Use of the implantable cardioverter-defibrillator in long-term survivors of orthotopic heart transplantation.
BACKGROUND
Orthotopic heart transplantation is considered an effective treatment for patients with refractory heart failure. The long-term survival of orthotopic heart transplantation recipients has increased over the last several decades, but many long-term survivors of orthotopic heart transplantation develop graft atherosclerosis and associated left ventricular dysfunction. The risk of sudden cardiac death in long-term survivors of orthotopic heart transplantation with these complications is believed to be high. There are no data on the usefulness of implantable cardioverter-defibrillators (ICDs) in this population; therefore, we report our early experience with ICD placement in such patients.


OBJECTIVE
The purpose of this study was to examine the use of ICDs in adults who are long-term survivors of heart transplantation.


METHODS
We retrospectively reviewed all adult patients who underwent orthotopic heart transplantation at Stanford University Hospital (Stanford, CA, USA) from 1980 to 2004. All patients who received an ICD after transplant were included in this study. We reviewed demographic data, medical history, ejection fraction, presence of graft atherosclerosis, indication for ICD placement, and any device therapy delivered.


RESULTS
Of the 925 patients who had orthotopic heart transplantation during this time period, 493 patients were alive at the beginning of the year 2000. Of these patients, 10 ( approximately 2%) had subsequent placement of an ICD. All 10 patients were male. The average age at orthotopic heart transplantation was 37.8 years. The average age at ICD placement was 50.5 years. The average time from orthotopic heart transplantation to ICD placement was 14.6 years. The average ejection fraction at the time of implant was 46.5%. Five of the 10 patients had a low ejection fraction (within this subgroup, the average ejection fraction was 31%, range 15%-45%) and graft atherosclerosis. ICDs were placed because of symptomatic episodes of ventricular tachycardia (3 patients), low ejection fraction and severe graft atherosclerosis without symptoms (3 patients), and after thorough evaluation for otherwise unexplained syncope (4 patients). The average follow-up after device implantation was 13 months. Complications related to ICD placement were an infected ICD system requiring explant in one patient and a lead fracture in another patient. Three patients had subsequent appropriate shocks for ventricular arrhythmias, and one patient underwent a second orthotopic heart transplantation. One patient died of malignancy.


CONCLUSIONS
Use of the ICD in long-term survivors of orthotopic heart transplantation should be considered in appropriately selected patients. Further data are needed regarding ICD use in this population.
Ptaszek
Leon M
LM
Department of Internal Medicine, Stanford University School of Medicine, Stanford, California 94305, USA.
Wang
Paul J
PJ
Hunt
Sharon A
SA
Valantine
Hannah
H
Perlroth
Mark
M
Al-Ahmad
Amin
A
D000328:Adult; D002140:California; D017147:Defibrillators, Implantable; D004562:Electrocardiography; D022062:Electrophysiologic Techniques, Cardiac; D005500:Follow-Up Studies; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000503:physiopathology; D006329:Heart Conduction System / Q000503:physiopathology; D006333:Heart Failure / Q000503:physiopathology / Q000628:therapy; D016027:Heart Transplantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013318:Stroke Volume; D016019:Survival Analysis; D017180:Tachycardia, Ventricular / Q000209:etiology / Q000503:physiopathology; D016896:Treatment Outcome