Abstract
Purpose
Ventricular arrhythmias (VAs) are common in patients after left ventricular assist device (LVAD) implant and are associated with worse outcomes. However, the prevalence and impact of VA in patients with durable biventricular assist device (BIVAD) is unknown. We performed a retrospective cohort study of patients with BIVADs to evaluate the prevalence of VA and their clinical outcomes.
Methods
Consecutive patients who received a BIVAD between June 2014 and July 2017 at our medical center were included. The prevalence of VA, defined as sustained ventricular tachycardia or fibrillation requiring defibrillation or ICD therapy, was compared between BIVAD patients and a propensity-matched population of patients with LVAD from our center. The occurrence of adverse clinical events was compared between BIVAD patients with and without VA.
Results
Of the 13 patients with BIVADs, 6 patients (46%) experienced clinically significant VA, similar to a propensity-matched LVAD population (38%, p = 1.00). There were no differences in baseline characteristics between the two cohorts, except patients in the non-VA group who had worse hemodynamics (mitral regurgitation and right-sided indices), had less history of VA, and were younger. BIVAD patients with VA had a higher incidence of major bleeding (MR 3.05 (1.07–8.66), p = 0.036) and worse composite outcomes (log-rank test, p = 0.046). The presence of VA was associated with worse outcomes in both LVAD and BIVAD groups.
Conclusions
Ventricular arrhythmias are common in patients with BIVADs and are associated with worse outcomes. Future work should assess whether therapies such as ablation improve the outcome of BIVAD patients with VA.
Similar content being viewed by others
Abbreviations
- AF:
-
Atrial fibrillation
- ATP:
-
Anti-tachycardia pacing
- BIVAD:
-
Biventricular assist device
- CVA:
-
Cerebrovascular accident
- EF:
-
Ejection fraction
- EPPY:
-
Events per patient year
- GFR:
-
Glomerular filtration rate
- GI:
-
Gastrointestinal
- HF:
-
Heart failure
- IABP:
-
Intra-aortic balloon pump
- ICD:
-
Implanted cardioverter-defibrillator
- INTERMACS:
-
Interagency Registry for Mechanically Assisted Circulatory Support
- LA:
-
Left atrium
- LVAD:
-
Left ventricular assist device
- LV-HVAD:
-
Left ventricular HeartWare ventricular assist device
- RA-HVAD:
-
Right atrial HeartWare ventricular assist device
- LVIDd:
-
Left ventricle internal diameter diastole
- PAPI:
-
Pulmonary artery pulsatility index
- PASP:
-
Pulmonary artery systolic pressure
- PCWP:
-
Pulmonary capillary wedge pressure
- PVR:
-
Pulmonary vascular resistance
- RAP:
-
Right atrial pressure
- RV:
-
Right ventricle
- RVSP:
-
Right ventricular systolic pressure
- RVSWI:
-
Right ventricular stroke work index
- RVAD:
-
Right ventricular assist device
- TAPSE:
-
Tricuspid annular plane systolic excursion
- VA:
-
Ventricular arrhythmia
- VT:
-
Ventricular tachycardia
References
Nair N, Gongora E. Reviewing the use of ventricular assist devices in the elderly: where do we stand today? Expert Rev Cardiovasc Ther. 2018;16:11–20.
Mancini D, Colombo PC. Left ventricular assist devices: a rapidly evolving alternative to transplant. J Am Coll Cardiol. 2015;65:2542–55.
Bedi M, Kormos R, Winowich S, McNamara DM, Mathier MA, Murali S. Ventricular arrhythmias during left ventricular assist device support. Am J Cardiol. 2007;99:1151–3.
Andersen M, Videbaek R, Boesgaard S, Sander K, Hansen PB, Gustafsson F. Incidence of ventricular arrhythmias in patients on long-term support with a continuous-flow assist device (HeartMate II). J Heart Lung Transplant. 2009;28:733–5.
Refaat M, Chemaly E, Lebeche D, Gwathmey JK, Hajjar RJ. Ventricular arrhythmias after left ventricular assist device implantation. Pacing Clin Electrophysiol. 2008;31:1246–52.
Garan AR, Levin AP, Topkara V, Thomas SS, Yuzefpolskaya M, Colombo PC, et al. Early post-operative ventricular arrhythmias in patients with continuous-flow left ventricular assist devices. J Heart Lung Transplant. 2015;34:1611–6.
Ho G, Braun OO, Adler ED, Feld GK, Pretorius VG, Birgersdotter-Green U. Management of arrhythmias and cardiac implantable electronic devices in patients with left ventricular assist devices. JACC Clin Electrophysiol. 2018;4:847–59.
Rosenbaum AN, Kremers WK, Duval S, Sakaguchi S, John R, Eckman PM. Arrhythmias in patients with cardiac implantable electrical devices after implantation of a left ventricular assist device. ASAIO J. 2016;62:274–80.
Miller LW, Pagani FD, Russell SD, John R, Boyle AJ, Aaronson KD, et al. Use of a continuous-flow device in patients awaiting heart transplantation. N Engl J Med. 2007;357:885–96.
