Impact of implantable cardioverter-defibrillators on waitlist outcomes in children with ventricular assist devices

Ventricular arrhythmias are common in patients with end-stage heart failure requiring ventricular assist devices (VADs). Studies evaluating implantable cardioverter-defibrillator (ICD) placement in adult VAD patients show conflicting benefits. With the increasing use of VADs as a bridge to transplant in pediatric patients, evidence guiding ICD use in this population remains limited.

This study aimed to compare waitlist composite mortality (death/delisting owing to clinical deterioration) and transplantation between pediatric VAD patients with and without ICDs.

Using the Scientific Registry of Transplant Recipients data (2010-2024), we identified pediatric VAD patients (aged <18 years) listed for primary heart-alone transplant with and without ICDs, performed propensity score matching, and applied cause-specific hazard models to compare waitlist outcomes.

Of 1263 pediatric VAD patients (83% left VAD, 15% bi-VAD, and 2.5% right VAD) listed for heart transplant, 79 (6.3%) had ICDs. There were no significant differences in race, underlying diagnosis, VAD type, inotrope use, ventilator use, or extracorporeal membrane oxygenation use. ICD patients were older at listing (15 vs 5 years; P < .0001), had higher amiodarone use (56% vs 13%; P = .0002), had greater cardiac output (3.9 vs 2.8 L/min; P = .0014), and were less often listed as United Network for Organ Sharing status 1A (84% vs 92%; P = .015). Compared with matched non-ICD patients, ICD use did not show a significant difference in waitlist mortality (hazard ratio 1.1; 95% confidence interval 0.40-2.5; P = .76) or in the likelihood of transplant (hazard ratio 1.2; 95% confidence interval 0.93-1.5; P = .17).

In a national cohort of pediatric VAD patients awaiting heart transplantation, there was no difference found in mortality, clinical deterioration, and rate of transplantation in patients with ICDs compared with those without.