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Alvarez PA, Sperry BW, Pérez AL, Yaranov DM, Randhawa V, Luthman J, Cantillon DJ, Starling RC. Implantable Cardioverter Defibrillators in Patients With Continuous Flow Left Ventricular Assist Devices: Utilization Patterns, Related Procedures, and Complications. J Am Heart Assoc 2019; 8:e011813. [PMID: 31280637 PMCID: PMC6662142 DOI: 10.1161/jaha.118.011813] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background The effect of implantable cardioverter defibrillators (ICD) in patients with continuous flow left ventricular assist devices (LVADs) on outcomes has not been evaluated in a randomized clinical trial. Methods and Results This is a retrospective single‐center study that included patients who underwent continuous flow LVAD implantation at the Cleveland Clinic between October 2004 and March 2017. Patients were evaluated according to the presence or absence of ICD at the time of LVAD insertion. Among 486 patients in the study cohort, 387 (79.6%) had an ICD before LVAD insertion. Patients with ICD before LVAD were older and had lower use of pre‐LVAD inotropes, extracorporeal membrane oxygenation, and mechanical ventilation. There were 81 patients (21.4% of patients with ICD) who required 93 procedures after LVAD: 74 generator exchanges, 12 lead revisions, and 7 complete system removals because of infection. Of the 99 patients without ICD, 52 (53%) underwent ICD implantation: 29 for primary prevention and 23 for secondary prevention. Patients were followed for a median of 401 (interquartile range 150–966) days. The presence of a pre‐LVAD ICD was not associated with mortality in a multivariable model (hazard ratio 1.19, 95% CI 0.73–1.93, P=0.492), nor was the presence of an ICD at any point when analyzed as a time‐varying covariate (hazard ratio 1.05, 95% CI 0.50–2.20, P=0.907). Conclusions There is no apparent mortality benefit associated with an ICD in a contemporary cohort of patients with continuous flow LVADs to balance considerable morbidity involving ICD‐related procedures and complications.
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Affiliation(s)
- Paulino A Alvarez
- 1 Department of Cardiovascular Medicine Cleveland Clinic Foundation Cleveland OH.,2 Department of Cardiovascular Medicine University of Iowa Iowa City IA
| | - Brett W Sperry
- 1 Department of Cardiovascular Medicine Cleveland Clinic Foundation Cleveland OH.,3 Mid America Heart Institute Saint Luke's Hospital of Kansas City Kansas City MO
| | - Antonio L Pérez
- 1 Department of Cardiovascular Medicine Cleveland Clinic Foundation Cleveland OH
| | - Dmitry M Yaranov
- 1 Department of Cardiovascular Medicine Cleveland Clinic Foundation Cleveland OH
| | - Varinder Randhawa
- 1 Department of Cardiovascular Medicine Cleveland Clinic Foundation Cleveland OH
| | - Jacob Luthman
- 1 Department of Cardiovascular Medicine Cleveland Clinic Foundation Cleveland OH
| | - Daniel J Cantillon
- 1 Department of Cardiovascular Medicine Cleveland Clinic Foundation Cleveland OH
| | - Randall C Starling
- 1 Department of Cardiovascular Medicine Cleveland Clinic Foundation Cleveland OH
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3
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Elkaryoni A, Badarin FA, Khan MS, Ellakany K, Potturi N, Poonia J, Kennedy KF, Magalski A, Sperry BW, Wimmer AP. Implantable cardioverter-defibrillators and survival in advanced heart failure patients with continuous-flow left ventricular assist devices: a systematic review and meta-analysis. Europace 2019; 21:1353-1359. [DOI: 10.1093/europace/euz125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 04/04/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
Implantable cardioverter-defibrillators (ICDs) implantation in heart failure (HF) patients with reduced ejection fraction improves survival by reducing mortality secondary to arrhythmic events. Whether advanced HF patients treated with continuous-flow left ventricular assist devices (CF-LVADs) derive similar benefit is controversial.
Methods and results
We searched PubMed, Cochrane Central Register of Controlled Trials, Embase, and Scopus from inception through November 2018 for studies examining the association between ICD implantation and all-cause mortality in patients with advanced HF and CF-LVADs. Analyses were performed using a random-effects model. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs). Heterogeneity and publication bias were formally assessed, using I2 and funnel plots, respectively. Eight observational studies with a total of 6416 patients (ICD group = 3450, no ICD group = 2966) met inclusion criteria. The majority of patients (84.6%) came from the two largest observational studies. There was no difference in mortality in the ICD and no ICD groups (HR 0.96, 95% CI 0.73–1.27, P = 0.79, I2 = 42%), and ICD implantation post-CF-LVAD was not associated with an improvement in mortality (HR 0.87, 95% CI 0.48–1.57, P = 0.64, I2 = 0%). Additionally, there was no significant difference in the likelihood of transplantation (HR 1.10, 95% CI 0.93–1.30, P = 0.28, I2 = 26%) or non-mortality adverse events between the two groups.
