Survival benefit of implantable cardioverter-defibrillators in left ventricular assist device-supported heart failure patients.
BACKGROUND
Implantable cardioverter-defibrillators (ICDs) reduce mortality in heart failure (HF). In patients requiring a ventricular assist device (VAD), the benefit from ICD therapy is not well established. The aim of this study was to define the impact of ICD on outcomes in VAD-supported patients.


RESULTS
We reviewed data for consecutive adult HF patients receiving VAD as a bridge to transplantation from 1996 to 2003. The primary outcome was survival to transplantation. A total of 144 VADs were implanted [85 left ventricular (LVAD), 59 biventricular (BIVAD), mean age 50 ± 12 years, 77% male, left ventricular ejection fraction 18 ± 9%, 54% ischemic]. Mean length of support was 119 days (range 1-670); 103 patients (72%) survived to transplantation. Forty-five patients had an ICD (33 LVAD, 12 BIVAD). More LVAD patients had an appropriate ICD shock before implantation than after (16 vs 7; P = .02). There was a trend toward higher shock frequency before LVAD implant than after (3.3 ± 5.2 vs 1.1 ± 3.8 shocks/y; P = .06). Mean time to first shock after VAD implant was 129 ± 109 days. LVAD-supported patients with an ICD were significantly more likely to survive to transplantation [1-y actuarial survival to transplantation: LVAD: 91% with ICD vs 57% without ICD (log-rank P = .01); BIVAD: 54% vs 47% (log-rank P = NS)]. An ICD was associated with significantly increased survival in a multivariate model controlling for confounding variables (odds ratio 2.54, 95% confidence interval 1.04-6.21; P = .04).


CONCLUSIONS
Shock frequency decreases after VAD implantation, likely owing to ventricular unloading, but appropriate ICD shocks still occur in 21% of patients. An ICD is associated with improved survival in LVAD-supported HF patients.
Division of Cardiology, University of California, San Francisco, California.
Marwan M
MM
Refaat
Toshikazu
T
Tanaka
Robert L
RL
Kormos
Dennis
D
McNamara
Jeffrey
J
Teuteberg
Steve
S
Winowich
Barry
B
London
Marc A
MA
Simon
D015331:Cohort Studies; D016208:Databases, Factual; D017147:Defibrillators, Implantable; D005260:Female; D006333:Heart Failure / Q000401:mortality* / Q000503:physiopathology / Q000628:therapy*; D016027:Heart Transplantation; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008875:Middle Aged; D010414:Pennsylvania / Q000453:epidemiology; D012189:Retrospective Studies; D016019:Survival Analysis; D017180:Tachycardia, Ventricular / Q000401:mortality* / Q000503:physiopathology / Q000628:therapy*; D016896:Treatment Outcome