Hybrid Catheter Ablation and minimally Invasive LVAD Implantation in a high-risk patient with Refractory Ventricular Tachycardia

Hybrid Catheter Ablation and minimally Invasive LVAD Implantation in a high-risk patient with Refractory Ventricular Tachycardia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Hybrid Catheter Ablation and minimally Invasive LVAD Implantation in a high-risk patient with Refractory Ventricular Tachycardia Xian Zhu, Minjian Kong, Youqi Fan, Jian Ye, Aiqiang Dong This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6267720/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Nov, 2025 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 13 You are reading this latest preprint version Abstract Background There remains ongoing controversy regarding the suitability of left ventricular assist device (LVAD) implantation in patients with end-stage heart failure who present with preoperative frequent ventricular arrhythmias. How to implement effective strategies to reduce the occurrence of postoperative ventricular arrhythmias following LVAD implantation has become a key focus of clinical attention. Case presentation A 59-year-old woman with hypertrophic cardiomyopathy and end-stage heart failure presented with recurrent Ventricular Tachycardia (VT) resistant to pharmacotherapy and electrical cardioversion. Contraindications to transplantation included hemodynamic instability and panel-reactive antibody sensitization. We adopted a single-stage minimally invasive approach to treat the patient, including VT radiofrequency ablation, atrial septal defect (ASD) closure, and minimally invasive left lateral LVAD implantation. Postoperatively, transient VT recurrence on day 4 resolved with amiodarone. The patient achieved stable hemodynamics, was extubated by day 2, and discharged on day 21. At 15-months follow-up, she maintained improved quality of life with no sustained VT episodes and stable cardiac function Conclusions This case demonstrates the feasibility of the hybrid minimally invasive strategy as a destination or bridge therapy for high-risk patients with refractory arrhythmias and transplant contraindications. Further follow-up is required to evaluate long-term outcomes. Figures Figure 1 Figure 2 Background LVAD has rapidly served as a critical therapeutic option for patients with end-stage heart failure. According to INTERMACS data, nearly 3,000 LVAD implantations are performed annually in the United States[ 1 ]. Although heart transplantation remains the gold standard for advanced heart failure, LVADs offer distinct advantages including independence from donor availability, avoidance of immunosuppressive therapy, and the potential for minimally invasive procedures [ 2 ]. Several literatures highlight the benefits of minimally invasive LVAD implantation, which reduces surgical trauma, accelerates recovery, and simplifies subsequent bridge-to-transplant surgery[ 3 ]. The suitability of LVAD implantation in patients with preoperative frequent ventricular arrhythmias (VAs) remains controversial. Although the left ventricular unloading provided by LVAD, portative arrhythmias remain a significant cause of LVAD failure or complications in bridge-to-transplant strategies[ 4 ]. For high-risk patients (INTERMACS profiles 1–2) with refractory VAs and limited access to donor hearts, LVAD might be a more considerable option. In this case, following the multidisciplinary discussion, we performed a one-stage hybrid minimally invasive procedure for a patient with end-stage heart failure and recurrent VT. The outcomes were satisfactory after 15 months follow-up. Case presentation A 59-year-old female patient was firstly diagnosed with hypertrophic non-obstruction cardiomyopathy ten years ago through echocardiography in her local community hospital. During the period, she received oral medical therapy intermittently to treat heart failure. Three months ago, she was admitted to local hospital because of exacerbated chest distress and dyspnea. The electrocardiogram (ECG) indicated the presence of pathological Q waves and ST-segment elevation in both the inferior and anterior leads. Transthoracic echocardiography (TTE) revealed severe left ventricular systolic dysfunction with an ejection fraction (EF) of 25%, moderate mitral regurgitation. Coronary angiography showed 30% stenosis in the left anterior descending artery. A month ago, the patient re-admitted to the local hospital for monomorphic ventricular tachycardia (VT). Electrical cardioversion was performed successfully after the failure of the pharmacological conversion. Subsequently, VT is still recurrent (Fig. 1 A). The patient rejected the implantation of ICD and was transferred to cardiology department of our hospital for advanced management. 4 days after the admission, the patient was transferred to ICU for mechanical ventilation because of unstable vital sign and recurrent VT. TTE confirmed the severe LV function (EF 16.4%), moderate mitral valve regurgitation and segmental LV hypokinesis. The results of Swan-Ganz results indicated elevated pulmonary artery pressures (40/28 mmHg, mean 32 mmHg), a pulmonary artery wedge pressure of 24 mmHg, and a pulmonary vascular resistance(PVR) of 194 dynes·s/cm⁵. Normal hepatic function and mild renal insufficiency was observed in blood test. CT scan of the chest, brain and peripheral vessel were normal. Heart transplantation was proposed initially by our multidisciplinary heart team. Panel-reactive antibody-1(PRA-1) was detected as 3.6%, which indicated low-level sensitization and increased the surgical risk of transplantation. Furthermore, her