Conclusion
Implantable cardioverter-defibrillator use was not associated with improved survival in advanced HF patients with CF-LVADs. These findings underscore the need to formally study the efficacy of ICDs in this population in a dedicated randomized controlled study.
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Affiliation(s)
- Ahmed Elkaryoni
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Firas Al Badarin
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- Division of Cardiovascular Disease, Saint Luke’s Mid America Heart Institute, 4330 Wornall Road, Ste 2000, Kansas City, MO, USA
| | - Muhammad Shahzeb Khan
- Division of Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, IL, USA
| | - Karim Ellakany
- Division of Cardiovascular Disease, Alexandria University, Alexandria, Egypt
| | - Nikitha Potturi
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Jasmin Poonia
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Kevin F Kennedy
- Division of Cardiovascular Disease, Saint Luke’s Mid America Heart Institute, 4330 Wornall Road, Ste 2000, Kansas City, MO, USA
| | - Anthony Magalski
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- Division of Cardiovascular Disease, Saint Luke’s Mid America Heart Institute, 4330 Wornall Road, Ste 2000, Kansas City, MO, USA
| | - Brett W Sperry
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- Division of Cardiovascular Disease, Saint Luke’s Mid America Heart Institute, 4330 Wornall Road, Ste 2000, Kansas City, MO, USA
| | - Alan P Wimmer
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- Division of Cardiovascular Disease, Saint Luke’s Mid America Heart Institute, 4330 Wornall Road, Ste 2000, Kansas City, MO, USA
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6
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Richardson TD, Hale L, Arteaga C, Xu M, Keebler M, Schlendorf K, Danter M, Shah A, Lindenfeld J, Ellis CR. Prospective Randomized Evaluation of Implantable Cardioverter-Defibrillator Programming in Patients With a Left Ventricular Assist Device. J Am Heart Assoc 2018; 7:JAHA.117.007748. [PMID: 29475875 PMCID: PMC5866326 DOI: 10.1161/jaha.117.007748] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ventricular arrhythmias are common in patients with left ventricular assist devices (LVADs) but are often hemodynamically tolerated. Optimal implantable cardioverter defibrillator (ICD) tachy-programming strategies in patients with LVAD have not been determined. We sought to determine if an ultra-conservative ICD programming strategy in patients with LVAD affects ICD shocks. METHODS AND RESULTS Adult patients with an existing ICD undergoing continuous flow LVAD implantation were randomized to standard ICD programming by their treating physician or an ultra-conservative ICD programming strategy utilizing maximal allowable intervals to detection in the ventricular fibrillation and ventricular tachycardia zones with use of ATP. Patients with cardiac resynchronization therapy (CRT) devices were also randomized to CRT ON or OFF. Patients were followed a minimum of 6 months. The primary outcome was time to first ICD shock. Among the 83 patients studied, we found no statistically significant difference in time to first ICD shock or total ICD shocks between groups. In the ultra-conservative group 16% of patients experienced at least one shock compared with 21% in the control group (P=0.66). There was no difference in mortality, arrhythmic hospitalization, or hospitalization for heart failure. In the 41 patients with CRT ICDs fewer shocks were observed with CRT-ON but this was not statistically significant: 10% of patients with CRT-ON (n=21) versus 38% with CRT-OFF (n=20) received shocks (P=0.08). CONCLUSIONS An ultra-conservative programming strategy did not reduce ICD shocks. Programming restrictions on ventricular tachycardia and ventricular fibrillation zone therapy should be reconsidered for the LVAD population. The role of CRT in patients with LVAD warrants further investigation. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01977703.
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Affiliation(s)
- Travis D Richardson
- Arrhythmia and Electrophysiology, Vanderbilt Heart and Vascular Institute, Nashville, TN
| | - Leslie Hale
- Arrhythmia and Electrophysiology, Vanderbilt Heart and Vascular Institute, Nashville, TN
| | - Christopher Arteaga
- University Centre, St. George's University School of Medicine, Grenada, West Indies
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Mary Keebler
- Advanced Heart Failure, Vanderbilt Heart and Vascular Institute, Nashville, TN
| | - Kelly Schlendorf
- Advanced Heart Failure, Vanderbilt Heart and Vascular Institute, Nashville, TN
| | - Matthew Danter
- Division of Cardiac Surgery, Vanderbilt Heart and Vascular Institute, Nashville, TN
| | - Ashish Shah
- Division of Cardiac Surgery, Vanderbilt Heart and Vascular Institute, Nashville, TN
| | - JoAnn Lindenfeld
- Advanced Heart Failure, Vanderbilt Heart and Vascular Institute, Nashville, TN
| | - Christopher R Ellis
- Arrhythmia and Electrophysiology, Vanderbilt Heart and Vascular Institute, Nashville, TN
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