Author + information
- Sing-Chien Yap, MD, PhD∗ (, )
- Faiz Ramjankhan, MD,
- Rahat Muslem,
- Nicolaas de Jonge, MD, PhD,
- Hans J. Kirkels, MD, PhD,
- Sakir Akin, MD,
- Olivier C. Manintveld, MD, PhD,
- Ozcan Birim, MD, PhD,
- Tamas Szili-Torok, MD, PhD and
- Kadir Caliskan, MD, PhD
- ↵∗Department of Cardiology, Erasmus Medical Center, ’s-Gravendijkwal 230, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands
Continuous-flow left ventricular assist devices (CF-LVADs) are increasingly used in the management of patients with end-stage heart failure; however, CF-LVAD support can be hampered by the occurrence of ventricular arrhythmias (VAs) (1–5). There are limited data on the temporal evolution of VA burden during long-term follow-up. The aim of the present study was to investigate the incidence, predictors, and clinical outcomes of VA in CF-LVAD patients.
We reviewed all adult patients receiving a CF-LVAD between March 2006 and April 2015 in 2 large Dutch LVAD centers. The primary outcome was the occurrence of VA, defined as VA that was sustained for >30 s or was treated by an implantable cardioverter-defibrillator (ICD). Multivariate Cox regression analysis was performed to investigate predictors of late (>30 days) post-LVAD VA.
Overall, 204 patients underwent CF-LVAD implantation (mean age at implantation 49.2 ± 12.5 years, 70.6% male, 70.6% nonischemic cardiomyopathy, 58.3% ICD). The majority of patients (93.6%) received an LVAD as a bridge to heart transplantation (HTX). Eighty-five patients (41.7%) had a history of VA before LVAD implantation. During a median follow-up of 17.3 months (interquartile range: 8.1 to 29.5 months), 62 patients (30.4%) experienced post-LVAD VA. The burden of VA followed a U-shaped curve, with the highest incidence in the first postoperative month, a nadir at 15 to 18 months, and a rise after that time (Figure 1A). Pre-LVAD VA, the presence of an ICD, the use of beta blockers, and atrial fibrillation were univariate predictors of late post-LVAD VA. In a multivariate Cox regression model, only pre-LVAD VA remained as an independent predictor of late post-LVAD VA (adjusted hazard ratio [HR]: 2.13; 95% confidence interval [CI]: 1.06 to 4.27; p = 0.03) (Figure 1B). During follow-up, 88 patients (43.1%) underwent HTX and 57 patients (27.9%) died. The 1-year mortality and HTX rates were 11.8% and 18.6%, respectively. The most common mode of death was noncardiac death (52.6%), followed by cardiac death (28.1%) and death of indeterminate causes (19.3%). Post-LVAD VA was not associated with increased mortality (HR: 1.10; 95% CI: 0.63 to 1.95; p = 0.73), HTX (HR: 0.99; 95% CI: 0.63 to 1.55; p = 0.96), or the combined endpoint of HTX or death (HR: 0.98; 95% CI: 0.69 to 1.41; p = 0.93). However, 3 of 62 patients (4.8%) with post-LVAD VA had difficult to control VA that required urgent HTX.
The incidence of post-LVAD VA was 30.4% in the present study, which is in agreement with previous studies (1–5). A high early post-operative burden of VA was followed by a relatively low VA burden after hospital discharge. However, at long-term follow-up, there appears to be increased vulnerability to VA, which could reflect incipient hemodynamic failure of appropriate LVAD support. Pre-LVAD VA was an independent predictor of late post-LVAD VA. This is not surprising, because it reflects the presence of an arrhythmogenic substrate that is not abolished by the implantation of an LVAD. The effect of post-LVAD VA on survival rates is ambiguous in the literature (2–4). In a small study comprising 61 patients with CF-LVAD and ICDs, post-LVAD VA was an independent predictor of mortality (3). We did not find an association between post-LVAD VA and increased mortality, albeit a minority of patients with therapy-resistant VA required urgent HTX as a bail-out procedure. Our study is hampered by its retrospective design. The incidence of VA might be underestimated when VA episodes are not documented properly, especially in patients without an ICD.
In summary, the incidence of post-LVAD VA followed a U-shaped curve with an increase in incidence at long-term follow-up. Patients with pre-LVAD VA were more prone to develop late post-LVAD VA. Post-LVAD VA did not appear to impact survival or HTX rates; however, urgent HTX was needed in some patients with therapy-resistant VA. It is important to realize that in destination-therapy patients with therapy-resistant VA, urgent HTX will probably not be a good option.
Please note: Dr. Ramjankhan has served as a proctor for Thoratec. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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