ICD Therapy Confers No Survival Advantage in a Global LVAD Population: Insights from the Trans-Atlantic Registry on VAD and Transplant (TRAViATA)

Abstract

There are conflicting data related to the use of implantable cardioverter-defibrillators (ICDs) in patients supported with continuous-flow ventricular assist devices (LVADs). Several US studies have shown a neutral effect on mortality, whereas a recent European study suggested better outcomes in LVAD patients who have an ICD. We aimed to investigate the benefit of ICDs in patients bridged to transplant with a LVAD in the TRans-Atlantic registry on VAd and TrAnsplant (TRAViATA). Data from consecutive patients that received a LVAD as a bridge to transplantation between January 2008 and April 2017 were collected in 7 EU (n=299) and 3 US centers (n=225). Survival analysis was performed using Kaplan-Meier and Cox proportion hazard regression analysis. Patients were censored at time of transplantation. Patients with an ICD at the time of LVAD (n=350) implantation were older (56 vs. 53 years, p<0.05), less likely to be female (13% vs. 21%, p<0.05) and to have ischemic cardiomyopathy (39% vs. 52%, p<0.05) compared to patients without an ICD (n=174). The proportion of patients with an ICD/LVAD was 66% in the EU and 68% in the US (p=0.49). Overall survival after LVAD was 86% at one year and 76% at two years. There was no difference in survival in patients with and without an ICD (Figure). These results were consistent when analyzing patients from each continent separately (Figure). In univariate Cox-regression age at time of implant and INTERMACS profile were associated with mortality (p<0.05) whereas presence of ICD was not. Sensitivity analysis excluding patients who received their ICD (n=25) after LVAD confirmed the results. In this retrospective study of LVAD patients from the EU and US ICD therapy conferred no survival advantage irrespective of geographic location. A prospective, randomized, trial of LVAD patients who have an existing ICD randomized to tachyarrhythmia therapy discontinuation is needed to validate these findings.