Contemporary Outcomes of Ventricular Tachycardia Ablation in Left Ventricular Assist Device Therapy: A Meta-Analysis

Contemporary Outcomes of Ventricular Tachycardia Ablation in Left Ventricular Assist Device Therapy: A Meta-Analysis | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL Journal of Cardiovascular Electrophysiology This is a preprint and has not been peer reviewed. Data may be preliminary. 17 July 2025 V1 Latest version Share on Contemporary Outcomes of Ventricular Tachycardia Ablation in Left Ventricular Assist Device Therapy: A Meta-Analysis Authors : Nelson Barrera 0000-0002-8031-0601 [email protected] , Yevhen Kushnir , Maria Solorzano , Francisco Gallegos , Patrick Lynch T , Flavia Queiroga F 0009-0006-5304-0657 , Juliana Giorgi , Alexandra R. D. Brigido , Guilherme Carvalho , Mihail Chelu 0000-0001-9688-1604 , Paolo Columbo , and Andre d'Avila Authors Info & Affiliations https://doi.org/10.22541/au.175277173.38345826/v1 Published Journal of Cardiovascular Electrophysiology Version of record Peer review timeline 520 views 212 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background and objective Ventricular arrhythmias (VAs) remain a pervasive and deadly arrhythmia in patients with left ventricular assist devices (LVADs). Catheter ablation has emerged as a treatment option for refractory VAs, yet evidence in the era of the HeartMate 3 (HM3) remains limited. This review aims to synthesize contemporary evidence for VA ablation in LVAD recipients. Methods A systematic review was performed across major electronic databases. The primary efficacy outcome was the recurrence of ventricular tachycardia (VT), and the primary safety outcome was the rate of procedural complications. The secondary outcomes were inability to induce any VT, all-cause mortality at twelve months, orthotropic heart transplantation (OHT). Sub-analyses were performed for patients with HM3 LVADs. Results Twenty-seven studies encompassing 300 LVAD recipients undergoing 325 VT ablations, after a mean follow-up of 327±175 days post VT ablation, VT recurred in 38% (95% CI, 28% to 49%) of cases and the complication rate was 8% (95% CI, 1.6% to 15.7%). VT was non-inducible in 61% of cases. One-year all-cause mortality was 26%, and 16% had OHT. Among HM3 recipients, electromagnetic interference (EMI) occurred in 51%, and no cases of device thrombosis were reported; one stroke was observed. Conclusions Catheter ablation is a safe and feasible treatment for refractory VAs in LVAD patients as evidenced by low complication rates and reasonable acute success. Yet, the persistence of considerable VT recurrence and all-cause mortality reflects the clinical complexity of this population. Procedural challenges include mapping limitations caused by EMI, particularly in the HM3 era. Contemporary Outcomes of Ventricular Tachycardia Ablation in Left Ventricular Assist Device Therapy: A Meta-Analysis Authors: Nelson I. Barrera, MD; a Yevhen Kushnir, MD; b Maria Solorzano, MD; b Francisco Gallegos, MD; b Patrick T Lynch, MD; c Flavia Queiroga, MD; d Juliana Giorgi, MD; e Alexandra Regia Dantas Brigido, MD f Guilherme Dagostin de Carvalho, MD, MSc; g Mihail G. Chelu, MD, PhD; c,h,i Paolo C. Colombo, MD; a Andre D’Avila, MD, PhD j Institutional Affiliations: a Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York City, New York. b SBH Health System, Department of Internal Medicine, New York City, New York. c Department of Medicine (Division of Cardiology), Baylor College of Medicine; d Deparment of Medicine, Emory University School of Medicine, Atlanta, Georgia. e Sirio Libanês Hospital, Dr.Melo Alves, São Paulo, Brasil f Heart Institute (InCor), Hospital das Clínicas, Faculty of Medicine, University of São Paulo. g Dante Pazzanese Institute of Cardiology, Department of Cardiac Arrhythmias and Electrophysiology, São Paulo, Brazil. h Cardiovascular Research Institute, i Texas Heart Institute at Baylor College of Medicine and Baylor St. Luke’s Medical Center, Houston, Texas, USA. j Beth Israel Deaconess Medical Center, Division of Cardiology, Harvard Medical School. 330 Brookline Ave, Boston, MA 02215, United States. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Dr. Mihail G. Chelu received funding from the Patient-Centered Outcomes Research Institute (PLACER 2021C3- 24160) and the National Institutes of Health (NIH). Conflict of Interest : MCG – received research funding from Impulse Dynamics and Abbott and modest speaking honoraria from Impulse Dynamics. PCC - reports receiving honoraria of less than $5,000 per calendar year from Abbott as a speaker and/or consultant. Correspondence: Nelson Barrera, MD; Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, Department of Internal Medicine, Division of Cardiology, 622 West 168th Street, New York City, NY. Fax : Word Count: 4891 Total number of references: 50 Figure: 4 Tables: 5 Supplementary Material: 1 Word document Running Title: VT Ablation Outcomes in Contemporary LVAD Therapy Twitter Handle: @TheVash12 and @Davilandre Twitter Publication: 🔥New Meta-Analysis: VT Ablation in #LVAD Patients🔥 (325 ablations, 300 pts across 28 studies) 🔹 VT recurrence: 38% 🔹 Complication rate: 8% 🔹 Most common mechanism: Scar-related VT 🔹 Novel finding: HM3-specific EMI in ~50% of cases ⚡ Ablation is a safe and feasible treatment for refractory VAs in LVAD #EPeeps #CardioTwitter #HeartFailure #HM3 Background and objective Ventricular arrhythmias (VAs) remain a pervasive and deadly arrhythmia in patients with left ventricular assist devices (LVADs). Catheter ablation has emerged as a treatment