Survival Benefit of Implantable Cardioverter Defibrillator Therapy on Patients with Left Ventricular Assist Device

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The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017

A.R. Garan ,1 X. Mai,1 V.K. Topkara,1 K. Takeda,1 K.J. Clerkin,1 R. Demmer,1 M. Yuzefpolskaya,1 H. Takayama,1 Y. Naka,1 J. Chyou,2 H.M. Spotnitz,1 N. Uriel,3 J. Dizon,1 P.C. Colombo.1  1Columbia University, New York, NY; 2SUNY Stonybrook, Stonybrook, NY; 3University of Chicago, Chicago, IL. Purpose: QRS prolongation predicts poor outcomes in heart failure (HF). Both cardiac resynchronization therapy (CRT) and continuous-flow left ventricular assist device (CF-LVADs) improve survival in advanced HF but CRT’s effects after CF-LVAD implant are poorly defined. As such, we sought to determine the effects of CRT in CF-LVAD recipients. Methods: We performed a retrospective analysis of CF-LVAD recipients at Columbia University between May 1, 2004 and September 30, 2014. Patients were divided into 3 groups; group 1 included patients with QRS duration less than 150msec, group 2 greater than or equal to 150msec without CRT, and group 3 with CRT. The primary outcome was a composite of all-cause mortality and CV readmission. CV readmissions were defined as unplanned admission to the hospital for HF not related to device malfunction or complication or for arrhythmia management. Results: We included 343 patients; 190 (55.4%) had no active CRT. Of these, 49 (25.8%) had QRS duration greater than 150msec. Mean age was 57.7±13.7 years and 273 (79.6%) were men. Patients with narrow QRS were younger than wide QRS and CRT patients (54.0±14.6 vs. 59.9±12.5 vs. 60.4±12.6 years; p< 0.001). There was no significant difference in the proportion of patients with ICDs between the wide and narrow QRS groups. During mean follow-up of 469.7±484.5 days, 116 (33.8%) patients experienced the primary outcome. In a multivariable analysis, narrow QRS and CRT patients were at lower risk of experiencing the composite endpoint than wide QRS patients (OR 0.27, 95% CI 0.11-0.65, p= 0.004; OR 0.41, 95% CI 0.18-0.93, p= 0.03, respectively; table). Conclusion: Narrow QRS patients have the best outcomes after CF-LVAD. Among patients with wide QRS, patients with CRT were at lower risk of experiencing death or cardiovascular readmission following LVAD implant than those without CRT.

Purpose: Left ventricular assist devices (LVAD) and implantable cardioverter defibrillators (ICD) both improve survival separately in heart failure patients. However, prognostic effect of concomitant use of LVAD and ICD is lacking. There are small studies with short follow up periods and the results are confusing. The aim of this study is to define survival effects of ICD therapy in patients with LVAD. Methods: We retrospectively analyzed LVAD implanted patients from December 2010 to May 2016. Survival of patients with and without ICD was compared. Kaplan Meier survival analysis was performed between groups. (p < 0.05 was considered statistically significant.) Results: In six years period 257 patients had continuous flow LVAD implantation in our hospital. All patients were included in the study but 30 could not survive more than a month and were excluded to avoid early surgical effects. Mean age of the patient population was 50±13 and follow up time was 16, 5 months and 104 (45, 8%) of the patients had ICD. 132 (58, 1%) patients reached the end point, 40 (17.6 %) patients had heart transplantation and 55 (24, 2 %) patients died. Survival analysis was performed between patients with and without ICD and statistically significant survival benefit of ICD therapy was found (Log-rank: p= 0, 018; HR 0.505; 95 % CI: 0.285-0.879) (Figure 1). There was no statistical significant difference between groups for baseline characteristics (Table 1). Conclusion: Our study has the largest LVAD patient population in literature and our results showed that ICD therapy is associated with improved survival in heart failure patients with LVAD support.

Multivariable Predictors of Cardiovascular Readmission or Death Variable

OR

95% CI

P value

Age (per year increase) Gender (male) Ischemic Cardiomyopathy ICD INTERMACS Profile 1 2 3 4 LV End Diastolic Diameter BSA Creatinine QRS Duration > = 150 msec <  150 msec CRT

1.03

1.01-1.06

0.006

0.50 0.55

0.23-1.06 0.28-1.05

0.07 0.07

5.65

1.58-20.16

0.008

1 0.47 0.46 3.91 0.71

NA 0.20-1.08 0.18-1.19 0.62-24.85 0.52-0.95

NA 0.08 0.11 0.15 0.02

6.42 1.82

2.00-20.58 1.10-3.01

0.002 0.02

1 0.27 0.41

NA 0.11-0.65 0.18-0.93

NA 0.004 0.03

Table 1

Follow up (months) Age (years) Male gender (%) Ischemic Etiology (%) LVAD Bridge to Tx(%) LVEF (%) Creatinin(mg/dl) Hypertension (%) Diabet (%) Hospitalisation (days)

ICD

No ICD

p

16.9±11.8 51.1±12.3 84.6 46.6 87.5 19.9±3.5 1.130.34 26.8 27.6 20±13

16.1±11.8 49.2±14 87 52.8 83.7 20.4±3.9 1.12±0.49 36.8 28.3 20±16

0.585 0.107 0.608 0.350 0.423 0.317 0.817 0.121 1 0.722

4( 61)

4( 62)

Survival Benefit of Implantable Cardioverter Defibrillator Therapy on Patients with Left Ventricular Assist Device E. Simsek ,1 S. Nalbantgil,1 E. Demir,1 H.S. Kemal,2 I. Mutlu,1 P. Ozturk,3 S. Ertugay,3 C. Engin,3 T. Yagdi,3 M. Ozbaran.3  1Cardiology, Ege University School of Medicine, İZMİR, Turkey; 2Cardiology, Near East University School of Medicine, Lefkoşa, Cyprus; 3Cardiovascular Surgery, Ege University School of Medicine, İZMİR, Turkey.

Impact of Cardiac Resynchronization Therapy (CRT) on Invasive Hemodynamics and Echocardiographic Parameters in Patients with Implanted Left Ventricular Assist Devices (LVADs) S. Adatya ,1 D.M. Tehrani,1 N. Sarswat,1 G.H. Kim,1 J. Raikhelkar,1 C. Juricek,1 V. Kagan,1 T. Ota,1 D. Burkhoff,2 G. Sayer,1 V. Jeevanandam,1 N. Uriel.1  1University of Chicago, Chicago, IL; 2Heartware International, Inc, Framingham, MA.