Atrial Arrhythmias and Electroanatomical Remodeling in Patients With Left Ventricular Assist Devices

Abstract

BackgroundThe incidence, predictors, and impact of atrial arrhythmias along with left atrial structural changes in patients with left ventricular assist devices (LVADs) remain undetermined.Methods and ResultsAll patients who underwent LVAD implantation from 2008 to 2015 at the University of Chicago Medical Center were included. Electronic medical records, electrocardiograms, echocardiograms, and cardiac electrical device interrogations were reviewed. The association of arrhythmias and clinical covariates with survival was evaluated by Kaplan–Meier and Cox proportional hazards analyses. A total of 331 patients were followed for a median of 330 days (range 0–2306 days). Mean age was 57.8±12.8 years, 256 participants (77.3%) were male, mean left ventricular ejection fraction was 20±6.6%, and 124 (37.5%) had ischemic cardiomyopathy. Atrial arrhythmias (53.8%) were highly prevalent and frequently coexisted before LVAD implantation: atrial fibrillation (AF) in 45.9%, atrial flutter in 13.9%, atrial tachycardia in 6.9%, and atrioventricular nodal reentrant tachycardia in 1.2%. New‐onset AF was documented in 14 patients (7.8% of patients without prior AF) after the first 30 days with an LVAD. Increasing age, renal insufficiency, and lung disease were predictors of new‐onset AF after LVAD implantation. Of patients with paroxysmal AF, 43% had no further AF after LVAD. Left atrial size and volume index improved with LVAD (P<0.005). History of persistent AF, atrial tachycardia, ventricular arrhythmia, coronary artery bypass, and low albumin were associated with decreased survival.ConclusionsAtrial arrhythmias are significantly prevalent in patients who require LVAD and are associated with increased mortality; however, LVADs induce favorable atrial structural and electrical remodeling.

Impact of preoperative atrial fibrillation in patients with left ventricular assist device: A systematic review and meta‐analysis

“…It also demonstrated a strong trend toward increased mortality rate, though it did not reach statistical significance. The study by Deshmukh et al reported a similar finding and further categorized patients into a paroxysmal AF group and permanent/persistent AF group. This study noted that a history of persistent/permanent AF was an independent predictor of mortality, while the group with a history of paroxysmal AF was not associated with an increased death rate.…”

“…Almost every patient in the pooled analysis had continuous flow devices. Less than 2% of patients in the study of Deshmukh et al used pulsatile LVADs. A summary of the included studies and clinical characteristics are provided in Table .…”

“…Another study was excluded because it did not provide adequate information to calculate a risk ratio. 11 Seven retrospective observational studies published between 2013 and 2018 [12][13][14][15][16][17][18] were included in this metaanalysis as shown in Table 1. Most of the studies examined patients undergoing LVAD implantation in the United States except for one study which was conducted in Europe (Germany).…”

“…It was postulated that LVAD support might favorably induce atrial remodeling. One study reported a significant portion of patients with preoperative AF never experienced AF after the implantation. LVAD has been reported to induce ventricular remodeling, both through mechanical unloading and through normalization of neurohormonal response to end‐stage heart failure.…”

“…For example, the patients in the LVAD group are at an advanced stage of heart failure, they usually have different hemodynamic profiles and they require anticoagulation with rigorous monitoring after implantation of LVAD. In addition, literature shows that LVAD therapy potentially helps induce atrial and ventricular remodeling …”