hemodynamic instability and limited donor availability precluded the possibility of the immediate transplantation. LVAD was an available destination treatment with the appropriate right ventricular function and PVR. However, recurrent VT still occur probably after the implantation of the LVAD. According to discussion, our team planned to performed the one-stage VT radiofrequency ablation (RFA) combined with atrial septal defect closure and minimal invasive implantation of the LVAD. Under general anesthesia, the patient underwent VT radiofrequency. After the right femoral vein access was established, the transseptal puncture was conducted by using SL1 sheath. Using the CARTO 3D mapping system, the ablation was performed in low-voltage(<0.5mV) zones and fragmented potentials at the left ventricular septum and apical regions(Fig. 1 B). Ablation power​ was set to ​40W and ​catheter tip temperature​ maintained at ​43°C. ​Substrate-based ablation​ was performed across the critical isthmus regions. After the process, repeated ablation stimulation failed to induce ventricular tachycardia, confirming procedural effectiveness. Subsequently, an 18-24mm ASD occluder was utilized to eliminate right to left shunting induced by transseptal puncture (Fig. 1 C). After femoral artery and vein cannulation, a left fifth intercostal incision exposed the ventricular apex and a right second intercostal incision exposed ascending aorta. 3 − 0 Prolene suture was placed at the apex, followed by insertion of the LVAD inflow pump (CH-VAD, BrioHealth Technologies Suzhou) (Fig. 2 A). The outflow graft was anastomosed to the ascending aorta through the right intercostal incision by using 5 − 0 Prolene suture (Fig. 2 B). A subcutaneous tunnel was created for the pump driveline at the right subcostal region. After confirming the stable hemodynamics and normal LVAD flow (3.5L/min and 2700rpm), the patient was transferred to intensive care unit (ICU) with the maintain of low-dose vasoactive drug (norepinephrine 0.05 mg/kg/min and epinephrine 0.03 mg/kg/min). The position of the LVAD demonstrated perfect by the chest X-ray (Fig. 2 C). Extubation was performed on postoperative day 2. VT recurrent on postoperative day 4 and it terminated by intravenous amiodarone. VT did not recur during the subsequent hospitalization. The patient was transferred to general ward on day 6 and was discharged on postoperative day 21. 1 month after the discharge, TTE demonstrated stable heart function with the aid of LVAD (3.7L/min and 2700rpm). 4 months after discharge, a 24-hour Holter electrocardiogram indicated that the patient had 12,670 premature ventricular contractions and did not experience sustained VT. β-blocker was used to control arrhythmia. At the 15-mongths follow-up, the patient maintains a good quality of life with no significant complaints. Discussion and conclusions Because of the shortage of the heart donor, LVAD has gradually became a vital treatment method of end-stage heart failure patients. The 1-year and 3-year survival rates has approached those of heart transplantation.[ 5 ] However, postoperative ventricular tachyarrhythmias is still a common complication, occurring in 20–50% patient within the first year after the implantation of the LVAD[ 6 ]. The mechanisms underlying the development of VAs in LVAD patients are multifactorial including continue-flow perfusion, presence of pre-existing cardiac conditioning, device-related mechanical stimulation, and so on[ 7 ]. It has been reported that the recurrent VAs, especially VT or ventricular fibrillation (VF), would adversely affect life quality, survival and heart transplantation rate. Preoperative factors play a significant role in the occurrence of the VAs after the implantation of the LVAD.[ 8 ] At present, the treatment methods related to LVAD contain medication therapy, device adjustment and catheter ablation[ 9 ]. Commonly used antiarrhythmic medications include β-adrenergic antagonists and sodium channel blockers[ 10 ]. It is also crucial to monitor and correct electrolyte abnormalities during pharmacotherapy. Additionally, it is also an effective method to adjust the flow and rotate speed of the LVAD appropriately to improve the filling status of the heart[ 11 ]. If the patients recurrent VT inducing hemodynamic unstable and low-flow alerts, radiofrequency ablation was considered as an effective method. The morphological analysis of ECG plays a pivotal role in guiding ablation strategies. Monomorphic ventricular tachycardia (VT) typically demonstrating superior efficacy. The timing of RFA is also crucial. Controversies surrounding postoperative RFA include: 1) electromagnetic interference between the LVAD motor and the 3D mapping system;2)The pump thrombosis and the risk of catheter suction into the inflow pump; 3. Limitation of the access route. The data showed that the short-term success rate of the RFA is 80%, while the recurrence rate range from 15–86%.