option for refractory VAs, yet evidence in the era of the HeartMate 3 (HM3) remains limited. This review aims to synthesize contemporary evidence for VA ablation in LVAD recipients. Methods A systematic review was performed across major electronic databases. The primary efficacy outcome was the recurrence of ventricular tachycardia (VT), and the primary safety outcome was the rate of procedural complications. The secondary outcomes were inability to induce any VT, all-cause mortality at twelve months, orthotropic heart transplantation (OHT). Sub-analyses were performed for patients with HM3 LVADs. Results Twenty-seven studies encompassing 300 LVAD recipients undergoing 325 VT ablations, after a mean follow-up of 327±175 days post VT ablation, VT recurred in 38% (95% CI, 28% to 49%) of cases and the complication rate was 8% (95% CI, 1.6% to 15.7%). VT was non-inducible in 61% of cases. One-year all-cause mortality was 26%, and 16% had OHT. Among HM3 recipients, electromagnetic interference (EMI) occurred in 51%, and no cases of device thrombosis were reported; one stroke was observed. Conclusions Catheter ablation is a safe and feasible treatment for refractory VAs in LVAD patients as evidenced by low complication rates and reasonable acute success. Yet, the persistence of considerable VT recurrence and all-cause mortality reflects the clinical complexity of this population. Procedural challenges include mapping limitations caused by EMI, particularly in the HM3 era. Keywords : Catheter Ablation; Ventricular Tachycardia; Left Ventricular Assist Devices; Heart Failure. Abbreviatures: LVAD = Left Ventricular Assist Device, HF = Heart Failure, VAs = Ventricular Arrhythmias, ICD = Implantable Cardioverter-Defibrillator, VTA = Ventricular Tachycardia Ablation, VT = Ventricular Tachycardia, OHT = Orthotopic Heart Transplantation, EMI= Electromagnetic interference INTRODUCTION The use of left ventricular assist devices (LVADs) has increased in recent years in parallel to the rising prevalence of advanced heart failure (HF). Advanced HF patients who receive an LVAD experienced improved outcomes with survival rates of 80% at 2 years 12(,). However, LVADs are associated with major complications, including ventricular arrhythmias (VAs), particularly among patients with a history of VAs pre-LVAD 34(,). Anti-arrhythmic medications and implantable cardioverter-defibrillators (ICDs) are typically the first-line treatment for VAs; nonetheless, refractory arrhythmias can still occur after LVAD implantation 45(,). In such cases, catheter ablation has emerged as a promising treatment option for drug-refractory VAs. In LVAD recipients, ventricular tachycardia ablation (VTA) presents specific challenges, including selecting appropriate candidates, determining the optimal timing for the procedure, and overcoming technical limitations such as those affecting mapping and ablation due to the device’s magnetic field. Current evidence supporting the use of catheter ablation in LVAD patients is limited and derived primarily from high-volume, pooled analyses of single-center studies 6(). The recent clinical consensus statement from the European Heart Rhythm Association and the Heart Failure Association of the European Society of Cardiology (ESC) recommends catheter ablation for recurrent, symptomatic VAs that do not respond to antiarrhythmic drugs and/or ICD reprogramming with a moderate level of evidence 7(). A better understanding of the role of VTA in LVAD patients remains warranted. This systematic review and meta-analysis aims to consolidate current evidence on the efficacy and safety of VTA in this population, emphasizing procedural outcomes and complication rates in the era of contemporary LVAD technology. METHODS Protocol and Registration This systematic review was conducted according to the guidelines of PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analysis 8(). The PRISMA checklist is presented in Supplementary Table 1. The review protocol was registered in Prospero [CRD42025630461]. Literature search The literature search was conducted by two reviewers (NB & MS) using five electronic databases (Science Direct, PubMed, Google Scholar, CENTRAL, and EMBASE). The keywords used included (Ventricular Tachyarrhythmias, Ventricular Tachycardia, Ventricular Fibrillation OR VT) AND (Catheter Ablation, Radiofrequency Ablation OR RFA) AND (Left Ventricular Assist Devices OR LVAD OR mechanical support), with slight modifications per database to maximize results. Reference lists of studies were also reviewed for additional relevant studies on LVAD recipients undergoing VTA, and the clinicaltrial.gov registry was checked for unpublished trials. Eligibility Criteria & Data Extraction Duplicate studies were removed, and the remaining studies were evaluated against several exclusion criteria: (1) not published in English; (2) no documented VT during or after LVAD implant; (3) post-implant VTA not reported as an intervention; (4) lack of outcome data; or (5) secondary analysis. Included studies comprised case reports, case series, case-control studies, cohort studies, and clinical trials. Extracted data included study author, design, sample size, age, sex distribution, HF etiology, mean LVEF, history of VT episodes, presence of ICD, prior VTA history, and VT storm. Outcomes Analysis was landmarked at the time of VTA. The primary efficacy outcome was recurrence of VT, and the primary safety outcome was rate of procedural complications. Secondary endpoints were non-inducibility of VAs at the end of ablation, successful bridging