Echocardiographic Predictors of Ventricular Arrhythmias in Patients With Left Ventricular Assist Devices and Implantable Cardioverter-Defibrillator

Abstract

Aim: To evaluate the predictive value of preoperative echocardiographic parameters for occurrence of VAs in patients with preexisting ICD undergoing LVAD implantation.

Methods and results: All consecutive patients (n = 264) with previous ICD who underwent LVAD surgery between May 2011 and December 2019 at our institution were included. The patients were predominantly male (89%) with NICM (59%) and a mean age of 59 ± 10 years. All LVADs were continuous flow device (154 HVAD, 21 HeartMate II, and 89 HeartMate 3). A total of 102 (39%) patients had VAs in the first year after LVAD implantation. We compared echocardiographic parameters in patients with and without VAs before LVAD, at 1 month and 1 year after LVAD implantation. Increased pre-LVEDD ≥ 72 mm predicted the occurrence of VAs after LVAD implantation for ICM patients (HR: 2.9, 95% confidence interval (CI): [1.3-6.6], p = 0.012), while a larger pre-RVEDD ≥ 46 mm was predictive in NICM patients (HR: 2.8, (CI): [1.4-5.9], p = 0.004). Moreover, a larger RVEDD at 1 year after LVAD was highly associated with VAs in the first year after LVAD implantation (50 ± 10 vs. 45 ± 8 mm, p = 0.001). All patients demonstrated a significant decrease in LVEDD as well as a reduction in severity of mitral and tricuspid regurgitation during 1 year after LVAD implantation, reflecting left ventricular unloading through the LVAD.

Conclusions: Larger left and right ventricular diameters before LVAD predict the occurrence of VAs after LVAD implantation in ICM and NICM patients. Persistent RV remodeling post-LVAD is also associated with VAs.

Keywords: echocardiographic predictors; left ventricular assist device; ventricular arrhythmias.

Figure 1

Etiology of NICM in LVAD patients.

Figure 2

Kaplan–Meier plot of the time to the first VA event according to pre‐LVEDD in ICM patients (A), pre‐RVEDD in ICM patients (B), pre‐LVEDD in NICM patients (C), and pre‐RVEDD in NICM patients (D). (A) 8‐month rate for ICM patients with pre‐LVEDD ≥ 72 mm 47% CI [32.5–61.1], for patients with pre‐LVEDD < 72 mm 74% CI [61.6–85.6]. (B) 8‐month rate for ICM patients with pre‐RVEDD ≥ 46 mm 61% CI [45.2–77.0], for patients with pre‐RVEDD < 46 mm 61% CI [47.5–74.1]. (C) 8‐month rate for NICM patients with pre‐LVEDD ≥ 72 mm 68% CI [56.6–78.6], for patients with pre‐LVAD < 72 mm 59% CI [47.5–70.3]. (D) 8‐month rate for NICM patients with pre‐RVEDD ≥ 46 mm 55% CI [43.2–67.2], for patients with pre‐RVEDD < 46 mm 71% CI [60.2–82.2].

Figure 3

Kaplan–Meier plot of the time to the first VA event according to RV diameter reduction at 1 year after LVAD. 8‐month rate for patients with RV diameter reduction ≥ 2 mm 66% CI [54.3–77.9], for those with RV diameter reduction < 2 mm 51% CI [39.8–61.4].