[ 12 , 13 ] Pre-LVAD ablation or surgical -ablation concomitant with the initial LVAD implantation may offer benefits for VTs. In a cohort of 10 patients, simultaneous LVAD implantation and VT radiofrequency ablation led to reduced arrhythmia burden postoperatively. The results at 5-month follow-up demonstrated a marked decrease in VT episodes[ 14 ]. Additionally, epicardial ablation[ 15 ] and cryoballoon ablation[ 16 ] were both reported in some particular cases, but they could not be used in minimally invasive approach. However, the two approaches could not be combined with mini-LVAD implantation. Another key point of the case needs to discuss is the minimally invasive approach of LVAD, which has constantly increased worldwide[ 17 ]. Mini-LVAD implantation have three approaches: left anterolateral thoracotomy, right anterior thoracotomy or partial sternotomy[ 18 ]. The patients meeting the mini-approach criteria can derive significant clinical benefits[ 19 ]. Recent studies data have demonstrated the benefits of the mini-incision, including reduced infection, improved right ventricular function, reduced bleeding and reduced ICU and hospital stay[ 10 ]. Additionally, the mini-approach could minimize the mediastinal adhesions to simplify the future heart transplantation[ 20 ]. Our case successfully adopted a single-stage hybrid minimally invasive treatment strategy. Currently, it is rare to report the hybrid mini-approach. The radiofrequency ablation was preventatively conducted on the patient according to the analysis of ECG and the crisis condition. An ASD closure was placed because of the transseptal puncture to prevent the shunt blood. Finally, minimally invasive approach of the LVAD implantation reduce the surgical trauma. The 15-months follow-up demonstrated the patients' improving quality of life. This clinical result substantiates the procedural efficacy of our hybrid minimally invasive surgical decision. Abbreviations LVAD left ventricular assist device VT ventricular Tachycardia ASD atrial septal defect VAs ventricular arrhythmias ECG electrocardiogram TTE Transthoracic echocardiography EF ejection fraction PRA-1 Panel-reactive antibody-1 NSVT non-sustained ventricular tachycardia PVR pulmonary vascular resistance VF ventricular fibrillation ICU intensive care unit RFA radiofrequency ablation Declarations Ethics approval and consent to participate Written informed consent was obtained from the patient for the publication of this case report Consent for publication All authors approved the publication of the case report. Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing interests The authors declare no competing interests Acknowledgements None Author contributions XZ and AQD conceived the conception of the study. AQD, MJK and XZ completed the surgical procedure. XZ and MJK contributed to data collection. YQF and JY completed the catheter ablation procedure and contributed the data collection. XZ drafted the original manuscript. MJK and AQD critically reviewed and revised the manuscript draft. All authors approved the final version of the manuscript to be published. Funding statement Supported by Key research and development program of Zhejiang Province (2025C02143) Competing interests The authors declare no competing interests Author details 1 Department of Cardiovascular Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China 2 Department of Cardiology, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China References Jorde UP, Saeed O, Koehl D, Morris AA, Wood KL, Meyer DM et al. The Society of Thoracic Surgeons Intermacs 2023 Annual Report: Focus on Magnetically Levitated Devices. Ann Thorac Surg. 2024;117:33–44. Saeed D, Feldman D, Banayosy AE, Birks E, Blume E, Cowger J, et al. The 2023 International Society for Heart and Lung Transplantation Guidelines for Mechanical Circulatory Support: a 10- Year Update. J Heart Lung Transpl. 2023;42:e1–222. Zubair MH, Brovman EY. Lateral thoracotomy versus sternotomy for left ventricular assist device implantation. Curr Opin Anaesthesiol. 2023;36:25–9. Ahmed A, Amin M, Boilson BA, Killu AM, Madhavan M. Ventricular Arrhythmias in Patients with Left Ventricular Assist Device (LVAD). Curr Treat Options Cardiovasc Med. 2019;21:75. Bhandari K, Sama V, Shorbaji K, Witer L, Houston BA, Tedford RJ, et al. Risk Factors for 1-Year Mortality After Heart Transplant in Obese Patients Bridged with an LVAD. Ann Thorac Surg. 2024;117:404–11. Kataoka N, Imamura T. Catheter Ablation for Tachyarrhythmias in Left Ventricular Assist Device Recipients: Clinical Significance and Technical Tips. J Clin Med 2023;12. Shi J, Yu X, Liu Z. A Review of New-Onset Ventricular Arrhythmia after Left Ventricular Assist Device Implantation. Cardiology. 2022;147:315–27. Sisti N, Santoro A, Carreras G, Valente S, Donzelli S, Mandoli GE, et al. Ablation therapy for ventricular arrhythmias in patients with LVAD: Multiple faces of an electrophysiological challenge. J Arrhythm. 2021;37:535–43. Maradey JA, Singleton MJ, O'Neill TJ, Bhave PD. Management of ventricular arrhythmias in patients with LVAD. Curr Opin Cardiol. 2020;35:289–94. Saeed D, Feldman D, Banayosy AE, Birks E, Blume E, Cowger J, et al. The 2023 International Society for Heart and Lung Transplantation Guidelines for Mechanical Circulatory Support: a 10- Year Update. J Heart Lung Transpl. 2023;42:e1–222. Peichl P, Bayes-Genis A, Deneke T, Chioncel O, Deriva M, Crespo-Leiro MG et al. Drug therapy and catheter ablation for management of arrhythmias in continuous flow left ventricular assist device's patients: a Clinical Consensus Statement of the European Heart Rhythm Association and the Heart Failure Association of the ESC. Europace 2024;26. Anderson RD, Lee G, Virk S, Bennett RG, Hayward CS, Muthiah K, et al. Catheter Ablation of Ventricular Tachycardia in Patients with a Ventricular Assist Device: a Systematic Review of Procedural Characteristics and Outcomes. JACC Clin Electrophysiol. 2019;5:39–51. Imamura T, Nguyen A, Chung B, Rodgers D, Sarswat N, Kim G, et al. Association of Inflow Cannula Position with Left Ventricular Unloading and Clinical Outcomes in Patients with HeartMate II Left Ventricular Assist Device. ASAIO J. 2019;65:331–5. Tankut S, Gosev I, Yoruk A, Younis A, Mcnitt S, Bjelic M, et al. Intraoperative Ventricular Tachycardia Ablation During Left Ventricular Assist Device Implantation in High-Risk Heart Failure Patients. Circ Arrhythm Electrophysiol. 