to orthotopic heart transplant (OHT), and mortality at 6 and 12 months. Clinical variables were compiled across all studies, including patient characteristics, indications for LVAD implantation, and details of VTA procedure such as approach, mapping technique, scar location, and VT mechanism. Procedure-related complications were also measured and compiled among all studies. We performed pre-specified subgroup analyses in recipients of HeartMate 3 (HM3) and in patients who underwent VTA at the time of LVAD implantation. Statistical analysis We conducted a single-arm meta-analysis of proportions for primary and secondary endpoints, reported as event rates per 100 observations with 95% confidence intervals. Procedural techniques, scar location, VT mechanism, and the breakdown of complications were summarized as percentages. Continuous variables were presented in means with standard deviations or medians with interquartile ranges. We assessed heterogeneity using a random-effects model and the Cochrane Q test, identifying high heterogeneity with I² values over 75%. Evidence quality was evaluated with the ROBINS-1 tool for observational studies and the Joanna Briggs Institute tools for case series and reports. Publication bias was analyzed using the Egger test, considering p < 0.05 as indicative of bias. A leave-one-out sensitivity analysis was performed with the “metainf” function in the meta package, and data analyses utilized Microsoft Excel and R Studio. RESULTS Study Eligibility Literature search yielded 735 articles, of which 556 were duplicates. Of the remaining 179 publications, 65 were excluded based on review of the title & abstract and 114 were retrieved for detailed evaluation and application of our eligibility criteria. Ultimately, 35 articles were included as summarized in Figure 1 . Study Characteristics Table 1 summarizes the studies included in the systematic review and their characteristics. Of the 35 included studies, three were case-control studies, seventeen were retrospective case series, and fifteen were case reports. Twenty-seven studies examined patients with post-implant VTA, while eight studies focused on patients experiencing ablation during the LVAD implantation. Among the 300 patients with post-implant VTA ablation, the mean age was 61.8 ±7.1 years, and 82% were male. Etiology of HF was ischemic cardiomyopathy (ICM) in 62% and non-ischemic cardiomyopathy (NICM) in 38%, and one patient (0.01%) had both. Left ventricular ejection fraction ranged from 10% to 22%, and 82.1% of patients had an ICD; 76% had a history of VAs before LVAD implantation. Among these, 16% had undergone a VTA before implantation, 45% had prior VT storm, and 8% underwent redo-ablation for VT. Quality Assessment We found that three non-randomized studies had a moderate risk of bias, while only the studies from the case series and case report had an intermediate risk of bias, as described in Supplementary Tables 2A, 2B, and 2C. The leave-one-out sensitivity analysis demonstrated that no individual study significantly altered the pooled estimate of all outcomes, indicating the robustness of the results— Supplementary Figure 1. When assessing publication bias, our funnel plot exhibited a symmetrical distribution, and the Egger’s test result was nonsignificant (P > .05) for all outcomes, indicating no evidence of publication bias, as shown in Supplementary Figure 2. Characteristics of LVAD therapies in the included studies A total of 285 individuals were reported with information and details regarding varying types of LVADs. The characteristics of the LVAD therapies are presented in Supplementary Table 3. The predominant devices utilized in this study included the HeartMate II (HMII), accounting for 47% of cases, followed by the HeartWare ventricular assist device (HVAD), which comprised 24%. The HM3 also accounted for 24% of the devices used. Older LVAD models (5%) were considered obsolete and therefore not included in the analysis. Additionally, the device type was not reported in 15 patients. LVADs were used as a bridge to transplant therapy in 46.9% and as destination therapy in 53.1% cases. The time interval between LVAD implantation and VT ablation was highly variable across studies, with a median of 181 days (IQR: 66-365), reflecting both early and late arrhythmic presentations following LVAD placement. Ventricular tachycardia ablation characteristics Among patients undergoing VTA, 75% underwent a trans-septal approach, 19% a retrograde aortic approach, 1% an epicardial approach, and 5.2% a combined trans-septal and retrograde approach (Supplementary Figure 3A). Entrainment or activation mapping was the most implemented technique for mapping, reported in 36.1% of studies, while substrate and pace mapping were each used in 19.4% of studies. Coherent mapping was reported in 3% of studies, while a combination of any of the aforementioned mapping strategies was used in 22.2% of studies. (Supplementary Figure 3B) A total of 540 Vas were mapped, with a mean of 2 ± 1 VT per patient. The most common mechanism was scar-related macro-reentrant, observed in 80% of cases. Inflow cannula–related reentry occurred in 18%, bundle branch reentry in 3%, and focal micro–reentry in 2%. The most frequent scar locations were the septum (30%), the apex (30%), the anterior wall (27%), and the lateral wall (22%). A summary is provided in the Central Illustration. Outcomes The mean duration of follow-up for the case series was 327 ± 175 days, whereas for the case reports, it was 196 ± 157 days. Primary efficacy endpoint: VT recurrence