Epidemiology, management, and outcomes of sustained ventricular arrhythmias after continuous-flow left ventricular assist device implantation

doi:10.1016/j.ahj.2012.06.018

American Heart Journal

Volume 164, Issue 3, September 2012, Pages 373-378

https://doi.org/10.1016/j.ahj.2012.06.018 Get rights and content

Background

Left ventricular assist devices (LVADs) are pivotal treatment options for patients with end-stage heart failure. Despite robust left ventricular unloading, the right ventricle remains unsupported and susceptible to hemodynamic perturbations from ventricular arrhythmias (VAs). Little is known about the epidemiology, management, resource use, and outcomes of sustained VAs in continuous-flow LVAD patients.

Methods

We reviewed data from all consecutive patients receiving a continuous-flow LVAD at the University of North Carolina from January 2006 to February 2011. Patient demographics, pharmacotherapies, resource use, and outcomes were recorded. Descriptive statistics were generated, and multivariable logistic regression was used to assess the independent association of clinical variables on the development of postimplantation VAs.

Results

Of 61 patients, 26 (43%) had sustained VAs after LVAD. Most were male (65%), had history of hypertension (65%), and had nonischemic cardiomyopathy (62%). Patients with VAs after LVAD more often had preimplant VAs (62% vs 14%, P < .01), prior implantable cardioverter-defibrillator (92% vs 71%, P = .04), and history of implantable cardioverter-defibrillator discharge (38% vs 11%, P < .01). Although length of stay was similar, those with postimplant VAs had greater rehospitalization rates, greater antiarrhythmic drug use, and frequently required external defibrillation. Using multivariable logistic regression, only history of prior VA was associated with postimplant arrhythmias (odds ratio 13.7, P < .001).

Conclusions

Ventricular arrhythmias in LVAD patients are common, often refractory to conservative therapy, and associated with frequent rehospitalization. Post-LVAD VAs, however, did not significantly impact survival or transplantation rates. Arrhythmia burden should be considered before LVAD placement, and future study should focus on the impact of VAs on quality of life.

Section snippets

Methods

We retrospectively reviewed the electronic medical records for all consecutive adult patients receiving a surgically implanted continuous-flow LVAD at the University of North Carolina from January 2006 through February 2011. All patients received either a Heartmate II (Thoratec Corp, Pleasanton, CA) or Jarvik 2000 (Jarvik Heart Inc, New York, NY) device, and all were implanted by cardiac surgeons who had performed at least 25 prior LVAD procedures. Patients were followed up through August 2011

Demographics

Of 61 patients, 26 (43%) had a sustained VA after continuous-flow LVAD implantation. Most patients with postimplant VAs were male (65%), had a history of hypertension (65%), had prior implantable cardioverter-defibrillator (ICD) placement (92%), and had nonischemic cardiomyopathy (62%) (Table I).

A cumulative total of 83 VA episodes were identified among the study population—each affected individual averaged 3 VA events. Of the 26 patients who had VAs after device implantation, 12 patients were

Discussion

Ventricular arrhythmias after continuous-flow LVAD implantation are common. They are often refractory to conservative therapy, are associated with frequent symptoms, and result in increased resource use and hospital readmission. Post-LVAD VAs were observed immediately after device placement in a quarter of our study population, whereas >1 in 10 patients went on to develop new arrhythmic events after hospital discharge. In total, more than one-third of all implanted patients at our institution

References (14)

S.J. Park et al.
Left ventricular assist devices as destination therapy: a new look at survival
J Thorac Cardiovasc Surg
(2005)
E.A. Genovese et al.
Incidence and patterns of adverse event onset during the first 60 days after ventricular assist device implantation
Ann Thorac Surg
(2009)
M. Andersen et al.
Incidence of ventricular arrhythmias in patients on long-term support with a continuous-flow assist device (Heartmate II)
J Heart Lung Transpl
(2009)
A.V. Ambardekar et al.
Implantable cardioverter-defibrillator shocks in patients with a left ventricular assist device
J Heart Lung Transpl
(2010)
O. Ziv et al.
Effects of left ventricular assist device therapy on ventricular arrhythmias
J Am Coll Cardiol
(2005)
M. Bedi et al.
Ventricular arrhythmias during left ventricular assist device support
Am J Cardiol
(2007)
D. Cantillon et al.
Improved survival among ventricular assist device recipients with a concomitant implantable cardioverter-defibrillator
Heart Rhythm
(2010)

There are more references available in the full text version of this article.