2022;15:e010660. Nishino K, Watanabe M, Ooka T, Sato T, Anzai T. Simultaneous epicardial ablation based on intraoperative electroanatomic mapping during left ventricular assist device implantation. J Arrhythm. 2024;40:632–5. Zhang S, Li J, Tan C, Chen M, Hu L, Tang H, et al. Case Report: Left ventricular assist device implantation combined with cryoballoon ablation for ventricular tachycardia. Front Surg. 2024;11:1449007. Kocabeyoglu SS, Kervan U, Sert DE, Unal EU, Demirkan B, Guray Y, et al. Is it Possible to Implant HeartMate 3 Less Invasively? New Pump, New Approach. Artif Organs. 2018;42:1132–8. Ribeiro R, Lee J, Elbatarny M, Friedrich JO, Singh S, Yau T, et al. Left ventricular assist device implantation via lateral thoracotomy: a systematic review and meta-analysis. J Heart Lung Transpl. 2022;41:1440–58. Sileshi B, O'Hara BK, Davis ME, Haglund NA, Meng X, Deegan R, et al. Outcomes of Patients Implanted Using a Left Thoracotomy Technique for a Miniaturized Centrifugal Continuous-Flow Pump. ASAIO J. 2016;62:539–44. Rabin J, Ziegler LA, Cipriano S, Madathil RJ, Feller ED, Sorensen EN, et al. Minimally Invasive Left Ventricular Assist Device Insertion Facilitates Subsequent Heart Transplant. Innovations (Phila). 2021;16:157–62. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Nov, 2025 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 25 Jul, 2025 Reviews received at journal 03 Jun, 2025 Reviews received at journal 22 May, 2025 Reviewers agreed at journal 18 May, 2025 Reviews received at journal 08 May, 2025 Reviews received at journal 04 May, 2025 Reviewers agreed at journal 30 Apr, 2025 Reviewers agreed at journal 30 Apr, 2025 Reviewers agreed at journal 29 Apr, 2025 Reviewers invited by journal 29 Apr, 2025 Editor assigned by journal 21 Mar, 2025 Submission checks completed at journal 21 Mar, 2025 First submitted to journal 20 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6267720","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":450525530,"identity":"372bd168-5819-49ab-bb4a-813a80050f6b","order_by":0,"name":"Xian Zhu","email":"","orcid":"","institution":"Second Affiliated Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Xian","middleName":"","lastName":"Zhu","suffix":""},{"id":450525531,"identity":"0bd5df67-b862-41e2-b5e0-c6fe3bb9889e","order_by":1,"name":"Minjian Kong","email":"","orcid":"","institution":"Second Affiliated Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Minjian","middleName":"","lastName":"Kong","suffix":""},{"id":450525532,"identity":"1a2cfca1-14c5-4ddb-87ef-a5dafa6bd28e","order_by":2,"name":"Youqi Fan","email":"","orcid":"","institution":"Second Affiliated Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Youqi","middleName":"","lastName":"Fan","suffix":""},{"id":450525533,"identity":"e25c6c65-7b62-4dfb-9ed4-4cdcaee46bde","order_by":3,"name":"Jian Ye","email":"","orcid":"","institution":"Second Affiliated Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Jian","middleName":"","lastName":"Ye","suffix":""},{"id":450525534,"identity":"dfe82fd7-f2aa-436f-99a2-6d98c5d646ed","order_by":4,"name":"Aiqiang Dong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIiWNgGAWjYDCCAwwMEiCajYGxAUjZQCgeErSkkaAFCg5DKHxa+G4fYLzxcUetPB97cuPngl/n7ZlnJDA+eNvGIG+OQ4vkuQRmy5lnjhu28Txslp7Zd5uZcUYCs+HcNgbDnQ3YtRicYWCT5m07xtgmkdggzdtzmw2oBSTCkGBwAL8We6CW5t+8Ped4gFrYfxOhpSYRqKVNmufHAQmQLcz4tEieYQD6pe1AMtAvbda8DckGjD0PmyXnnJMw3IBDC98ZBmCItdXZzm9Pf3yb54+dvWF78sEPb8ps5HHZwsDA/4EBEh0JDAyMbQwMhg3gyJTApR4G6iBaGP4wMMgTUjsKRsEoGAUjDgAAPFFamTdb93wAAAAASUVORK5CYII=","orcid":"","institution":"Second Affiliated Hospital of Zhejiang University","correspondingAuthor":true,"prefix":"","firstName":"Aiqiang","middleName":"","lastName":"Dong","suffix":""}],"badges":[],"createdAt":"2025-03-20 08:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6267720/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6267720/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-025-03696-0","type":"published","date":"2025-11-19T15:59:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82153533,"identity":"88ad258b-e934-4d3b-824a-b42b9b7195d6","added_by":"auto","created_at":"2025-05-07 07:26:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4229410,"visible":true,"origin":"","legend":"\u003cp\u003eA) Ventricular tachycardia of the preoperative twelve-lead ECG; B) Voltage map in left anterior oblique (LAO) view and right anterior oblique (RAO) view. The ablation region located in LV septum and apex; C) the location of the ASD occluder.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6267720/v1/b72be32ef128307a14ff69d2.png"},{"id":82153531,"identity":"8383d6c9-3efc-45b2-b4b1-5ff7bcb39033","added_by":"auto","created_at":"2025-05-07 07:26:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2017908,"visible":true,"origin":"","legend":"\u003cp\u003eA) implantation of the inflow through left anterolateral thoracotomy; B) prosthetic graft anastomosis via a right second intercostal incision; C) the chest X-ray on postoperative day 1.