The primary endpoint for VT recurrence in the pooled analysis of case series and retrospective studies was 38% (95% CI, 28% to 49%), with moderate heterogeneity observed across studies (I² = 59%) ( Figure 2A ), and 21 patients underwent redo-ablation. Among the 12 patients described in case reports, VT recurred in 5 individuals, and 4 underwent redo ablation; among these, 2 underwent mini-thoracotomy for epicardial ablation and one had VT originating from canula scar. Notably, in one case, VT recurred after the first ablation and resolved thereafter; this patient underwent orthotopic heart OHT prior to the planned second ablation. Primary safety endpoint: Procedural Complication A total of 325 procedures were performed: among the 309 procedures in the case series, 45 of 309 (14%) experienced procedure-related complications, yielding an overall pooled event rate of 7.4% (95% CI, 1.6% to 15.7%; I 2 :71%) ( Figure 2B ). Procedural complications were reported in 5 of 16 procedures from case reports (31%). Major complications occurred in 38 of 325 procedures (12%), whereas minor complications were observed in approximately 12 (4%) cases. The most frequently reported major complication was stroke or embolism, which occurred in 19 patients (6%), followed by device thrombosis in 10 patients (3%). Severe hypoxemia, attributed to an atrial septal defect, was reported in 3 patients (1%). Cardiogenic shock and volume overload each occurred in 1 patient (0.3%). There was one procedural-related death (0.3%) in which the patient experienced post-procedure hypoxemia requiring intubation and later died from hypoxic brain injury. No catheter entrapment was reported. Minor complications included groin hematoma in 5 patients (1.5%) and access site complications in 6 patients (2%). Table 2 provides a detailed breakdown of procedural complications. Secondary outcomes No inducibility of any VT after VTA Acute non-inducibility of VT was achieved in 61.5% (95% CI [47.5%, 74.8%]) of patients in the case series ( Figure 3A). Outcomes had moderate heterogeneity between studies (I 2 = 73.1%). In the case reports, clinical VT was rendered non-inducible in 11 out of the 12 patients. Heart transplant after VTA The rate of successful bridging to OHT was 17% (95% CI [6.2%, 30%]). The outcome had moderate heterogeneity across the studies, I 2 = 72.3% (Figure 3B). In the case reports, 3 of 12 patients received OHT during the follow-up period. Mortality outcomes Aggregate mortality rate combined among case series and observational studies was 12% (95% CI [3.6%, 23.1%] I 2 :52%) at 6 months after ablation and increased to 26% (95% CI [13.5%, 40.7%] I 2 :68%) at 12 months. (Figure 4 A and B) . Among the 13 patients included in the case reports, only one had died within one year of follow-up. The common causes of death included advanced HF, infectious complications, multi-organ failure, and stroke. A detailed summary of the causes of death is presented in Table 3. HeartMate 3 Outcomes We identified 69 patients with a HM3 who underwent VTA. Only one study specifically focused on HM3 recipients, while the other two were observational studies that included data on various devices. Notably, four out of six studies reported technical limitations during the ablation procedures, which ranged from temporary visualization loss of the catheter at some point during the procedure to incomplete mapping and even severe electromagnetic interference (EMI). However, no procedures were aborted due to EMI. To mitigate EMI, approaches included using CARTO patches placed away from the LVAD and the complementary use of intracardiac echocardiography. Table 4 presents a summary of the HM3 included studies. HeartMate 3 was associated with low post-ablation complication rates; only one patient experienced a stroke that was considered secondary to profound hypoxemia caused by an iatrogenic atrial septal defect. No cases of device thrombosis or catheter entrapment were reported. Characteristics of VTA Performed Concurrently with LVAD Implantation Table 5 summarizes the results of the included studies. Across five case series and 4 case reports, 29 patients underwent concomitant VTA during LVAD implantation. In these patients, there was nearly a universal history of VA before implantation (93%). Most individuals had an ICD at the time of surgery (79%), while a minority of patients had a prior ablation (38%). Six patients (32%) experienced VT recurrence after LVAD implantation. The most common complication during follow-up was sepsis (14%). Device thrombosis occurred in 2 cases; the recipients had a HM II, and one case of severe lateral wall edema resulting in partial inflow cannula obstruction was reported. Only one patient who underwent both LVAD implantation and VTA died within the 30-day postoperative period. DISCUSSION This meta-analysis summarizes the cumulative experiences of high-volume tertiary centers with VTA in LVAD recipients. Our pooled analysis provided several key clinical insights into the management of this population: 1. Despite the technical challenges of performing VTA, we identified a low rate of procedural complications and acceptable rates of procedural success and of VT recurrence during follow-up. 2. Ischemic cardiomyopathy was the most common underlying VT substrate. The predominant arrhythmogenic mechanism were scar-related macro–reentrant circuits, most frequently located in the septum or apical wall. 3. In contrast to older LVAD generations, no cases of thromboembolism were reported following VTA in the sixty-nine patients with HM3 