The Role of Implantable Cardioverter-Defibrillators in Patients With Continuous Flow Left Ventricular Assist Devices

Abstract

Background— The prognosis for patients experiencing ventricular arrhythmias (VAs) while on continuous flow left ventricular assist device (LVAD) support has not been well elucidated. Accordingly, the role of implantable cardioverter-defibrillators (ICDs) in this patient population remains undefined. Methods and Results— Records of 106 consecutive patients undergoing implantation of the HeartMate II LVAD at a single center were reviewed. For patients surviving >30 days postimplant (98 patients), the impact of VAs and ICDs on survival was analyzed. Mean age was 56.6±11.4 years, 82.1% were male, 42.5% had an ischemic cardiomyopathy, 87.7% were bridge to transplantation, and median length of support was 217 days. Twenty-one (19.8%) patients died, 60 (56.6%) survived to transplantation, and 25 patients (23.6%) reached the end of study, had the LVAD explanted, or were lost to follow-up. Post-LVAD VAs occurred in 37 patients (34.9%) but were not associated with increased mortality (hazard ratio, 0.58 [0.18–1.90]). Sixty-two (63.3%) patients had an active ICD, and 36 (36.7%) patients had no ICD or an inactivated ICD post-LVAD. Patients with an ICD were more likely to be INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) level 3 or 4 at the time of implant (54.8% versus 33.3%; P =0.04). An appropriate shock was delivered in 27.3% of patients, but the presence of an active ICD was not associated with improved survival (hazard ratio, 1.12 [0.37–3.35]). Conclusions— VAs are common in patients with continuous flow LVADs. Although some episodes may be clinically significant, VAs are not associated with a worse prognosis, and concomitant ICDs in these patients may not reduce mortality.

Cardiac Resynchronization Therapy and Clinical Outcomes in Continuous Flow Left Ventricular Assist Device Recipients

“…Incidence of VA (defined as sustained ventricular tachyarrhythmias lasting >30 s or requiring ICD therapy) and ICD shocks following CF‐LVAD implantation in our study was comparable to the previous studies evaluating this 6, 21, 22, 27, 29. However, in contrast to the prior study from Schleifer et al,14 we did not observe any significant reduction in the incidence of VA or ICD shocks in the CRT group.…”

Implantable Cardioverter-defibrillator Therapy in the Patient with a Left Ventricular Assist Device: Still a Black Box

“…Several retrospective evaluations have suggested a survival benefit for ICD therapy in patients with LVAD support, 9,10 while others have not come to this conclusion. [11][12][13][14] Two meta-analyses have been performed in recent years that may provide insight into the disparity of these results. One analysis performed by Vakil et al examined six observational studies encompassing data from 937 patients, 93% of whom had LVAD therapy as a bridge to transplantation, 39% of whom had a continuous-flow (CF) device, and 38% of whom had an ICD in place.…”

Is there a need for an implantable cardioverter defibrillator in patients with left ventricular assist devices? Time for MADIT-VAD!

“…Data on patients with continuous flow LVADs are more scarce. Enriquez et al [14] investigated the effects of ICD in 98 LVAD recipients followed for 7 months. They had 63% of their LVAD patients implanted with an ICD prior to LVAD, with no apparent survival benefit in the ICD group.…”