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6267720/v1/b59eb4a731b453f56a51e511.png"},{"id":96650243,"identity":"68072180-0abe-4e63-b1a5-4d4ad4ed0920","added_by":"auto","created_at":"2025-11-24 16:10:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":8818597,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6267720/v1/386f4ce8-05a6-4491-b227-a53cd11c6bb2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Hybrid Catheter Ablation and minimally Invasive LVAD Implantation in a high-risk patient with Refractory Ventricular Tachycardia","fulltext":[{"header":"Background","content":"\u003cp\u003eLVAD has rapidly served as a critical therapeutic option for patients with end-stage heart failure. According to INTERMACS data, nearly 3,000 LVAD implantations are performed annually in the United States[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although heart transplantation remains the gold standard for advanced heart failure, LVADs offer distinct advantages including independence from donor availability, avoidance of immunosuppressive therapy, and the potential for minimally invasive procedures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Several literatures highlight the benefits of minimally invasive LVAD implantation, which reduces surgical trauma, accelerates recovery, and simplifies subsequent bridge-to-transplant surgery[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe suitability of LVAD implantation in patients with preoperative frequent ventricular arrhythmias (VAs) remains controversial. Although the left ventricular unloading provided by LVAD, portative arrhythmias remain a significant cause of LVAD failure or complications in bridge-to-transplant strategies[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. For high-risk patients (INTERMACS profiles 1\u0026ndash;2) with refractory VAs and limited access to donor hearts, LVAD might be a more considerable option.\u003c/p\u003e \u003cp\u003eIn this case, following the multidisciplinary discussion, we performed a one-stage hybrid minimally invasive procedure for a patient with end-stage heart failure and recurrent VT. The outcomes were satisfactory after 15 months follow-up.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 59-year-old female patient was firstly diagnosed with hypertrophic non-obstruction cardiomyopathy ten years ago through echocardiography in her local community hospital. During the period, she received oral medical therapy intermittently to treat heart failure. Three months ago, she was admitted to local hospital because of exacerbated chest distress and dyspnea. The electrocardiogram (ECG) indicated the presence of pathological Q waves and ST-segment elevation in both the inferior and anterior leads. Transthoracic echocardiography (TTE) revealed severe left ventricular systolic dysfunction with an ejection fraction (EF) of 25%, moderate mitral regurgitation. Coronary angiography showed 30% stenosis in the left anterior descending artery.\u003c/p\u003e \u003cp\u003eA month ago, the patient re-admitted to the local hospital for monomorphic ventricular tachycardia (VT). Electrical cardioversion was performed successfully after the failure of the pharmacological conversion. Subsequently, VT is still recurrent (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). The patient rejected the implantation of ICD and was transferred to cardiology department of our hospital for advanced management. 4 days after the admission, the patient was transferred to ICU for mechanical ventilation because of unstable vital sign and recurrent VT. TTE confirmed the severe LV function (EF 16.4%), moderate mitral valve regurgitation and segmental LV hypokinesis. The results of Swan-Ganz results indicated elevated pulmonary artery pressures (40/28 mmHg, mean 32 mmHg), a pulmonary artery wedge pressure of 24 mmHg, and a pulmonary vascular resistance(PVR) of 194 dynes·s/cm⁵. Normal hepatic function and mild renal insufficiency was observed in blood test. CT scan of the chest, brain and peripheral vessel were normal.\u003c/p\u003e \u003cp\u003eHeart transplantation was proposed initially by our multidisciplinary heart team. Panel-reactive antibody-1(PRA-1) was detected as 3.6%, which indicated low-level sensitization and increased the surgical risk of transplantation. Furthermore, her hemodynamic instability and limited donor availability precluded the possibility of the immediate transplantation. LVAD was an available destination treatment with the appropriate right ventricular function and PVR. However, recurrent VT still occur probably after the implantation of the LVAD. According to discussion, our team planned to performed the one-stage VT radiofrequency ablation (RFA) combined with atrial septal defect closure and minimal invasive implantation of the LVAD.\u003c/p\u003e \u003cp\u003eUnder general anesthesia, the patient underwent VT radiofrequency. After the right femoral vein access was established, the transseptal puncture was conducted by using SL1 sheath. Using the CARTO 3D mapping system, the ablation was performed in low-voltage(\u0026lt;0.5mV) zones and fragmented potentials at the left ventricular septum and apical regions(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Ablation power​ was set to ​40W and ​catheter tip temperature​ maintained at ​43°C. ​Substrate-based ablation​ was performed across the critical isthmus regions. After the process, repeated ablation stimulation failed to induce ventricular tachycardia, confirming procedural effectiveness. Subsequently, an 18-24mm ASD occluder was utilized to eliminate right to left shunting induced by transseptal puncture (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003eAfter femoral artery and vein cannulation, a left fifth intercostal incision exposed the ventricular apex and a right second intercostal incision exposed ascending aorta. 