LVADs. Only one case of post-ablation stroke was documented in a subgroup analysis, suggesting a favorable safety profile of the HM3 during VTA. 4. In patients with HM3 LVAD, mapping was hampered by EMI in 51% of cases, particularly when mapping near the inflow cannula. Despite this unique procedural challenge, no catheter entrapment or procedural abortion was reported, and the use of intracardiac echocardiography mitigated the impacts of EMI. 5. Despite high clinical complexity, those who underwent VTA during LVAD implantation had a low complication rate, although there was a notable recurrence rate of 32%. Study Cohort and Ventricular Arrhythmia Characteristics Several mechanisms contribute to the high incidence of ventricular arrhythmias in this population, including increased sympathetic tone, fluid and electrolyte disturbances, peri-operative use of inotropes, transient alterations in cardiac repolarization, cannula suction events, and scar formation at the ventricular apex cannulation site, creating a substrate for re-entrant VT 9() (). Consistent with prior reviews, our cohort was predominantly older males with an ischemic substrate, reflecting the population of LVAD recipients established to have the highest risk for developing ventricular arrhythmias 6(). We were surprised to find relatively low rates of VTA performed for the treatment of inflow cannula-related reentry VA, which accounted for only 18% of VTA cases. Interestingly, most arrhythmogenic scars were instead located in the anterior wall and septum, which corroborates recent evidence that a septal origin of VT may be associated with the highest risk of VT recurrence and development of intractable VT 11(). While we found that entrainment mapping remained the predominant technique for VT characterization during electrophysiology study, we noted a trend towards increased adoption of substrate mapping, pace mapping, or a combined approach, reflecting the complexity of management of VT in patients with numerous VT circuits. Efficacy and Safety of VTA As ventricular arrhythmias in LVAD patients are often well tolerated and sudden arrhythmic death is uncommon, the justification for VTA must be guided by a favorable risk–benefit profile, with particular attention to minimizing procedural harm. Consistent with prior systematic reviews 6(), we observed a low complication rate, with only one death in the included studies that was directly related to procedural complications, which we feel is an appropriate level of risk considering the high burden of comorbidities in this patient population. Stroke emerged as the most common reported major complication; a single stroke, related to systemic hypoxia, occurred in a patient with HM3, while all other stroke events occurred in patients with earlier generation LVADs. We attribute this favorable safety profile in such a high-risk patient cohort to diligent multidisciplinary pre-procedural planning, high operator expertise, significant advancements in mapping technology, and the introduction of the HM3, which has been associated with a major reduction in thromboembolic adverse events. Contemporary Treatment of VA in LVAD Patients The HM3 is distinct in its use of a magnetically levitated centrifugal pump, which reduces shear stress and the incidence of hemocompatibility-related complications. There was no reported stroke due to thromboembolism and device thrombosis following VTA in HM3 recipients, reaffirming that VTA is both safe and appropriate in this population. Strategies to reduce VAs in LVAD patients, especially those awaiting transplant, remain under debate. In particular, the optimal timing of VTA — before, during, or after LVAD implantation — remains unclear. VTA before implantation offers has certain advantages, but may not account for VT that may originate from the cannula insertion site 1213(,). Ongoing trials like CASTLE-VT will evaluate the efficacy and safety of this approach 14(). Intraoperative VTA during LVAD implantation remains an appealing strategy to lower post-implant arrhythmia burden as well. In particular, intraoperative VTA is appealing due to its direct access to epicardial tissue, which is of particular relevance in LVAD recipients as they have high levels of epicardial low-voltage zones, underscoring the critical role of epicardial substrate in this population. Still, intraoperative ablation presents challenges, including catheter tracking and impedance issues due to open-air exposure and prolonged surgical time 1516(,) . In our cohort, patients who underwent intraoperative VTA had a recurrence rate of 32%, though the procedure remained safe with no deaths linked to ablation. One of the studies included in our review indicated that this method is both safe and effective, with a median mapping time of just 12 minutes to identify arrhythmogenic areas, although the level of evidence remains low 17(). We look forward to the results of the ongoing PIVATAL trial, which aims to explore the role of a combined approach in reducing VA burden 18(). Limitations This review has several limitations. First, all included studies were retrospective, introducing risks of selection bias, unmeasured confounders, and inconsistent reporting of outcomes. Although no publication bias was detected, case reports and series describing complications are more likely to be published. Second, considerable heterogeneity was noted across studies, which may have been influenced by patient populations, procedural characteristics. However, sensitivity analysis revealed that no individual study had a significant