Yoruk A, Sherazi S, Massey HT, Kutyifa V, McNitt S, Hallinan W, et al. Predictors and clinical relevance of ventricular tachyarrhythmias in ambulatory patients with a continuous flow left ventricular assist device. Heart Rhythm. 2016;13:1052–6.
Shah P, Ha R, Singh R, Cotts W, Adler E, Kiernan M, et al. Multicenter experience with durable biventricular assist devices. J Heart Lung Transplant. 2018;37:1093–101.
Tran HA, Pollema TL, Silva Enciso J, Greenberg BH, Barnard DD, Adler ED, et al. Durable biventricular support using right atrial placement of the HeartWare HVAD. ASAIO J. 2018;64:323–7.
Cork DP, Tran HA, Silva J, Barnard D, Greenberg B, Adler ED, et al. A case series of biventricular circulatory support using two ventricular assist devices: a novel operative approach. Ann Thorac Surg. 2015;100:e75–7.
Kirklin JK, Pagani FD, Kormos RL, Stevenson LW, Blume ED, Myers SL, et al. Eighth annual INTERMACS report: special focus on framing the impact of adverse events. J Heart Lung Transplant. 2017;36:1080–6.
Clerkin KJ, Topkara VK, Mancini DM, Yuzefpolskaya M, Demmer RT, Dizon JM, et al. The role of implantable cardioverter defibrillators in patients bridged to transplantation with a continuous-flow left ventricular assist device: a propensity score matched analysis. J Heart Lung Transplant. 2017;36:633–9.
Austin PC. Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies. Pharm Stat. 2011;10:150–61.
Ziv O, Dizon J, Thosani A, Naka Y, Magnano AR, Garan H. Effects of left ventricular assist device therapy on ventricular arrhythmias. J Am Coll Cardiol. 2005;45:1428–34.
Shehab S, Macdonald PS, Keogh AM, Kotlyar E, Jabbour A, Robson D, et al. Long-term biventricular HeartWare ventricular assist device support--case series of right atrial and right ventricular implantation outcomes. J Heart Lung Transplant. 2016;35:466–73.
Oswald H, Schultz-Wildelau C, Gardiwal A, Lusebrink U, Konig T, Meyer A, et al. Implantable defibrillator therapy for ventricular tachyarrhythmia in left ventricular assist device patients. Eur J Heart Fail. 2010;12:593–9.
Raasch H, Jensen BC, Chang PP, Mounsey JP, Gehi AK, Chung EH, et al. Epidemiology, management, and outcomes of sustained ventricular arrhythmias after continuous-flow left ventricular assist device implantation. Am Heart J. 2012;164:373–8.
Brenyo A, Rao M, Koneru S, Hallinan W, Shah S, Massey HT, et al. Risk of mortality for ventricular arrhythmia in ambulatory LVAD patients. J Cardiovasc Electrophysiol. 2012;23:515–20.
Cantillon DJ, Tarakji KG, Kumbhani DJ, Smedira NG, Starling RC, Wilkoff BL. Improved survival among ventricular assist device recipients with a concomitant implantable cardioverter-defibrillator. Heart Rhythm. 2010;7:466–71.
Enriquez AD, Calenda B, Miller MA, Anyanwu AC, Pinney SP. The role of implantable cardioverter-defibrillators in patients with continuous flow left ventricular assist devices. Circ Arrhythm Electrophysiol. 2013;6:668–74.
Sacher F, Reichlin T, Zado ES, Field ME, Viles-Gonzalez JF, Peichl P, et al. Characteristics of ventricular tachycardia ablation in patients with continuous flow left ventricular assist devices. Circ Arrhythm Electrophysiol. 2015;8:592–7.
Snipelisky D, Reddy YN, Manocha K, Patel A, Dunlay SM, Friedman PA, et al. Effect of ventricular arrhythmia ablation in patients with Heart Mate II left ventricular assist devices: an evaluation of ablation therapy. J Cardiovasc Electrophysiol. 2017;28:68–77.
Moss JD, Flatley EE, Beaser AD, Shin JH, Nayak HM, Upadhyay GA, et al. Characterization of ventricular tachycardia after left ventricular assist device implantation as destination therapy: a single-center ablation experience. JACC Clin Electrophysiol. 2017;3:1412–24.
Garan AR, Iyer V, Whang W, Mody KP, Yuzefpolskaya M, Colombo PC, et al. Catheter ablation for ventricular tachyarrhythmias in patients supported by continuous-flow left ventricular assist devices. ASAIO J. 2014;60:311–6.
Borlak J, Thum T. Hallmarks of ion channel gene expression in end-stage heart failure. FASEB J. 2003;17:1592–608.
Depre C, Shipley GL, Chen W, Han Q, Doenst T, Moore ML, et al. Unloaded heart in vivo replicates fetal gene expression of cardiac hypertrophy. Nat Med. 1998;4:1269.
Garan AR, Yuzefpolskaya M, Colombo PC, Morrow JP, Te-Frey R, Dano D, et al. Ventricular arrhythmias and implantable cardioverter-defibrillator therapy in patients with continuous-flow left ventricular assist devices: need for primary prevention? J Am Coll Cardiol. 2013;61:2542–50.