3 − 0 Prolene suture was placed at the apex, followed by insertion of the LVAD inflow pump (CH-VAD, BrioHealth Technologies Suzhou) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). The outflow graft was anastomosed to the ascending aorta through the right intercostal incision by using 5 − 0 Prolene suture (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). A subcutaneous tunnel was created for the pump driveline at the right subcostal region. After confirming the stable hemodynamics and normal LVAD flow (3.5L/min and 2700rpm), the patient was transferred to intensive care unit (ICU) with the maintain of low-dose vasoactive drug (norepinephrine 0.05 mg/kg/min and epinephrine 0.03 mg/kg/min). The position of the LVAD demonstrated perfect by the chest X-ray (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). Extubation was performed on postoperative day 2. VT recurrent on postoperative day 4 and it terminated by intravenous amiodarone. VT did not recur during the subsequent hospitalization. The patient was transferred to general ward on day 6 and was discharged on postoperative day 21.\u003c/p\u003e \u003cp\u003e1 month after the discharge, TTE demonstrated stable heart function with the aid of LVAD (3.7L/min and 2700rpm). 4 months after discharge, a 24-hour Holter electrocardiogram indicated that the patient had 12,670 premature ventricular contractions and did not experience sustained VT. β-blocker was used to control arrhythmia. At the 15-mongths follow-up, the patient maintains a good quality of life with no significant complaints.\u003c/p\u003e "},{"header":"Discussion and conclusions","content":"\u003cp\u003eBecause of the shortage of the heart donor, LVAD has gradually became a vital treatment method of end-stage heart failure patients. The 1-year and 3-year survival rates has approached those of heart transplantation.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] However, postoperative ventricular tachyarrhythmias is still a common complication, occurring in 20–50% patient within the first year after the implantation of the LVAD[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The mechanisms underlying the development of VAs in LVAD patients are multifactorial including continue-flow perfusion, presence of pre-existing cardiac conditioning, device-related mechanical stimulation, and so on[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. It has been reported that the recurrent VAs, especially VT or ventricular fibrillation (VF), would adversely affect life quality, survival and heart transplantation rate. Preoperative factors play a significant role in the occurrence of the VAs after the implantation of the LVAD.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eAt present, the treatment methods related to LVAD contain medication therapy, device adjustment and catheter ablation[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Commonly used antiarrhythmic medications include β-adrenergic antagonists and sodium channel blockers[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. It is also crucial to monitor and correct electrolyte abnormalities during pharmacotherapy. Additionally, it is also an effective method to adjust the flow and rotate speed of the LVAD appropriately to improve the filling status of the heart[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIf the patients recurrent VT inducing hemodynamic unstable and low-flow alerts, radiofrequency ablation was considered as an effective method. The morphological analysis of ECG plays a pivotal role in guiding ablation strategies. Monomorphic ventricular tachycardia (VT) typically demonstrating superior efficacy. The timing of RFA is also crucial. Controversies surrounding postoperative RFA include: 1) electromagnetic interference between the LVAD motor and the 3D mapping system;2)The pump thrombosis and the risk of catheter suction into the inflow pump; 3. Limitation of the access route. The data showed that the short-term success rate of the RFA is 80%, while the recurrence rate range from 15–86%.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Pre-LVAD ablation or surgical -ablation concomitant with the initial LVAD implantation may offer benefits for VTs. In a cohort of 10 patients, simultaneous LVAD implantation and VT radiofrequency ablation led to reduced arrhythmia burden postoperatively. The results at 5-month follow-up demonstrated a marked decrease in VT episodes[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Additionally, epicardial ablation[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and cryoballoon ablation[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] were both reported in some particular cases, but they could not be used in minimally invasive approach. However, the two approaches could not be combined with mini-LVAD implantation.\u003c/p\u003e\u003cp\u003eAnother key point of the case needs to discuss is the minimally invasive approach of LVAD, which has constantly increased worldwide[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Mini-LVAD implantation have three approaches: left anterolateral thoracotomy, right anterior thoracotomy or partial sternotomy[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The patients meeting the mini-approach criteria can derive significant clinical benefits[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Recent studies data have demonstrated the benefits of the mini-incision, including reduced infection, improved right ventricular function, reduced bleeding and reduced ICU and hospital stay[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Additionally, the mini-approach could minimize the mediastinal adhesions to simplify the future heart transplantation[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur case successfully adopted a single-stage hybrid minimally invasive treatment strategy. Currently, it is rare to report the hybrid mini-approach. The radiofrequency ablation was preventatively conducted on the patient according to the analysis of ECG and the crisis condition. An ASD closure was placed because of the transseptal puncture to prevent the shunt blood. Finally, minimally invasive approach of the LVAD implantation reduce the surgical trauma. The 15-months follow-up demonstrated the patients' improving quality of life. This clinical result substantiates the procedural efficacy of our hybrid minimally invasive surgical decision.