impact on the results. Moreover, variability in the reporting of procedural limitations—such as catheter visualization issues and EMI—may also have introduced bias into our analysis. Finally, nearly half of the included LVADs were older models, and only one study focused exclusively on HM3, limiting generalizability. Conclusions This systematic review summarizes the experience of multiple institutions with VTA in LVAD recipients, with a particular focus on the impact of the contemporary HM3 on VTA outcomes. Our findings indicate that VTA is a feasible and acceptably safe treatment strategy for managing refractory VAs, particularly in patients supported with the contemporary HeartMate 3. However, further research is needed to better understand the appropriate indications and optimal timing of VTA in LVAD recipients. REFERENCES 1. Mehra MR, Uriel N, Naka Y et al. A Fully Magnetically Levitated Left Ventricular Assist Device - Final Report. N Engl J Med 2019;380:1618-1627.2. Miller LW, Pagani FD, Russell SD, et al. Use of a continuous-flow device in patients awaiting heart transplantation. N Engl J Med 2007;357:885-896.3. Brenyo A, Rao M, Koneru S et al. Risk of mortality for ventricular arrhythmia in ambulatory LVAD patients. J Cardiovasc Electrophysiol 2012;23:515-20.4. 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Refractory ventricular tachycardia caused by inflow cannula mechanical injury in a patient with left ventricular assist device: Catheter ablation and pathological findings. Journal of Arrhythmia 2017;33:494-496.30. Lü F, Eckman PM, Liao KK et al. Catheter ablation of hemodynamically unstable ventricular tachycardia with mechanical circulatory support. International Journal of Cardiology 2013;168:3859-3865.31. Snipelisky D, Reddy YNV, Manocha K et al. Effect of Ventricular Arrhythmia Ablation in Patients With Heart Mate II Left Ventricular Assist Devices: An Evaluation of Ablation Therapy. Journal of Cardiovascular Electrophysiology 2017;28:68-77.32. Osaki S, Alberte C, Murray MA et al. Successful radiofrequency ablation therapy for intractable ventricular tachycardia with a ventricular assist device. J Heart Lung Transplant 2008;27:353-356.33. Hottigoudar RU, Deam AG, Slaughter MS et al. Ventricular tachycardia ablation in patients with HeartMate II left ventricular assist devices: rhythm still matters in the bionic age. J Innov Card Rhythm Manage 2011;2:537-547.34. Dandamudi G, Ghumman WS, Das MK, Miller JM. Endocardial catheter ablation of ventricular tachycardia in patients with ventricular assist devices. Heart Rhythm 2007;4:1165-1169.35. Garan AR, Iyer V, Whang W et al. Catheter ablation for ventricular tachyarrhythmias in patients supported by continuous-flow left ventricular assist devices. ASAIO journal (American Society for Artificial Internal Organs: 1992) 2014;60:311-316.36. Sacher F, Reichlin T, Zado ES et al. Characteristics of Ventricular Tachycardia Ablation in Patients With Continuous Flow Left Ventricular Assist Devices. Circulation: Arrhythmia and Electrophysiology 2015;8:592-597.37. Bergau L, Sommer P, Hamriti ME et al. Lessons learned from catheter ablation of ventricular arrhythmias in patients with a fully magnetically levitated left ventricular assist device. Clinical Research in Cardiology 2021;111:574.38. Izumida T, Kataoka N, Imamura T et al. Bail-out Ablation of Ventricular Tachycardia Electrical Storm in a Patient with a Durable Left Ventricular Assist Device. Intern Med 2023;62:2201-2204.39. Van den Bruck J, Hohendanner F, Heil E et al. Characterization of ventricular tachycardia ablation in end-stage heart failure patients with left ventricular assist device (CHANNELED registry). EP Europace 2025.40. Niknam N, Paydar AH, Naveed H et al. Ablation of Ventricular Tachycardia in Patients with Left Ventricular Assist Device. Medicine 2024.41. Grinstein J, Garan AR, Oesterle A et al. Increased Rate of Pump Thrombosis and Cardioembolic Events Following Ventricular Tachycardia Ablation in Patients Supported With Left Ventricular Assist Devices. Asaio J 2020;66:1127-1136.42. Oates CP, Towheed A, Hadadi CA. Refractory hypoxemia from intracardiac shunting following ventricular tachycardia ablation in a patient with a left ventricular assist device. HeartRhythm Case Reports 2022;8:760-764.43. Wang R, Mainville DJ, Vacaru A, Pasca I. Iatrogenic Hypoxemia and Atrial Septal Defect Due to Electrical Storm Ablation After Left Ventricular Assist Device: A Case Report. Cureus 2023;15:e39418.44. Lynch PT, Maloof A, Badjatiya A et al. Mortality in Recipients of Durable Left Ventricular Assist Devices Undergoing Ventricular Tachycardia Ablation. JACC Clin Electrophysiol 2024;10:2049-2058.45. Mulloy DP, Bhamidipati CM, Stone ML et al. Cryoablation during left ventricular assist device implantation reduces postoperative ventricular tachyarrhythmias. J Thorac Cardiovasc Surg 2013;145:1207-13.46. Tankut S, Gosev I, Yoruk A et al. Intraoperative Ventricular Tachycardia Ablation During Left Ventricular Assist Device Implantation in High-Risk Heart Failure Patients. Circulation: Arrhythmia and Electrophysiology 2022;15:e010660.47. Nishino K, Watanabe M, Ooka T, Sato T, Anzai T. Simultaneous epicardial ablation based on intraoperative electroanatomic mapping during left ventricular assist device implantation. Journal of Arrhythmia 2024;40:632-635.48. Rao SD, Chahal CAA, Atluri P, Mather P, Santangeli P, Arkles J. Massive myocardial edema and inflow cannula obstruction due to epicardial surgical ventricular tachycardia cryoablation at time of left ventricular assist device