**5.2 Catheter ablation**

Catheter ablation of atrial arrhythmias in adult patients with heart failure has been proven to be feasible and effective [29, 49, 50]. Atrial fibrillation in setting of VAD therapy treated with catheter ablation has been associated with improved symptoms and cardiac function. Studies have demonstrated return to sinus rhythm, resolution of symptoms, and resolution of right heart failure with catheter ablation of atrial flutter in patients with VAD. No significant procedural complications or adverse events have been reported in this patient population, suggesting that radiofrequency catheter ablation of atrial arrhythmias in patients with VAD may be a reasonable first-line therapy. There are no similar data available in pediatric patients.

There have been no large studies investigating the role of catheter ablation in ventricular arrhythmias in pediatric patients with LVADs. There are a handful of adult case series and cohort studies documenting experience with 101 patients total [25]. These studies demonstrated relatively high procedural success (77–86%) with variable recurrence. One study demonstrated improved one year survival in the absence of arrhythmia recurrence [51]. It must be noted that there are specific considerations necessary for ablations in this patient population. They will require strict fluid management, invasive hemodynamic monitoring, and special care maneuvering in the vicinity of the cannula. Additionally, there may be effects on electroanatomic mapping and signal quality. Surgical ablation at the time of LVAD implant may be considered and is a class IIb indication in the 2017 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death [35]. Again, there are no published pediatric studies examining ventricular catheter ablations in patients with VADs.
