Ventricular arrhythmia ablation with different mechanical circulatory support platforms: a Bayesian network meta-analysis

Background Catheter ablation treats ventricular tachycardia (VT) and electrical storm, but unstable VT often precludes activation mapping and may trigger acute hemodynamic decompensation (AHD). Temporary mechanical circulatory support (tMCS) is used in high-risk cases, yet device-specific comparative data are limited. Objective Compare tMCS strategies for VT/electrical storm ablation in patients at high risk of AHD. Methods Systematic review and Bayesian network meta-analysis of observational cohorts comparing veno-arterial extracorporeal membrane oxygenation (V-A ECMO), percutaneous LV assist devices (Impella/TandemHeart), intra-aortic balloon pump (IABP), and no tMCS. Co-primary outcomes were intraprocedural AHD and ventricular arrhythmia (VA) recurrence rate at follow up; secondary outcomes were post-ablation VT inducibility at electrophysiologic study and major periprocedural complications and procedure time. Results Eleven studies (n=1076; 88% male; mean LVEF 29%, 95%CI 27–31%) were included; Impella represented 76% of supported cases. Versus no tMCS, V-A ECMO was associated with lower AHD (OR 0.014, 95%CrI 0.0001–0.264), lower VA recurrence rate (IRR 0.26, 95%CrI 0.08–0.70), and reduced post-ablation inducibility (OR 0.015, 95%CrI 0.0005–0.307). Impella was associated with higher major complications versus no tMCS (OR 4.33, 95%CrI 1.14–28.81). TandemHeart resulted significantly longer procedure time versus no tMCS (MD +104 min, 95%CrI 12–185). Conclusion In selected high-risk patients, within the available network, estimates for V-A ECMO favored lower risks of AHD and VA recurrence, whereas complication risk appeared higher with Impella. Nevertheless, the low certainty of evidence, substantial clinical heterogeneity and multiplicity of exploratory analyses preclude definitive treatment recommendations, underscoring the need for prospective randomized investigations.