implantation. HeartRhythm Case Rep 2020;6:523-527.49. Orozco-Hernandez EJ, Argueta-Sosa EE, Joly JM, Pamboukian SV, Tallaj JA, Hoopes CW. Cryoablation during left ventricular assist device implantation: A case report: Ignoramus et Ignorabimus, Sapere Aude. JTCVS Tech 2020;1:55-57.50. McIlvennan CK, Babu AN, Brieke A, Ambardekar AV. Concomitant surgical cryoablation for refractory ventricular tachycardia and left ventricular assist device placement: a dual remedy but a recipe for thrombosis? Journal of Cardiothoracic Surgery 2016;11:53. Figure Legends. Figure 1: A PRISMA Flow diagram summarizing the search strategy Figure Legend: Flow diagram summarizing the systematic search process: 179 records were screened from five databases after deduplication, 35 studies were included in the final review following full-text assessment. (Abbreviation: CENTRAL = Cochrane Central Register of Controlled Trials.) Figure 2 A-B: Primary Efficacy and Safety Outcome After VTA in LVAD recipients Figure Legend 2A- 2B In patients with LVADs, VT recurrence was 38% after catheter ablation (95% CI: 28%–49%; I² = 59%), showing a high recurrence rate. The pooled complication rate from 309 procedures was 7.4%, indicating low procedural risk for LVAD patients undergoing VTA. Figure 3A-3B: No inducibility of VT and bridge-to-OHT after VTA in LVAD Figure Legend 3A Acute outcomes of VTA showed 62% achieved complete non-inducibility of arrhythmias, indicating procedural success— Figure Legend 3 B. Additionally, 17% of patients successfully moved on to heart transplantation. Figure 4: Mortality Following VTA in Patients with LVADs: 6- and 12-Month Figure Legend 4A-B. The pooled mortality rate was 13.3% at 6 months and 26% at 1 year, based on data from case series and observational studies. Central Illustration: The most common VT mechanism was scar-related macro-reentry (80%), with inflow cannula circuits in 18%. Scar localization was most frequent at the apex/pericannula (30%) and septum (29%). Graphical Abstract: VT recurrence in 38%, with procedure-related complications in 8% and non-inducibility post-ablation in 56% of cases. Catheter ablation remains a feasible and effective strategy in this complex population. FIGURES Figure 1 Figure 2 A-B Figure 3 A-B Figure 4 Table 1. Characteristics of Patients with LVAD Who Underwent Catheter Ablation for Ventricular Tachycardia After LVAD Implantation Moss et al.,2017 19() Case series. USA 21 62 ± 10 19 / 2 ICM 14 (67) 18 ± 5 15 (71) 21 (100) 4 (19) 6 (28) NICM 7 (33) Cantillon et al., 2012 20() Case series USA 21 56 ± 13 18 / 3 ICM 12 (57) 14 ± 6 8 (38) 11 (52) - - NICM 9 (43) Whang et al., 2014 21() Case report USA 1 70 1 / 0 ICM 1(100) 10 - 15 - 1 (100) 0 0 Thosani et al., 2017 22() Case report USA 1 72 1 / 0 ICM 1(100) - - 1 (100) 0 1(100) Schade et al., 2014 23() Case report Germany 1 66 1 / 0 ICM 1(100) 20 1(100) 1 (100) 0 1(100) Komeyama et al., 2022 24() Case report Japan 1 52 1 / 0 ICM 1(100) - - 1 (100) - 1(100) Herweg et al., 2010 25() Case report USA 1 72 1 / 0 ICM 1 (100) - 0 1 (100) 0 1(100) Romano et al., 2015 26() Case report Italy 1 63 1 / 0 ICM 1 (100) - 0 1 (100) 0 1(100) Herweg et al., 2012 27() Case series USA 6 61.5 6 / 0 ICM 4 (67) 20 4 (67) 6 (100) 1 (16) 5 (83) NICM 2 (33) Szegedi et al., 2015 28() Case report Hungary 1 38 1 / 0 ICM 1 (100) - 1 1 (100) 0 1(100) Pedretti et al., 2017 29() Case report Italy 1 58 1 / 0 ICM 1 (100) - 0 0 0 0 Lü et al., 2013 30() Case series USA 6 65 ± 13 5 / 1 ICM 4 (67) 14 ± 6 - 0 6 (100) 6(100) NICM 2 (33) Snipelsky et al., 2016 31() Case series USA 6 64.5 4 / 2 ICM 3 (50) 21.2 3 (50) 6 (100) 0 0 NICM 3 (50) Osaki et al., 2008 32() Case report USA 1 65 1 / 0 ICM 1(100) 10 1(100) 1 (100) 0 0 Hottigoudar et al., 201133() Case series Canada 3 61 3 / 0 ICM 1 (33) 10-15 2 (67) 2 (67) 1 (33) 0 NICM 2 (67) Dandamudi et al., 2007 34() Case series USA 3 55 3 / 0 ICM 1 (33) 20 1 (33) 2 (67) 1 (33) 1 (33) NICM 2 (67) Garan et al., 2014 35() Case series USA 7 66 7 / 0 ICM 5 (71) - 7 (100) 7 (100) 5 (71) 1 (14) NICM 2 (29) Sacher et al., 2015 36() Case series France 34 58 ± 10 30 / 4 ICM 21(62) 17±5 27 (79) 32 (94) 5 (15) 5 (15) NICM 13 (28) Bergau et al., 202137() Case series Germany 9 60 ± 8 9 / 0 ICM 4 (44) 22±6 7 (77) 9 (100) 4 (44) 9 (100) NICM 5 (56) Izumida et al., 2023 38() Case report Japan 1 53 0 / 1 NICM 1(100) - 1(100) 1 (100) 0 0 Bruck et al., 2024 39() Case control study Germany 69 61 ± 8 43 / 6 ICM 41(59) 21± 6 44 (64) 63 (91) - 47 (68) NICM 28 (41) Niknam et al., 2024 40() Case series USA 7 64 ± 6 - ICM - - 7 (100) - - NICM 6 (86) Combined 1(14) Grinstein et al., 2020 41() Case-control study USA 43 63 ± 10 39 / 4 ICM 28 (65) - 29 (67) 31 (72) 3 (7) 27 (63) NICM 15 (35) Oates et al., 2022 42() Case report USA 1 74 1 / 0 NICM 1(100) - 1 (100) 1 (100) 1 (100) 1 (100) Wang et al., 2023 43() Case report USA 1 59 1 / 0 ICM 1(100) 20 1 (100) 1 (100) - - Nof et al., 2022 11() Case series France 19 65 ± 8 18 / 1 ICM 15 (79) 17 ± 5 17 (89) VT - 8 (42) 10 (53) NICM 4 (21) 4 VF (21) Lynch et al., 2024 44() Case control study USA 34 62 ± 9 32 / 2 ICM 23 (68) - 24 (71) 28 (83) 10 (29) - NICM 11 (32) ICM = ischemic cardiomyopathy, NICM = non-ischemic cardiomyopathy, LVEF = left ventricular ejection fraction, Values are mean ± SD or n (%) Table 2 . Procedural complications of VT catheter ablation in the case series and case reports. Minor Groin hematoma 1923353644(,) 5 (1.5) Access site complications 2339(,) 6 (2) Pericardial effusion39() 1 (0.3) Major Groin pseudoaneurysm/fistula requiring surgical repair 20() 2 (1) Cardiogenic shock 36() 1 (0.3) Stroke/embolism 