Implantable defibrillator therapy for ventricular tachyarrhythmia in left ventricular assist device patients

Oswald, Hanno; Schultz-Wildelau, Claudia; Gardiwal, Ajmal; Lüsebrink, Ulrich; König, Tobias; Meyer, Anna; Duncker, David; Pichlmaier, Maximilian; Klein, Gunnar; Strüber, Martin

doi:10.1093/eurjhf/hfq048

Cited by 95 publications

(93 citation statements)

References 24 publications

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“…Survival, transplantation rates, and hospitalizations were similar during follow‐up. Mortality rates noted in our study are comparable to randomized trials of CF‐LVAD as well as prior studies evaluating ICD therapies in LVADs 1, 2, 6, 19, 20…”

Section: Discussionsupporting

confidence: 87%

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

Gopinathannair

Roukoz

Bhan

et al. 2018

JAHA

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BackgroundMany patients with heart failure continue cardiac resynchronization therapy (CRT) after continuous flow left ventricular assist device (CF‐LVAD) implant. We report the first multicenter study to assess the impact of CRT on clinical outcomes in CF‐LVAD patients.Methods and ResultsAnalysis was performed on 488 patients (58±13 years, 81% male) with an implantable cardioverter defibrillator (ICD) (n=223) or CRT‐D (n=265) who underwent CF‐LVAD implantation at 5 centers from 2007 to 2015. Effects of CRT on mortality, hospitalizations, and ventricular arrhythmia incidence were compared against CF‐LVAD patients with an ICD alone. Baseline differences were noted between the 2 groups in age (60±12 versus 55±14, P<0.001) and QRS duration (159±29 versus 126±34, P=0.001). Median biventricular pacing in the CRT group was 96%. During a median follow‐up of 478 days, Kaplan–Meier analysis showed no difference in survival between groups (log rank P=0.28). Multivariate Cox regression demonstrated no survival benefit with type of device (ICD versus CRT‐D; P=0.16), whereas use of amiodarone was associated with increased mortality (hazard ratio 1.77, 95% confidence interval 1.1–2.8, P=0.01). No differences were noted between CRT and ICD groups in all‐cause (P=0.06) and heart failure (P=0.9) hospitalizations, ventricular arrhythmia incidence (43% versus 39%, P=0.3), or ICD shocks (35% versus 29%, P=0.2). During follow‐up, 69 (26%) patients underwent pulse generator replacement in the CRT‐D group compared with 36 (15.5%) in the ICD group (P=0.003).ConclusionsIn this large, multicenter CF‐LVAD cohort, continued CRT was not associated with improved survival, hospitalizations, incidence of ventricular arrhythmia and ICD therapies, and was related to a significantly higher number of pulse generator changes.

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Section: Discussionsupporting

confidence: 87%

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

Gopinathannair

Roukoz

Bhan

et al. 2018

JAHA

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“…As mentioned, ventricular arrhythmias are among the most common, occurring in 20-50 % of supported patients. [4][5][6][7][8][9] While the greatest risk tends to be in the first month following device implantation, 8 there is a growing body of evidence to suggest that later arrhythmic events are still important. In addition, recurrence following an initial episode is common, 9 making care of affected patients an ongoing and laborious challenge.…”

Section: Epidemiology and Aetiology Of Ventricular Arrhythmias Duringmentioning

confidence: 99%

“…Some investigators have demonstrated greater rates of arrhythmic events among patients with ischaemic heart disease, 10,11 while others have suggested that non-ischaemic patients are at higher risk. 8 The absence of postoperative beta-blocker therapy, 12 prolongation of the baseline QT interval, 13 and deranged serum electrolytes have all been touted as risk factors as well, 11 but none of these have been well validated. In fact, only the presence of pre-implantation ventricular tachycardia (VT) has been repeatedly shown to be a powerful predictor of future episodes of VT after LVAD.…”

Section: Epidemiology and Aetiology Of Ventricular Arrhythmias Duringmentioning

confidence: 99%

“…In fact, only the presence of pre-implantation ventricular tachycardia (VT) has been repeatedly shown to be a powerful predictor of future episodes of VT after LVAD. 4,6,8,9 Mechanisms of Ventricular Arrhythmias in the LVAD Patient Table 2 lists proposed mechanisms for the provocation of arrhythmias during LVAD support. It is not only plausible, but also quite probable that the majority of these conditions do not exist in isolation, but rather may conspire together to trigger an arrhythmic event.…”

Section: Epidemiology and Aetiology Of Ventricular Arrhythmias Duringmentioning

confidence: 99%

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The Burden of Ventricular Arrhythmias Following Left Ventricular Assist Device Implantation

