moreover, longer ischemic time have been stated to be a significant factor leading to a graft failure.5 In this study, the authors did not report any information about the importance of racial/ethnic differences and graft ischemic time. Their study would have been strengthened if they had added the data of the abovementioned suggestions. Finally, we would conclude by congratulating Bergenfeldt et al1 on their outstanding study.
Ahmet Dolapoglu, MD,a and Ilimbek Beketaev, MDb From the aCardiovascular Surgery Department; and the bCenter for Stem Cell Engineering, Texas Heart Institute, Houston, Texas
We deeply appreciate the authors Bergenfeldt et al1 for their recently published article in The Journal of Heart and Lung Transplantation (January 2015), ‘‘Outcomes after ABO-incompatible heart transplantation in adults: A registry study’’. The authors prepared a high-quality research on the topic of ABO-incompatible heart transplantation. As far as we saw in literature, this is one of the largest ABOincompatible studies in heart transplant patients; however, we would like to make a few important suggestions regarding this study. It is essential to keep in mind that racial and ethnic differences influence the graft outcome after heart transplantation.2,3 Several studies have demonstrated that recipients of a racial/ethnic minority background are more likely to have donor-recipient human leukocyte antigen mismatch and are more likely to have an episode of rejection during the first year after transplantation. According to panel reactive antibody screening, black recipients were more susceptible to graft failure than other ethnic groups due to higher levels of panel reactive antibody. These differences
None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.
References 1. Collura CA, Johnson JN, Moir C, Ackerman MJ. Left cardiac sympathetic denervation for the treatment of long QT syndrome and catecholaminergic polymorphic ventricular tachycardia using videoassisted thoracic surgery. Heart Rhythm 2009;6:752-9. 2. Wilde AA, Bhuiyan ZA, Crotti L, et al. Left cardiac sympathetic denervation for catecholaminergic polymorphic ventricular tachycardia. N Engl J Med 2008;358:2024-9. 3. Bourke T, Vaseghi M, Michowitz Y, et al. Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation. Circulation 2010;121:2255-62. 4. Ajijola OA, Lellouche N, Bourke T, et al. Bilateral cardiac sympathetic denervation for the management of electrical storm. J Am Coll Cardiol 2012;59:91-2.
Disclosure statement None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.
References 1. Bergenfeldt H, Andersson B, Bućin D, et al. Outcomes after ABOincompatible heart transplantation in adults: a registry study. J Heart Lung Transplant 2015, http://dx.doi.org/10.1016/j.healun.2015.01.008. [E-pub ahead of print]. 2. Allen JG, Weiss ES, Arnaoutakis GJ, et al. The impact of race on survival after heart transplantation: an analysis of more than 20,000 patients. Ann Thorac Surg 2010;89:1956-63: [discussion 1963-4]. 3. Cohen O, De La Zerda D, Beygui RE, Hekmat D, Laks H. Ethnicity as a predictor of graft longevity and recipient mortality in heart transplantation. Transplant Proc 2007;39:3297-302. 4. Morris AA, Cole RT, Veledar E, et al. Influence of race/ethnic differences in pre-transplantation panel reactive antibody on outcomes in heart transplant recipients. J Am Coll Cardiol 2013;62:2308-15. 5. Marasco SF, Esmore DS, Negri J, et al. Early institution of mechanical support improves outcomes in primary cardiac allograft failure. J Heart Lung Transplant 2005;24:2037-42.