113641(,) 19 (6) Hypoxia /Hypoxemia 244243(,) 3 (1) Volume overload 33() 1 (0.3) Device Thrombosis 41() 10 (3) Procedure Related Death 39() 1 (0.3) Aortic Dissection 39() 1 (0.3) Table 3. Breakdown of Mortality Outcomes at 6 and 12 Months After VT Catheter Ablation 6 months 12 Months Bruck et al., 2024 39() 9 26 Heart failure, intracranial bleeding, sepsis, procedure related hypoxemia. Hottigoudar et al., 2011 33() 1 1 Multiorgan failure. Garan et al., 2014 35() - 3 Device-related death, RV failure, and Multiorgan failure. Niknam et al., 2024 40() - 2 NR Bergau et al., 2021 37() 1 2 Septic shock, paralytic ileus and Severe pneumonia. Lü et al., 2013 30() 1 - End-stage HF Moss et al., 2017 19() 6 10 Hemolysis, infection, multiorgan failure, LVAD pump failure, and intracranial hemorrhage. Herweg et al., 2012 27() 3 5 RV failure, stroke, pump pocket failure, emphysema, and pulmonary embolism. Dandamudi et al., 2007 34() 1 1 Infection Romano et al., 2015 26() - 1 Sepsis and ischemic stroke (device thrombosis) Sacher et al., 2015 36() - 10 End-stage HF, septic shock, LVAD deactivation, Intracranial hemorrhage, sudden death, Hemolysis, Cable failure/redo surgery. Snipelisky et al., 2016 31() - 1 NR Lynch et al., 2024 44() 4 6 NR Table 4 : Summary of VTA procedural complications in patients supported with HeartMate 3 Bruck et al., 2024 39() 42 Stroke: 0 12 EMI mild Transient loss of visualization catheter No LVAD flow adaptation performed DT: 0 †ARF: 1 Bergau et al., 2021 37() 5 Stroke: 0 Minor EMI 1 Difficult trans-aortic approach due to closed aortic valve Temporal LVAD pump stop DT: 0 - Oates et al., 2022 42() 1 Stroke: 0 1 Significant EMI NR DT: 0 Iatrogenic ASD with R-L Shunting Nof et al., 2022 11() 19 Stroke: 1 Significant EMI in all cases. No abortion due to EMI Reported -CARTO system patches distribution -LVAD Battery removal -CARTO system low pass filter was lowered -Intra-cardiac signals as reference -Adjust the ECG to the 40–20 Hz range. DT:0 CAVB Wang et al., 2023 43() 1 Stroke: 0 NR - DT:0 ASD with R-L Shutting Lynch et al., 2024 44() 1 NR NR - ARF = acute respiratory failure, EMI = electromagnetic interference CAVB = complete atrioventricular block, ASD = atrial septal defect. Table 5. Catheter ablation of ventricular arrhythmias during left ventricular assist device implantation Patel et al., 2016 15() 5 363 ± 368 HMII: 2(40) Levitronix: 1(20) HM XVE: 2(40) 5 (100) 5 (80) 4 (80) 2 (40) NR Hemorrhagic stroke 99 days after ablation :1 sepsis, multi-organ failure at month six months :1 Moss et al., 2019 17() 2 311 (168-469) NR 2 (100) 2 (100) NR 1 (50) NR Stroke:1 Mulloy et al., 2022 45() 7 144.9 ± 76.6 HMII: 7 (100) 7 (100) 6 (86) 3 (43) 2 (29) IABP: 2 Intubated before vad: 0 Cardiac Tamponade requiring intervention :1 Prolonged ventilation :3 Gastro-intestinal bleeding :1 Tankut et al., 2022 46() 10 360 HMII 4 (40) HM3 | 6 (60) 8 (80) 8 (80) 1 (100) NR 3 (30) Mechanical Support 5 (50) Inotropes Sepsis :3 Nishino et al., 2024 47() 1 1080 HM3 (100) 1 (100) 1 (100) 1 (100%) 0 1 (100) Inotrope NR Rao et al., 2020 48() 1 NR HVAD: 1 1 (100) 1 (100) 1 (100) 1 (100) Treated with stellate ganglion block 1 (100) Inotrope Severe lateral wall edema causing partial inflow cannula obstruction Orozco et al., 2020 49() 1 NR HM3: 1 1 (100) 1 (100) 1 (100) 1 (100) IABP: 1 NR Mcllvenan et al., 2016 50() 2 11 ± 2 HM2:2 2 (100) NR NR NR IABP :1 ECMO :1 Device Thrombosis: 2 Both required device exchange IABP = intra-aortic balloon pump, ECMO = extracorporeal membrane oxygenation, NR= not reported. Information & Authors Information Version history V1 Version 1 17 July 2025 Peer review timeline Published Journal of Cardiovascular Electrophysiology Version of Record 13 Oct 2025 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Collection Journal of Cardiovascular Electrophysiology Keywords basic: activation mapping of arrhythmias basic: ventricular tachycardia/fibrillation clinical: catheter ablation – ventricular tachycardia clinical: electrophysiology – ventricular tachycardia Authors Affiliations Nelson Barrera 0000-0002-8031-0601 [email protected] Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital View all articles by this author Yevhen Kushnir SBH Health System Department of Internal Medicine View all articles by this author Maria Solorzano SBH Health System Department of Internal Medicine View all articles by this author Francisco Gallegos SBH Health System Department of Internal Medicine View all articles by this author Patrick Lynch T Baylor College of Medicine View all articles by this author Flavia Queiroga F 0009-0006-5304-0657 Emory University School of Medicine View all articles by this author Juliana Giorgi Hospital Sirio-Libanes View all articles by this author Alexandra R. D. Brigido Universidade de Sao Paulo Instituto do Coracao View all articles by this author Guilherme Carvalho Instituto Dante Pazzanese de Cardiologia View all articles by this author Mihail Chelu 0000-0001-9688-1604 Baylor College of Medicine View all articles by this author Paolo Columbo Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital View all articles by this author Andre d'Avila Beth Israel Deaconess Medical Center View all articles by this author Metrics & Citations Metrics Article Usage 520 views 212 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Nelson Barrera, Yevhen Kushnir, Maria Solorzano, et al. Contemporary Outcomes of Ventricular Tachycardia Ablation in Left Ventricular Assist Device Therapy: A Meta-Analysis. Authorea . 17 July 2025. 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