Cited by (107)

Meta-Analysis on the Impact of Ventricular Arrhythmias on Mortality in Patients With Continuous Flow Left Ventricular Assist Devices
2023, American Journal of Cardiology
Patients with continuous flow left ventricular assist devices (CFLVADs) have an increased risk of ventricular arrhythmias (VA), but the impact of VA on survival is unclear. A systematic search of electronic databases was conducted to identify studies that reported the impact of VA on all-cause mortality and right ventricular failure (RVF) in patients with CFLVAD. The Mantel–Haenszel method was used to calculate the 95% confidence interval (CI) and pooled risk ratio (RR) with a random-effects model. A total of 19 observational studies with 4,544 patients and a median follow-up of 18.5 months (interquartile range 11.5 to 26.4) were included. There was statistically significantly higher mortality in patients with any VA than in those with no VA after CFLVAD implantation (RR 1.33, 95% CI 1.01 to 1.75, p = 0.04, I² = 78%). On sensitivity analysis, after removing the largest study by Rehorn et al,¹⁰ the association between overall mortality and VA was lost, suggesting that these results should be interpreted with caution. Early VA developing within 30 days after implantation was associated with a higher risk of mortality (RR 1.37, 95% CI 1.15 to 1.63, p <0.01, I² = 52%), whereas late VA developing after 30 days after CFLVAD implantation was not associated with any significant difference in mortality (RR: 1.00; 95% CI: 0.80 to 1.24; p = 0.98, I² = 35%). In addition, there was a statistically significant higher risk of RVF in patients with VA than in those with no VA (RR 1.58, 95% CI 1.20 to 2.08, p <0.01, I² = 0%). In conclusion, in patients with CFLVAD, the development of any VA was associated with a 33% higher risk of all-cause mortality. Early VA developing within 30 days after implantation was significantly associated with a higher risk of mortality, whereas late VA was not associated with mortality. VA after left ventricular assist device was significantly associated with a higher risk of developing RVF.
Transvenous Lead Extraction in the Left Ventricular Assist Device Patient
2023, Cardiac Electrophysiology Clinics
Implantable cardioverter-defibrillator–related procedures and associated complications in continuous flow left ventricular assist device recipients: A multicenter experience
2021, Heart Rhythm O2
Limited data exist regarding complication rates of implantable cardioverter-defibrillators (ICD) and cardiac resynchronization therapy devices (CRT-D) in patients with left ventricular assist devices (LVAD).
We describe the incidence and characteristics of ICD- and CRT-D-related procedures and complications in a multicenter LVAD cohort.
A total of 537 LVAD patients with a pre-existing ICD or CRT-D from 5 centers were included. Details on device type, device therapies, procedural complications, and long-term survival were analyzed.
Of 537 patients, 280 had a CRT-D and 257 had ICD only. During a median follow-up of 538 days, 126 patients underwent generator replacement with significantly higher rate in the CRT group (79 [28.2%] vs 47 [18.3%], P = .0006). Device-related complications occurred in 36 (13%) CRT-D and 20 (8%) ICD patients (P = .06). Incidence of pocket hematoma (3.2% vs 2.7%), infection (4.3% vs 1.6%), and lead malfunction (3.1% vs 2.8%) was similar in both groups, with no effect of device complication on long-term survival (log-rank P = .7). There was a higher incidence of post-LVAD antitachycardia pacing for ventricular arrhythmias in the CRT-D group compared to the ICD group (35% vs 26%, P = .03).
Cardiac implantable electronic device–related procedures are common in LVAD patients. Compared to ICD only, continued CRT-D therapy post-LVAD results in a significantly higher number of generator changes and a trend towards higher device- or lead-related complications. Device-related complications were not associated with reduced survival.
Cardiovascular implantable electronic device therapy in patients with left ventricular assist devices: insights from TRAViATA
2021, International Journal of Cardiology
Citation Excerpt :
