Outcomes of a PAINESD score–guided multidisciplinary management approach for patients with ventricular tachycardia storm and advanced heart failure: A pilot study

The management of electrical storm from ventricular tachycardia (VT-ES) in patients with structural heart disease and advanced heart failure (advanced HF) is challenging. In addition to refractory VT, the downstream sequelae of VT-ES in patients with advanced HF include further worsening of pump function and end-organ damage, often leading to early mortality. 1 Santangeli P. Frankel D.S. Tung R. et al. Early mortality after catheter ablation of ventricular tachycardia in patients with structural heart disease. J Am Coll Cardiol. 2017; 69: 2105-2115 Crossref PubMed Scopus (101) Google Scholar , 2 Santangeli P. Muser D. Zado E.S. et al. Acute hemodynamic decompensation during catheter ablation of scar-related VT: incidence, predictors and impact on mortality. Circ Arrhythm Electrophysiol. 2015; 8: 68-75 Crossref PubMed Scopus (116) Google Scholar , 3 Mathuria N. Wu G. Rojas-Delgado F. et al. Outcomes of pre-emptive and rescue use of percutaneous left ventricular assist device in patients with structural heart disease undergoing catheter ablation of ventricular tachycardia. J Interv Card Electrophysiol. 2017; 48: 27-34 Crossref PubMed Scopus (56) Google Scholar , 4 Vergara P. Tung R. Vaseghi M. et al. Successful ventricular tachycardia ablation in patients with electrical storm reduces recurrences and improves survival. Heart Rhythm. 2018; 15: 48-55 Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar Catheter ablation is an important strategy in the management of drug-refractory VT-ES but carries a high risk of periprocedural morbidity and adverse outcomes. 4 Vergara P. Tung R. Vaseghi M. et al. Successful ventricular tachycardia ablation in patients with electrical storm reduces recurrences and improves survival. Heart Rhythm. 2018; 15: 48-55 Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar ,5 Muser D. Liang J.J. Pathak R.K. et al. Long-term outcomes of catheter ablation of electrical storm in nonischemic dilated cardiomyopathy compared with ischemic cardiomyopathy. JACC Clin Electrophysiol. 2017; 3: 767-778 Crossref PubMed Scopus (61) Google Scholar In particular, the occurrence of periprocedural acute hemodynamic decompensation (AHD) is a major concern owing to its significant association with short-term postprocedural mortality. 1 Santangeli P. Frankel D.S. Tung R. et al. Early mortality after catheter ablation of ventricular tachycardia in patients with structural heart disease. J Am Coll Cardiol. 2017; 69: 2105-2115 Crossref PubMed Scopus (101) Google Scholar ,2 Santangeli P. Muser D. Zado E.S. et al. Acute hemodynamic decompensation during catheter ablation of scar-related VT: incidence, predictors and impact on mortality. Circ Arrhythm Electrophysiol. 2015; 8: 68-75 Crossref PubMed Scopus (116) Google Scholar ,6 Enriquez A. Liang J. Gentile J. et al. Outcomes of rescue cardiopulmonary support for periprocedural acute hemodynamic decompensation in patients undergoing catheter ablation of electrical storm. Heart. 2018; 15: 75-80 Google Scholar The PAINESD risk score has been developed and validated in independent cohorts as a predictor of periprocedural AHD and adverse postprocedural outcomes and may help identify patients with advanced HF undergoing VT ablation who may derive the greater benefit from preprocedural hemodynamic optimization and periprocedural mechanical hemodynamic support. 2 Santangeli P. Muser D. Zado E.S. et al. Acute hemodynamic decompensation during catheter ablation of scar-related VT: incidence, predictors and impact on mortality. Circ Arrhythm Electrophysiol. 2015; 8: 68-75 Crossref PubMed Scopus (116) Google Scholar ,3 Mathuria N. Wu G. Rojas-Delgado F. et al. Outcomes of pre-emptive and rescue use of percutaneous left ventricular assist device in patients with structural heart disease undergoing catheter ablation of ventricular tachycardia. J Interv Card Electrophysiol. 2017; 48: 27-34 Crossref PubMed Scopus (56) Google Scholar ,7 Muser D. Liang J.J. Castro S.A. et al. Outcomes with prophylactic use of percutaneous left ventricular assist devices in high-risk patients undergoing catheter ablation of scar-related ventricular tachycardia: a propensity-score matched analysis. Heart Rhythm. 2018; 15: 1500-1506 Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar ,8 Baratto F. Pappalardo F. Oloriz T. et al. Extracorporeal membrane oxygenation for hemodynamic support of ventricular tachycardia ablation. Circ Arrhythm Electrophysiol. 2016; 9e004492 Crossref PubMed Scopus (84) Google Scholar We have previously reported our institutional outcomes with rescue circulatory support with extracorporeal membrane oxygenation (ECMO) in patients with advanced HF and VT-ES in whom periprocedural AHD occurred 6 Enriquez A. Liang J. Gentile J. et al. Outcomes of rescue cardiopulmonary support for periprocedural acute hemodynamic decompensation in patients undergoing catheter ablation of electrical storm. Heart. 2018; 15: 75-80 Google Scholar and documented a 76% mortality rate at a median follow-up of 10 days postprocedure, with 62% of patients dying during the same hospital admission. A retrospective calculation of the PAINESD score in these patients confirmed a baseline high risk profile in all cases (ie, PAINESD score > 17); in that study, however, the PAINESD score was not used as a tool to guide pre- and intraprocedural management. In response to these findings, we have developed and implemented a multidisciplinary management pathway for patients with advanced HF and VT-ES with high PAINESD scores (>17), which involves collaboration between cardiac electrophysiologists, advanced HF specialists, and cardiothoracic surgeons, and evaluated this approach in the context of a pilot study.