Is There a Need for an Implantable Cardioverter Defibrillator in Patients with Left Ventricular Assist Devices?

Objectives: Patients (pts.) with left ventricular assist devices (LVAD) are prone to ventricular tachyarrhythmias (VTAs). The ISHLT suggests reactivation of cardioverter defibrillator (ICD) following LVAD placement or implantation of an ICD, although these VTAs are not associated with symptoms or hemodynamic compromise. These recommendations are not backed by hard evidence supporting the general use of ICDs in LVAD recipients.

Methods: Pts. receiving LVAD between July 2011 and November 2016 who already had an ICD or CRT-D or received an ICD shortly after LVAD implantation were enrolled in this retrospective study. Recorded events with appropriate and inappropriate ICD therapies were documented during outpatient follow-up until September 2017.

Results: A total of 61 LVAD pts. (54 male, 88.5%) were included. 22 (36.1%) pts. died and 11 (18.0%) received heart transplantation. A single-chamber ICD had been implanted in 23 (37.7%) patients, a dual-chamber ICD in 10 (16.4%) pts. and a CRT-ICD in 28 (45.9%) pts. The ICD indication was primary in 40 (65.6%) pts. and secondary prevention in 21 (34.4%) pts. Appropriate ICD therapies occurred in 8 pts., prior to LVAD implantation. ICD interrogation was missing in 5 pts. An ICD generator exchange was performed in 10 (16.4%) pts. and 10 pts. suffered from device-related complications after LVAD implantation. A VTA episode was seen in 29 pts. (54.1%). Appropriate ICD therapy was delivered in 20 of these 29 pts. (35.7%).There was no difference in the occurrence of VTA episodes between pts. with a primary or secondary prevention ICD indication. 20 LVAD pts. (54.1%) with primary and 9 LVAD recipients (47.4%) with secondary prevention had VTA episodes (p = 0.96). Appropriate ICD therapies were delivered for the first VTA episode in 12 of these 18 LVAD pts. with primary and in 8 of 9 pts. with secondary prevention. Inappropriate therapies were seen in 3 pts. with primary prevention and 3 pts. with secondary prevention.

Conclusions: The incidence of VTA episodes and appropriate ICD therapies in LVAD pts. with an ICD is relatively high. No difference was detected with regards to the occurrence of VTA episodes and appropriate ICD therapies between pts. with a primary or secondary prevention ICD indication. Large multicenter registries and prospective trials are required to evaluate whether the ICD therapy is associated with a potential survival benefit in LVAD recipients despite device-related complications in these pts.