\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cp\u003eLVAD left ventricular assist device\u003c/p\u003e \u003cp\u003eVT ventricular Tachycardia\u003c/p\u003e \u003cp\u003eASD atrial septal defect\u003c/p\u003e \u003cp\u003eVAs ventricular arrhythmias\u003c/p\u003e \u003cp\u003eECG electrocardiogram\u003c/p\u003e \u003cp\u003eTTE Transthoracic echocardiography\u003c/p\u003e \u003cp\u003eEF ejection fraction\u003c/p\u003e \u003cp\u003ePRA-1 Panel-reactive antibody-1\u003c/p\u003e \u003cp\u003eNSVT non-sustained ventricular tachycardia\u003c/p\u003e \u003cp\u003ePVR pulmonary vascular resistance\u003c/p\u003e \u003cp\u003eVF ventricular fibrillation\u003c/p\u003e \u003cp\u003eICU intensive care unit\u003c/p\u003e \u003cp\u003eRFA radiofrequency ablation\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for the publication of this case report\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors approved the publication of the case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXZ and AQD conceived the conception of the study. AQD, MJK and XZ completed the surgical procedure. XZ and MJK contributed to data collection. YQF and JY completed the catheter ablation procedure and contributed the data collection. XZ drafted the original manuscript. MJK and AQD critically reviewed and revised the manuscript draft.\u003c/p\u003e\n\u003cp\u003eAll authors approved the final version of the manuscript to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupported by Key research and development program of Zhejiang Province (2025C02143)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1 Department of Cardiovascular Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China\u003c/p\u003e\n\u003cp\u003e2 Department of Cardiology, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJorde UP, Saeed O, Koehl D, Morris AA, Wood KL, Meyer DM et al. The Society of Thoracic Surgeons Intermacs 2023 Annual Report: Focus on Magnetically Levitated Devices. Ann Thorac Surg. 2024;117:33\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaeed D, Feldman D, Banayosy AE, Birks E, Blume E, Cowger J, et al. The 2023 International Society for Heart and Lung Transplantation Guidelines for Mechanical Circulatory Support: a 10- Year Update. J Heart Lung Transpl. 2023;42:e1\u0026ndash;222.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZubair MH, Brovman EY. Lateral thoracotomy versus sternotomy for left ventricular assist device implantation. Curr Opin Anaesthesiol. 2023;36:25\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed A, Amin M, Boilson BA, Killu AM, Madhavan M. Ventricular Arrhythmias in Patients with Left Ventricular Assist Device (LVAD). Curr Treat Options Cardiovasc Med. 2019;21:75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhandari K, Sama V, Shorbaji K, Witer L, Houston BA, Tedford RJ, et al. Risk Factors for 1-Year Mortality After Heart Transplant in Obese Patients Bridged with an LVAD. Ann Thorac Surg. 2024;117:404\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKataoka N, Imamura T. Catheter Ablation for Tachyarrhythmias in Left Ventricular Assist Device Recipients: Clinical Significance and Technical Tips. J Clin Med 2023;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShi J, Yu X, Liu Z. A Review of New-Onset Ventricular Arrhythmia after Left Ventricular Assist Device Implantation. Cardiology. 2022;147:315\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSisti N, Santoro A, Carreras G, Valente S, Donzelli S, Mandoli GE, et al. Ablation therapy for ventricular arrhythmias in patients with LVAD: Multiple faces of an electrophysiological challenge. J Arrhythm. 2021;37:535\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaradey JA, Singleton MJ, O'Neill TJ, Bhave PD. Management of ventricular arrhythmias in patients with LVAD. Curr Opin Cardiol. 2020;35:289\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaeed D, Feldman D, Banayosy AE, Birks E, Blume E, Cowger J, et al. The 2023 International Society for Heart and Lung Transplantation Guidelines for Mechanical Circulatory Support: a 10- Year Update. J Heart Lung Transpl. 2023;42:e1\u0026ndash;222.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeichl P, Bayes-Genis A, Deneke T, Chioncel O, Deriva M, Crespo-Leiro MG et al. Drug therapy and catheter ablation for management of arrhythmias in continuous flow left ventricular assist device's patients: a Clinical Consensus Statement of the European Heart Rhythm Association and the Heart Failure Association of the ESC. Europace 2024;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson RD, Lee G, Virk S, Bennett RG, Hayward CS, Muthiah K, et al. Catheter Ablation of Ventricular Tachycardia in Patients with a Ventricular Assist Device: a Systematic Review of Procedural Characteristics and Outcomes. JACC Clin Electrophysiol. 