Cantillon DJ, Saliba WI, Wazni OM, Kanj M, Starling RC, Tang WH, et al. Low cardiac output associated with ventricular tachyarrhythmias in continuous-flow LVAD recipients with a concomitant ICD (LoCo VT study). J Heart Lung Transplant. 2014;33:318–20.
Joly JM, El-Dabh A, Kirklin JK, Marshell R, Smith MG, Acharya D, et al. High right atrial pressure and low pulse pressure predict gastrointestinal bleeding in patients with left ventricular assist device. J Card Fail. 2018;24:487–93.
Sparrow CT, Nassif ME, Raymer DS, Novak E, LaRue SJ, Schilling JD. Pre-operative right ventricular dysfunction is associated with gastrointestinal bleeding in patients supported with continuous-flow left ventricular assist devices. JACC Heart Fail. 2015;3:956–64.
Silva Enciso J, Tran HA, Brambatti M, Braun OO, Pretorius V, Adler ED. Management of RVAD thrombosis in biventricular HVAD supported patients: case series. ASAIO J. 2018;65:36–41.
Cleveland JC Jr, Naftel DC, Reece TB, Murray M, Antaki J, Pagani FD, et al. Survival after biventricular assist device implantation: an analysis of the Interagency Registry for Mechanically Assisted Circulatory Support database. J Heart Lung Transplant. 2011;30:862–9.
Levin AP, Jaramillo N, Garan AR, Takeda K, Takayama H, Yuzefpolskaya M, et al. Outcomes of contemporary mechanical circulatory support device configurations in patients with severe biventricular failure. J Thorac Cardiovasc Surg. 2016;151:530–5 e2.
Harvey L, Holley C, Roy S, Eckman P, Cogswell R, Liao K, et al. Age as predictor of clinical outcomes after LVAD placement. J Heart Lung Transplant. 2015;34:S208.
Dobrovie M, Spampinato RA, Efimova E, da Rocha ESJG, Fischer J, Kuehl M, et al. Reversibility of severe mitral valve regurgitation after left ventricular assist device implantation: single-centre observations from a real-life population of patients. Eur J Cardiothorac Surg. 2018;53:1144–50.
Refaat MM, Tanaka T, Kormos RL, McNamara D, Teuteberg J, Winowich S, et al. Survival benefit of implantable cardioverter-defibrillators in left ventricular assist device-supported heart failure patients. J Card Fail. 2012;18:140–5.
Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2018;72:e91–e220.
Feldman D, Pamboukian SV, Teuteberg JJ, Birks E, Lietz K, Moore SA, et al. The 2013 International Society for Heart and Lung Transplantation guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant. 2013;32:157–87.
Ho G, Tran HA, Urey MA, Adler ED, Pretorius VG, Hsu JC. Successful ventricular tachycardia ablation in a patient with a biventricular ventricular assist device and heparin-induced thrombocytopenia using bivalirudin. HeartRhythm Case Rep. 2018;4:367–70.
Mulukutla V, Lam W, Simpson L, Mathuria N. Successful catheter ablation of hemodynamically significant ventricular tachycardia in a patient with biventricular assist device support. HeartRhythm Case Rep. 2015;1:209–12.
Cantillon DJ, Bianco C, Wazni OM, Kanj M, Smedira NG, Wilkoff BL, et al. Electrophysiologic characteristics and catheter ablation of ventricular tachyarrhythmias among patients with heart failure on ventricular assist device support. Heart Rhythm. 2012;9:859–64.
Patel M, Rojas F, Shabari FR, Simpson L, Cohn W, Frazier OH, et al. Safety and feasibility of open chest epicardial mapping and ablation of ventricular tachycardia during the period of left ventricular assist device implantation. J Cardiovasc Electrophysiol. 2016;27:95–101.
Funding
This work was partially supported by a research grant from the American Heart Association (19CDA34760021).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
The study protocol was approved by the institutional review board at University of California San Diego and adhered to the principles of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study.
Conflict of interest
Drs. Lin, Tran, Brambatti, Pretorius, Pollema, Hoffmayer, and Han have no disclosures. Dr. Adler is a consultant for Medtronic and Abbott. Dr. Feld is Director of the Cardiac Electrophysiology Fellowship Training Program whom receives fellowship stipend support from Medtronic, Abbott, Boston Scientific, Biosense Webster, and Biotronik. Dr. Krummen reports fellowship support from Medtronic, Boston Scientific, Abbott, and Biotronik. Dr. Ho has received research grants from the National Institutes of Health (1KL2TR001444) and the American Heart Association (19CDA34760021) for work related to this project, grant support from Abbott for work unrelated to this project, fellowship support from Medtronic, Boston Scientific, Abbott, and Biotronik, and has equity in Vektor Medical Inc. which is unrelated to this project.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Lin, A.Y., Tran, H., Brambatti, M. et al. Ventricular arrhythmias in patients with biventricular assist devices. J Interv Card Electrophysiol 58, 243–252 (2020). https://doi.org/10.1007/s10840-019-00682-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10840-019-00682-0