Internal Cardioverter Defibrillator Use after Implantation of Continuous Flow Left Ventricular Assist Device as Both Bridge to Transplant and Destination Therapy

Purpose: Internal Cardioverter Defibrillators (ICD) are a well-established treatment modality for the prevention of sudden cardiac death from ventricular arrhythmias in heart failure (HF) patients with severely reduced left ventricular systolic function. The benefit of ICDs on mortality diminishes as HF symptoms progress. Whether left ventricular assist device (LVAD) patients derive long-term benefit from ICDs remains unclear. Methods: Data were reviewed on 76 adult patients implanted with an LVAD between December 2009 and July 2014; 43% ischemic and 57% nonischemic etiology. The majority of patients had an ICD prior to LVAD implantation (N = 64, median age 60) with a minority undergoing insertion of an ICD after LVAD (N = 10, median age 28). 2 patients did not receive an ICD. Patients were categorized based on timing of ICD insertion—before LVAD implantation (preLVAD) vs. after LVAD implantation (postLVAD). Outcomes were mortality, re-hospitalization and incidence of ICD therapy after LVAD. Groups were compared using the Wilcoxon rank-sum test, Fisher's exact test, or the log-rank test, as appropriate. Results: PostLVAD patients were more likely to be younger and have nonischemic etiology. PreLVAD patients had a significantly higher incidence of both ATP (P = .0023) and shock therapy (P = .0060) compared to postLVAD patients. 13 out of 31 (41.9%) patients with right heart failure (RHF) after LVAD had ATP or ICD shock post implant while 16 out of 33 (48.5%) patients without RHF post implant had ATP or ICD shock post implant (P = .6248). There was no statistical difference in mortality (P = .1039) or re-hospitalization (P = .7146) between preLVAD and postLVAD patients. Conclusions: There were no significant predictors of ICD therapy after LVAD implantation, including ATP or ICD shock prior to LVAD implantation. ICD insertion after LVAD implantation did not confer a mortality benefit or reduction in hospitalizations. Younger patients with nonischemic cardiomyopathy may not derive long-term benefit from an ICD after LVAD implantation. Further prospective studies are warranted to determine which subset of advanced HF patients undergoing LVAD implantation require ICDs.