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Ventricular Arrhythmias in Left Ventricular Assist Device Patients with Implantable
Cardioverter Defibrillators
Erika Stahl, RN,BSN, Sunil Pauwaa, M.D., Sejal Modi, C.C.P., Pat Pappas, M.D., Antone Tatooles, M.D. and Geetha Bhat, Ph.D., M.D.
The Center for Heart Transplant and Assist Devices,
Advocate Christ Medical Center, Oak Lawn, Illinois, United States, 60453.
Title: Ventricular Arrhythmias in Left Ventricular Assist Device Patients with Implantable Cardioverter
Defibrillators
Table 1. LVAD Patients Requiring ICD Therapy
Erika Stahl, RN,BSN1, Sunil Pauwaa, M.D.1, Sejal Modi, C.C.P.1, Pat Pappas, M.D.1, Antone
Tatooles, M.D.1 and Geetha Bhat, Ph.D., M.D.1. 1The Center for Heart Transplant and Assist Devices,
Advocate Christ Medical Center, Oak Lawn, Illinois, United States, 60453.
Body: Introduction: Most patients undergoing left ventricular assist device (LVAD) implantation for
destination therapy (DT) also have an implantable cardioverter defibrillator (ICD). The incidence of
ventricular arrhythmias (VA) requiring ICD therapies in patients post-LVAD is not well described, nor
is the role of ICDs post-LVAD.
Purpose: The purpose of our study was to determine the incidence of VAs requiring ICD therapies
(anti-tachycardia pacing (ATP) and/or defibrillator shock) after LVAD implant.
Patient (#)
Type of VA
Time Post-LVAD (days)
ICD Therapy
1 (HM XVE)
3 (HMII)
4 (HMII)
VT
VT
VT/VF
VT/VF
VT
VT
VT
VT/VF
VT/VF
VT
5
25
98
546
567
589
591
643
48
271
ATP
ATP/Shock
Shock x 8
ATP/Shock
ATP
ATP/Shock
ATP
Shock
Shock
ATP
5 (HMII)
VT
9
ATP/Shock x 6
2 (HMII)
Methods: Retrospective chart review was performed in 62 patients (84% male, 53% ischemic
etiology, 19% mean ejection fraction) who underwent LVAD implant for DT from 2005 to 2008. ICDs
were present in 52/62 (84%) patients pre-LVAD. Patients with simultaneous LVAD and ICD support
were evaluated for significant VA occurrence. Significant VAs were defined as any ventricular
tachycardia (VT) or ventricular fibrillation (VF) episodes requiring ICD therapy (ATP or shock) as
confirmed by device interrogation reports.
Results:
The mean duration of LVAD support at VA occurrence was 213 days (range 3-591). At discharge
after LVAD, 69% were on amiodarone and 79% were on beta blockers.
ICD therapies were required in 9/52 (16%) patients for VAs (Table 1).
Table 1. LVAD Patients Requiring ICD Therapy
Patient (#)
Type of VA
Time Post-LVAD (days)
ICD Therapy
1
VT
5
Shock
VT
11
ATP
VT
25
ATP/Shock
VT/VF
98
Shock x 8
VT/VF
546
ATP/Shock
VT
567
ATP
VT
589
ATP/Shock
VT
591
ATP
3
VT/VF
48
Shock
4
VT
271
ATP
5
VT
9
ATP/Shock x 6
6
VF
265
Shock
7
VT/VF
461
ATP/Shock
8
VT
118
ATP/Shock
9
VT
3
Shock x 2
VT
5
Shock
VT
6
Shock
2
Conclusion: Our experience shows that 16% of LVAD patients have significant VA requiring ICD
therapies despite left ventricular support. ICDs in post-LVAD patients appear to have a role in the
treatment of these VA. Further studies are necessary to determine if ICDs should be implanted as
standard of care in LVAD candidates prior to discharge.
Introduction
Most patients undergoing left ventricular assist
device (LVAD) implantation for destination therapy (DT)
also have an implantable cardioverter defibrillator
(ICD). Ventricular arrhythmias (VAs) are of unclear
clinical significance in patients with LVADs; as such the
exact role for ICDs in patients with LVADs has yet to be
determined.
The purpose of our study was to determine the
incidence of VAs requiring ICD therapies (antitachycardia pacing (ATP) and/or defibrillator shock)
after LVAD implantation.
Materials and Methods
6 (HMII)
7 (HMII)
8 (HM XVE)
9 (HMII)
VF
VT/VF
VT
VT
VT
VT
265
461
118
3
5
6
Shock
ATP/Shock
ATP/Shock
Shock x 2
Shock
Shock
Caucasian
African American
Average Age at time of first implant
Number of years of HF prior to LVAD
Type of LVAD at time of firing
Pre-LVAD EF
Etiology of HF
Ischemic
Non-ischemic
History of Ventricular Arrhythmias
(Prior to LVAD implant)
Post-VAD medications
Amiodarone
Beta-Blocker
Average time of follow up from LVAD implantation.
Results
The mean duration of LVAD support at VA
occurrence was 213 days. At discharge after LVAD, 69%
were on amiodarone and 79% were on beta blockers.
ICD therapies were required in 9/52 (16%) patients
for VAs (Table 1).
Conclusions and
Recommendations
A number of conclusions are suggested by the
results of our study.
Table 2. Patient Information
Males
Race
Retrospective chart review was performed in 62 patients
(84% male, 53% ischemic etiology, 19% mean ejection
fraction) who underwent LVAD implant for DT from 2005 to
2008. ICDs were present in 52/62 (84%) patients pre-LVAD.
Patients with simultaneous LVAD and ICD support were
evaluated for significant VA occurrence. Significant VAs were
defined as any ventricular tachycardia (VT) or ventricular
fibrillation (VF) episodes requiring ICD therapy (ATP or
shock) as confirmed by device interrogation reports.
VA (n=9)
8/9 (88.90%)
No VA (n=43)
36/43 (83.70%)
66.70%
33.30%
54 years old
88.9% > 1year
7 HMII (77.8%)
2 HM XVE (22.2%)
17.30%
53.50%
37.20%
64.8 years old
93.0% > 1 year
55.60%
44.40%
48.80%
51.20%
N/A
18.70%
66.70%
67.40%
77.80%
88.90%
600.3 days
57.90%
78.90%
737.8 days
ICD therapy can be safely used in combination with
LVADs. In our entire series, despite the fact that the
majority of LVAD patients had ICDs present at the time
of LVAD implantation, we did not have a single episode
of ICD or LVAD malfunction resulting from the interaction
between the two devices. Furthermore, in the patients
that had VAs requiring ICD therapy, the LVAD did not
interfere with proper ICD function.
Despite LVAD therapy, a significant number of
patients in our series did experience VAs (16%) and
were successfully treated by their ICDs.
The majority of ICD therapies occurred either very
early or late post-LVAD implantation. 47% of total VAs
occurred at <1 month, and 35% of total VAs occurred at
>6 months after LVAD.
Overall, further studies with larger numbers of
patients done in a prospective fashion are necessary to
determine if ICDs should be implanted as standard of
care in LVAD candidates prior to discharge, however at
this time it would appear that ICDs can safely and
feasibly be used in LVAD patients and that they do serve
a purpose in treating VAs in these patients.