Prognostic Impact of Implantable Cardioverter Defibrillators in Patients with Continuous Flow Left Ventricular Assist Devices

Abstract

Purpose Preventative implantation of implantable cardioverter defibrillators (ICD) improves survival of symptomatic heart failure (HF) patients with reduced left ventricular ejection fraction. Nevertheless, the prognostic impact of ICD therapy in continuous flow left ventricular assist device (LVAD) recipients remains controversial. Methods 162 consecutive HF patients underwent LVAD implantation at our institution between 2010 and 2019. All patients were evaluated according to the presence (n=94, ICD-group) or absence (n=68, Control-group) of ICDs prior to LVAD implantation. Apart from clinical baseline and follow-up parameters, adverse events related to ICD therapy and overall survival rates were retrospectively analyzed. Results Predominantly male patients (87.0%) with a median age of 57 (48.8-64.0) years were mainly treated with the Medtronic HVAD device (87.0%). Ischemic cardiomyopathy (60.3% vs. 38.3%, p=0.007) and severe HF symptoms (e.g., NYHA-class IV 85.5% vs. 59.6%, p=0.001) were more prevalent within the Control-group. Furthermore, the preoperative use of short-term circulatory support devices (e.g., IABP, ECMO, Impella) was higher within the Control-group (54.4% vs. 13.8%, p <0.001). Nevertheless, baseline severity of LV and RV dysfunction (LVEF 20%, TAPSE 15mm; p=0.87) was similar. Apart from an increased rate of temporary RVAD implantation within the Control-group (45.6% vs. 17.0%; p<0.001), procedural characteristics and 30-day mortality rates were comparable. Furthermore, overall-survival during a median follow-up of 14 (3.0-36.5) months was similar within both study-groups (35.1% ICD-group vs. 33.8% Control-group; p=0.46). During the first 2 years after LVAD implantation 49 ICD-related adverse events occurred within the ICD-group. Thereof, lead-dysfunction occurred in 18 patients and unplanned ICD-reintervention in 10 patients. Furthermore, in 16 patients adequate, but awake shocks occurred, whereas inadequate shocks occurred in 5 patients. Conclusion ICD therapy in LVAD recipients was not associated with a survival benefit or reduced morbidity after LVAD implantation. Furthermore, in the majority of LVAD recipients ICD-related adverse events occurred during follow-up. A randomized controlled trial is essential to elucidate the role of ICD therapy in LVAD recipients. Preventative implantation of implantable cardioverter defibrillators (ICD) improves survival of symptomatic heart failure (HF) patients with reduced left ventricular ejection fraction. Nevertheless, the prognostic impact of ICD therapy in continuous flow left ventricular assist device (LVAD) recipients remains controversial. 162 consecutive HF patients underwent LVAD implantation at our institution between 2010 and 2019. All patients were evaluated according to the presence (n=94, ICD-group) or absence (n=68, Control-group) of ICDs prior to LVAD implantation. Apart from clinical baseline and follow-up parameters, adverse events related to ICD therapy and overall survival rates were retrospectively analyzed. Predominantly male patients (87.0%) with a median age of 57 (48.8-64.0) years were mainly treated with the Medtronic HVAD device (87.0%). Ischemic cardiomyopathy (60.3% vs. 38.3%, p=0.007) and severe HF symptoms (e.g., NYHA-class IV 85.5% vs. 59.6%, p=0.001) were more prevalent within the Control-group. Furthermore, the preoperative use of short-term circulatory support devices (e.g., IABP, ECMO, Impella) was higher within the Control-group (54.4% vs. 13.8%, p <0.001). Nevertheless, baseline severity of LV and RV dysfunction (LVEF 20%, TAPSE 15mm; p=0.87) was similar. Apart from an increased rate of temporary RVAD implantation within the Control-group (45.6% vs. 17.0%; p<0.001), procedural characteristics and 30-day mortality rates were comparable. Furthermore, overall-survival during a median follow-up of 14 (3.0-36.5) months was similar within both study-groups (35.1% ICD-group vs. 33.8% Control-group; p=0.46). During the first 2 years after LVAD implantation 49 ICD-related adverse events occurred within the ICD-group. Thereof, lead-dysfunction occurred in 18 patients and unplanned ICD-reintervention in 10 patients. Furthermore, in 16 patients adequate, but awake shocks occurred, whereas inadequate shocks occurred in 5 patients. ICD therapy in LVAD recipients was not associated with a survival benefit or reduced morbidity after LVAD implantation. Furthermore, in the majority of LVAD recipients ICD-related adverse events occurred during follow-up. A randomized controlled trial is essential to elucidate the role of ICD therapy in LVAD recipients.