Implantable cardioverter defibrillators in patients with orthotopic heart transplant: A multicenter case series

Abstract

Background Sudden cardiac death (SCD) is common after orthotopic heart transplant (OHT). No clear guidelines for implantable cardioverter defibrillator (ICD) implantation in OHT patients at high risk for SCD currently exist. Objectives To assess the safety, efficacy, and benefit of ICDs and resynchronization therapy post‐OHT. We also provide a systematic review of previous reports. Methods A retrospective multicenter cohort study within the United States. Patients with ICD post‐OHT between 2000 and 2020 were identified. Results We analyzed 16 patients from 4 centers. The mean standard‐deviation (SD) age was 43 (18) years at OHT and 51 (20) years at ICD implantation. The mean (SD) duration from OHT to ICD implantation was 9 (5) years. The mean (SD) left ventricular ejection fraction (LVEF) was 35% (17%). There were 2 (13%) postprocedural complications: 1 hematoma and 1 death. Mean (SD) follow‐up was 24 (23) months. Survival rate was 63% (10/16) at 1 year and 56% (9/16) at 2 years, with 6/7 of those who died having LVEF < 35% at the time of the ICD implantation. Patients were more likely to receive appropriate therapy if their ICD was implanted for secondary (5/8) rather than primary (0/8) prevention (p = .007). Of those who did, 4 patients survived to 30 days post‐ICD therapy. Severe CAV was not associated with the rate of appropriate therapy. Conclusions Beneficial outcomes were observed when ICDs were implanted for secondary prevention only, and in patients with higher baseline LVEF. We also observed benefits with resynchronization therapy.

Defibrillators in heart transplant patients: Not always a shockingly good choice

“…The ICD implantation procedure itself carries unique risks for the OHT patient including: the comorbidities and frailty associated with having a chronic disease (transplantation), immunosuppression which may increase the risk of infection, and the fact that many OHT patients have had previous cardiac implantable electronic devices which may have been completely or only partially extracted at the time of their transplant, complicating vascular access. Maskoun et al, 5 were able to show the feasibility of ICD implantation in their OHT patients, albeit with a procedural complication rate somewhat higher than usually noted 12.5% versus <6% in the pivotal studies, 1-3 and one death. In two patients a right-sided approach was necessary because of access problems related to previous device extractions.…”

“…8 This may be related to the role of the sympathetic nervous system in such ventricular arrhythmias and the fact that, perhaps, the denervated transplanted heart might be more resistant to them, conferring less benefit from an ICD. Lastly, 37.5% of all of the OHT patients in Maskoun et al's 5 study, and fully 66.6% of those with an LVEF ≤ 35% were dead within a year of their ICD implantation, and even among those receiving appropriate therapy, 60% were dead within a year of that therapy. These numbers are significantly higher than those of Tsai et al, who noted a mortality rate of 11% after 51 ± 26 months of follow-up in OHT patients with ICDs, 6 which would be in line with general primary and secondary prevention studies [1][2][3] but does include three patients who underwent second heart transplants and does not look specifically at patients with a reduced EF.…”

“…It has not been clear how the more general guidance applies to this group and there is an important caveat for all of these recommendations: that the patient has an expected meaningful survival of greater than 1 year. 4 In this issue of the Journal of Cardiovascular Electrophysiology, Maskoun et al, 5 attempt to further clarify the safety, feasibility, and benefit of ICDs in patients who have previously undergone OHT. This is a small multicenter study involving 16 patients who were 9 ± 5 years post OHT at the time of ICD placement.…”

“…In this issue of the Journal of Cardiovascular Electrophysiology , Maskoun et al, 5 attempt to further clarify the safety, feasibility, and benefit of ICDs in patients who have previously undergone OHT. This is a small multicenter study involving 16 patients who were 9 ± 5 years post OHT at the time of ICD placement.…”