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Implantable cardioverter-defibrillators and survival in advanced heart failure patients with continuous-flow left
Ahmed Elkaryoni1, Firas Al Badarin1,2, Muhammad Shahzeb Khan3
1Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA.
Insights
Implantable cardioverter-defibrillators (ICDs) do not improve survival in advanced heart failure patients with continuous-flow left ventricular assist devices (CF-LVADs). Further randomized studies are needed to confirm the efficacy of ICDs in this high-risk population.
Area of Science:
- Cardiology
- Medical Devices
- Heart Failure Management
Background:
- Implantable cardioverter-defibrillators (ICDs) reduce mortality in heart failure (HF) patients with reduced ejection fraction.
- The benefit of ICDs in advanced HF patients with continuous-flow left ventricular assist devices (CF-LVADs) remains controversial.
Purpose of the Study:
- To evaluate the association between ICD implantation and all-cause mortality in advanced HF patients treated with CF-LVADs.
- To determine if ICDs improve survival or reduce adverse events in this specific patient population.
Main Methods:
- A systematic review and meta-analysis of observational studies was conducted.
- Searched PubMed, Cochrane, Embase, and Scopus for studies up to November 2018.
- Eight studies comprising 6416 patients were included in the analysis using a random-effects model.
Main Results:
- No significant difference in all-cause mortality was observed between patients with and without ICDs (HR 0.96, 95% CI 0.73-1.27).
- ICD implantation post-CF-LVAD was not associated with improved survival (HR 0.87, 95% CI 0.48-1.57).
- No significant differences were found in transplantation rates or non-mortality adverse events.
Conclusions:
- ICD use is not associated with improved survival in advanced HF patients with CF-LVADs.
- The findings highlight the need for dedicated randomized controlled trials to definitively assess ICD efficacy in this population.
Aims:
Implantable cardioverter-defibrillators (ICDs) implantation in heart failure (HF) patients with reduced ejection fraction improves survival by reducing mortality secondary to arrhythmic events. Whether advanced HF patients treated with continuous-flow left ventricular assist devices (CF-LVADs) derive similar benefit is controversial.
Methods And Results:
We searched PubMed, Cochrane Central Register of Controlled Trials, Embase, and Scopus from inception through November 2018 for studies examining the association between ICD implantation and all-cause mortality in patients with advanced HF and CF-LVADs. Analyses were performed using a random-effects model. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs). Heterogeneity and publication bias were formally assessed, using I2 and funnel plots, respectively. Eight observational studies with a total of 6416 patients (ICD group = 3450, no ICD group = 2966) met inclusion criteria. The majority of patients (84.6%) came from the two largest observational studies. There was no difference in mortality in the ICD and no ICD groups (HR 0.96, 95% CI 0.73-1.27, P = 0.79, I2 = 42%), and ICD implantation post-CF-LVAD was not associated with an improvement in mortality (HR 0.87, 95% CI 0.48-1.57, P = 0.64, I2 = 0%). Additionally, there was no significant difference in the likelihood of transplantation (HR 1.10, 95% CI 0.93-1.30, P = 0.28, I2 = 26%) or non-mortality adverse events between the two groups.
Conclusion:
Implantable cardioverter-defibrillator use was not associated with improved survival in advanced HF patients with CF-LVADs. These findings underscore the need to formally study the efficacy of ICDs in this population in a dedicated randomized controlled study.
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