Taken together, these results suggest lack of mortality benefit with CIED and potential increased morbidity in those with CRT and CF-LVAD. Ventricular arrhythmias remain common after LVAD implantation, yet there remains uncertainty on the use of continued defibrillator in patients with an LVAD in the absence of randomized-controlled trials. [3] In a recent retrospective multicenter European study from the PCHF-VAD registry involving 448 patients with 54% with pre-existing defibrillator, contrasting results to the present data were reported showing a survival advantage in those patients with a CIED-D vs no defibrillator (HR 0.65, 95% CI 0.46–0.91, p = 0.012) [7].
There is conflicting observational data on the survival benefit cardiac implantable electronic devices (CIED) in patients with LVADs.
Patients in whom an LVAD was implanted between January 2008 and April 2017 in the multinational Trans-Atlantic Registry on VAD and Transplant (TRAViATA) registry were separated into four groups based on the presence of CIED prior to LVAD implantation: none (n = 146), implantable cardiac defibrillator (ICD) (n = 239), cardiac resynchronization without defibrillator (CRT-P) (n = 28), and CRT with defibrillator (CRT-D) (n = 111).
A total of 524 patients (age 52 years ±12, 84.4% male) were followed for 354 (interquartile range: 166–701) days. After multivariable adjustment, there were no differences in survival across the groups. In comparison to no device, only CRT-D was associated with late right ventricular failure (RVF) (hazard ratio 2.85, 95% confidence interval [CI] 1.42–5.72, p = 0.003). There was no difference in risk of early RVF across the groups or risk of ICD shocks between those with ICD and CRT-D.
In a multinational registry of patients with LVADs, there were no differences in survival with respect to CIED subtype. However, patients with a pre-existing CRT-D had a higher likelihood of late RVF suggesting significant long-term morbidity in those with devices capable of LV‑lead pacing post LVAD implantation.
Electrical storm in patients with left ventricular assist devices: Risk factors, incidence, and impact on survival
2021, Heart Rhythm
Ventricular arrhythmias (VAs) and electrical storm (ES) are recognized complications following left ventricular assist device (LVAD) implantation; however, their association with long term-outcomes remains poorly understood.
The purpose of this study was to describe the clinical impact of ES in a population of patients undergoing LVAD implantation at a quaternary care center in the United States.
This was an observational retrospective study of patients undergoing LVAD implantation from 2009 to 2020 at Duke University Hospital. The incidence of ES (≥3 sustained VA episodes over a 24-hour period without an identifiable reversible cause) was determined from patient records. Risk factors for ES were identified using multivariable Cox proportional hazards modeling.
Among 730 patients undergoing LVAD implant, 78 (10.7%) developed ES at a median of 269 (interquartile range [IQR] 7–766) days following surgery. Twenty-seven patients (34.6%) developed ES within 30 days, while 51 (65.4%) presented with ES at a median 639 (IQR 281–1017) days after implant. Following ES, 41% of patients died within 1 year. Patients who developed ES were more likely to have a history of VAs, ventricular tachycardia ablation, antiarrhythmic drug use, and perioperative mechanical circulatory support around the time of LVAD implant than patients without ES.
ES occurs in 1 in 10 patients after LVAD and is associated with higher mortality. Risk factors for ES include a history of VAs, VT ablation, antiarrhythmic drug use, and perioperative mechanical circulatory support. Optimal management of ES surrounding LVAD implant, including escalation of medical therapy, catheter ablation, or adjunctive sympatholytic therapies, remains uncertain.
Open Chest Epicardial VT Ablation After LVAD: Ounce of Prevention or Pound of Cure?
2021, JACC: Case Reports

View all citing articles on Scopus

View full text

Clinical InvestigationCongetive Hearth FailureEpidemiology, management, and outcomes of sustained ventricular arrhythmias after continuous-flow left ventricular assist device implantation

Background

Methods

Results

Conclusions

Section snippets

Methods

Demographics

Discussion

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Heart Lung Transpl

J Heart Lung Transpl

J Am Coll Cardiol

Am J Cardiol

Heart Rhythm

Clinical Investigation
Congetive Hearth Failure
Epidemiology, management, and outcomes of sustained ventricular arrhythmias after continuous-flow left ventricular assist device implantation