Griffin¹,

Katz²

2014

Arrhythm Electrophysiol Rev

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Prior to the widespread availability of left ventricular assist devices (LVADs), many end-stage heart failure patients were forced to fight over scarce transplant resources or face the reality of impending death. For those considered transplant-ineligible, due to medical or psychosocial factors, symptom palliation and end-of-life care were the only available options. This all changed dramatically following the publication of the landmark Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial, 1 a multicentre investigation designed to determine the impact of a pulsatile LVAD compared with optimal pharmacotherapy in a high-risk cohort of patients with advanced disease. Boasting a remarkable 48 % reduction in mortality with LVAD support, 1 the results of this study promptly ushered in a historic evolution in mechanical circulatory support. Now, little more than a decade after REMATCH was presented, more than 10,000 patients have been implanted with a durable LVAD.2 Novel design changes have ensued, such that modern devices are substantially smaller and no longer pulsatile. By embracing continuous-flow technology, the field has seen incremental gains in patient survival and quality of life. Currently, over 80 % of patients are alive at one year, while two-year survival following device implantation now exceeds 70 per cent. With this in mind, the following review will highlight the epidemiology, symptomatology, complications and management goals for ventricular arrhythmias in the contemporary LVAD era. Evolution of Ventricular Assist Device TherapyFrom a historical perspective, LVADs have evolved considerably in a relatively short period of time. Initial first-generation LVADs were designed to be volume-displacement pumps. They provided pulsatile flow, as a blood-containing chamber would fill and then empty in concert with the heart's native contraction. These pumps were relatively large and required a number of moving parts in order to function optimally.As a result, they were difficult to implant in smaller patients and were prone to wear over time. In order to overcome some of these limitations, second generation LVADs employed continuous-flow technology through the use of an axial rotor. These devices were considerably smaller, could be implanted in a broader population of patients, and demonstrated enhanced durability. In addition, systemic pulsatility was abandoned in exchange for continuous ventricular unloading. Newer third-generation devices -designed with either hydrodynamically-or magnetically-elevated rotors -now provide cardiac support to advanced heart failure patients via centrifugal flow. Though they have only recently been introduced into the marketplace, and are currently the subject of ongoing investigation, implant volumes for these novel LVADs have been AbstractFew innovations in medicine have so convincingly and expeditiously improved patient outcomes more than the development of the left ventricular assist device (LVAD). Where optimal pharma...

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“…54,55 ventricular arrhythmias Ventricular arrhythmias affect at least one third of patients treated with long-term VAD support for advanced HF. 56 Several factors affect the likelihood of ventricular arrhythmias occurring during VAD support. Of these, the most consistently observed risk factor is a history of ventricular arrhythmias prior to initiation of VAD support.…”

Section: Atrial Arrhythmiasmentioning

confidence: 99%

Ventricular assist devices for heart failure: a focus on patient selection and complications

Cipriani¹,

Simone²,

D’Angelo³

et al. 2014

RRCC

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Heart transplantation represents the "gold standard" for the treatment of patients with end-stage heart failure, but remains challenged by inadequate donor supply, finite graft survival, and long-term complications arising from immunosuppressive therapy. In addition, a lot of patients waiting for a heart transplant experience clinical deterioration, and other patients become ineligible to undergo this treatment due to their age or relevant comorbidities. Left ventricular assist devices have emerged as a valid therapeutic option for advanced heart failure. In recent years, we have seen significant advances not only in the technologies available, but also in patient selection, indications for use, and management after implantation. Consequently, there has been an increase in the number of implants and an improvement in the survival rate and quality of life for these patients. At the same time, there are new challenges on the horizon. Patient selection is a difficult process, based on clinical and imaging parameters and risk scores, and more data are needed to refine patient selection criteria and the timing of the implant. Left ventricular assist device-related complications are still a serious problem, causing adverse events and hospital readmissions. Continuous progress in the development of these implantable devices, such as a further reduction in size and hopefully the abolition of the external driveline, will probably make ventricular assist devices an option also for less advanced stages of heart failure. Here, we discuss the current indications for left ventricular assist device implantation, patient selection criteria, and the most frequent complications associated with these devices.

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Implantable defibrillator therapy for ventricular tachyarrhythmia in left ventricular assist device patients

Cited by 95 publications

References 24 publications

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

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

The Burden of Ventricular Arrhythmias Following Left Ventricular Assist Device Implantation

Ventricular assist devices for heart failure: a focus on patient selection and complications

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