2019;5:39\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImamura T, Nguyen A, Chung B, Rodgers D, Sarswat N, Kim G, et al. Association of Inflow Cannula Position with Left Ventricular Unloading and Clinical Outcomes in Patients with HeartMate II Left Ventricular Assist Device. ASAIO J. 2019;65:331\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTankut S, Gosev I, Yoruk A, Younis A, Mcnitt S, Bjelic M, et al. Intraoperative Ventricular Tachycardia Ablation During Left Ventricular Assist Device Implantation in High-Risk Heart Failure Patients. Circ Arrhythm Electrophysiol. 2022;15:e010660.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNishino K, Watanabe M, Ooka T, Sato T, Anzai T. Simultaneous epicardial ablation based on intraoperative electroanatomic mapping during left ventricular assist device implantation. J Arrhythm. 2024;40:632\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang S, Li J, Tan C, Chen M, Hu L, Tang H, et al. Case Report: Left ventricular assist device implantation combined with cryoballoon ablation for ventricular tachycardia. Front Surg. 2024;11:1449007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKocabeyoglu SS, Kervan U, Sert DE, Unal EU, Demirkan B, Guray Y, et al. Is it Possible to Implant HeartMate 3 Less Invasively? New Pump, New Approach. Artif Organs. 2018;42:1132\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRibeiro R, Lee J, Elbatarny M, Friedrich JO, Singh S, Yau T, et al. Left ventricular assist device implantation via lateral thoracotomy: a systematic review and meta-analysis. J Heart Lung Transpl. 2022;41:1440\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSileshi B, O'Hara BK, Davis ME, Haglund NA, Meng X, Deegan R, et al. Outcomes of Patients Implanted Using a Left Thoracotomy Technique for a Miniaturized Centrifugal Continuous-Flow Pump. ASAIO J. 2016;62:539\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRabin J, Ziegler LA, Cipriano S, Madathil RJ, Feller ED, Sorensen EN, et al. Minimally Invasive Left Ventricular Assist Device Insertion Facilitates Subsequent Heart Transplant. Innovations (Phila). 2021;16:157\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6267720/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6267720/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThere remains ongoing controversy regarding the suitability of left ventricular assist device (LVAD) implantation in patients with end-stage heart failure who present with preoperative frequent ventricular arrhythmias. How to implement effective strategies to reduce the occurrence of postoperative ventricular arrhythmias following LVAD implantation has become a key focus of clinical attention.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA 59-year-old woman with hypertrophic cardiomyopathy and end-stage heart failure presented with recurrent Ventricular Tachycardia (VT) resistant to pharmacotherapy and electrical cardioversion. Contraindications to transplantation included hemodynamic instability and panel-reactive antibody sensitization. We adopted a single-stage minimally invasive approach to treat the patient, including VT radiofrequency ablation, atrial septal defect (ASD) closure, and minimally invasive left lateral LVAD implantation. Postoperatively, transient VT recurrence on day 4 resolved with amiodarone. The patient achieved stable hemodynamics, was extubated by day 2, and discharged on day 21. At 15-months follow-up, she maintained improved quality of life with no sustained VT episodes and stable cardiac function\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis case demonstrates the feasibility of the hybrid minimally invasive strategy as a destination or bridge therapy for high-risk patients with refractory arrhythmias and transplant contraindications. Further follow-up is required to evaluate long-term outcomes.\u003c/p\u003e","manuscriptTitle":"Hybrid Catheter Ablation and minimally Invasive LVAD Implantation in a high-risk patient with Refractory Ventricular Tachycardia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 07:25:55","doi":"10.21203/rs.3.rs-6267720/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-25T23:18:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-04T02:16:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-22T22:46:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155057604155195283184938787390054440167","date":"2025-05-18T11:43:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-08T20:02:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-04T23:57:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44604260804007907610648781359171545585","date":"2025-04-30T20:29:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62599070091138527672917485508786347636","date":"2025-04-30T18:57:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1609363499090860759033675364768802335","date":"2025-04-29T17:18:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-29T16:07:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-21T12:42:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-21T12:41:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-03-20T08:26:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d56dafb7-f2dc-4b69-b80e-c32b52e24130","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T16:05:06+00:00","versionOfRecord":{"articleIdentity":"rs-6267720","link":"https://doi.org/10.1186/s13019-025-03696-0","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2025-11-19 15:59:03","publishedOnDateReadable":"November 19th, 2025"},"versionCreatedAt":"2025-05-07 07:25:55","video":"","vorDoi":"10.1186/s13019-025-03696-0","vorDoiUrl":"https://doi.org/10.1186/s13019-025-03696-0","workflowStages":[]},"version":"v1","identity":"rs-6267720","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6267720","identity":"rs-6267720","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}