Management of Ventricular Tachycardia in

Advanced Heart Failure: ICD Implantation

in End Stage Heart Failure and LVAD

Patients: Who Needs an ICD?

Wayne Levy, MD, FACC

Medical Director

UW Regional Heart Center Clinic

Fellowship Director

Advanced Heart

Failure/Transplant Cardiology

University of Washington

Patient story JHLT 2006;490-491

• 55 y/o female with fulminant heart failure – CI 1.1 on IABP and dobutamine

• Emergent Heartmate XVE – Giant cell myocarditis

• POD #3 – Asystole – LVAD CO ~5.5 ~4.5 lpm

• Acute Fontan physiology with CVP ~15 mm Hg

• Only LVAD support

• Transplanted Day #18

• Alive >10 years

ICD Myths

ICDs are very effective in preventing sudden death

20-25% of patients with ICDs die of sudden death (SCD-HeFT, MADIT II)

Most ICD shocks are life saving

Most episodes of VT/VF do not require treatment (RELEVANT and MADIT-RIT)

ICD benefit is uniform

ICDs reduce sudden death ~60% overall

Sudden death benefit can vary from ~25% to 90% (Thuens, SCD-HeFT)

ICDs are more effective than medications in HF patients

ICDs decrease mortality no more than ACEI, BB, MRA

LVADs & ICDs

• Mode of death in Stage D heart failure

• Does all VT/VF need treatment in LVAD patients?

• Are ICDs life saving in LVAD patients?

• Should ICDs be programmed differently in patients with an LVAD?

LVADs & ICDs

• Mode of death in Stage D heart failure

• Does all VT/VF need treatment in LVAD patients?

• Are ICDs life saving in LVAD patients?

• Should ICDs be programmed differently in patients with an LVAD?

Mode of Death in HF – MERIT HF

NYHA II NYHA III NYHA IV

NYHA II NYHA III NYHA IV HF

12%

HF

26% HF

56%

Other 24% Other 15% Other 11%

SD

64%

SD

59%

SD

33%

7% 13% 25%

Annual Mortality Lancet 1999;353:2001

Mode of death in Heart Failure

0%

20%

40%

60%

80%P

rop

ort

ion

of

To

tal

Dea

ths

0 1 2 3 4Seattle HF Score

Proportions of Causes of Death

Pump Failure Death

Sudden Death

Non CV Death

BBBBBBBBBBJJJJJJJJJJHHHHHHHHHH00.10.20.30.40.50.60.70.800.050.10.150.20.250.30.350.4Proportion of DeathsAnnual MortalityBSudden DeathJPump FailureHOther Death

Annual Mortality 5% 10% 25% 55% 90%

Mozaffarian D et. al. Circulation 2007;116:392-398

MADIT II – Long Term F/U Circ 2010;122:1265

Overall 0.66

Early 0.66

Late 0.74

NYHA 1 and No HF Hosp 0.55

NYHA ≥2 or HF Hosp during trial 0.95

ADHF – Stage D High Risk AHJ 2008;155:341-9

Only 17% sudden death

Observational ICD had no benefit

SHFM - ICD Efficacy Circ 2009;120:835

Neutral Effect at Predicted Annual Mortality of ~25%

J J

J

J

J

F F

F

F

F

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1.1

0% 5% 10% 15% 20% 25%

Ha

zard

Ratio

Predicted Annual Mortality

J Mortality

FSuddenDeath

All Cause Mortality Interaction p=0.014Sudden Death Interaction p=0.0088

SHFM - ICD Mortality Levy et al. - Unpublished

>75% 1-Year Survival?

Mode of death in LVAD patient

• Ventricular arrhythmias are common in Advanced HF.

• REMATCH - 35% had an ICD

VA Rate/year Medical LVAD

0.56 0.45

• No sudden death in either group

LVADs & ICDs

• Mode of death in Stage D heart failure

• Does all VT/VF need treatment in LVAD patients?

• Are ICDs life saving in LVAD patients?

• Should ICDs be programmed differently in patients with an LVAD?

Not all VT/VF requires treatment

RELEVANT

NID 30/40 vs 12/16 VT 92%

FVT 91%

VF 67%

Inappr Tx 80%

HF Hosp 62%

MADIT – RIT

~50% lower mortality

VT/VF in LVAD patients

Some LVAD patients may survive

days to weeks in VT/VF or even

asystole

JHLT 2014;33:318

However, we don’t know how to

predict which patients have

adequate flow in VF

Should we perform EP testing to

ascertain hemodynamic stability

in VF and implant ICD only if

hemodynamic instability?

VF LVAD flow by ~1/3

LVADs & ICDs

• Mode of death in Stage D heart failure

• Does all VT/VF need treatment in LVAD patients?

• Are ICDs life saving in LVAD patients?

• Should ICDs be programmed differently in patients with an LVAD?

Preop VA - LVADs JACC 2013;61:2542, EJHF 20140;12:593

Adj HR 0.55

If ICD are not associated with

survival, are they necessary?

Observational ICD use in LVADs JCF 2012;18:140, Heart Rhythm 2010;7:466

2% of patients without an ICD

died of sudden death

Adj HR 0.55

HVAD – Arrhythmia Pamboukian et. al. HFSA 2014

83.4% 72.9% 97.9%

97.8% 89.2%

72.3%

P value = 0.70

Arrhythmia (N=137)

Non-arrhythmia (N=245)

There was no difference in survival whether a patient with an arrhythmia event

had an ICD (n=122) versus those without an ICD (n=15).

HVAD – ICDs in ADVANCE Levy et. al. unpublished

LVADs & ICDs

• Mode of death in Stage D heart failure

• Does all VT/VF need treatment in LVAD patients?

• Are ICDs life saving in LVAD patients?

• Should ICDs be programmed differently in patients with an LVAD?

Patient story

Ambulatory VF

What do you do after DCCV?

HeartMate II dizzy without syncope

Patient story

• Ambulatory VF without syncope – Medications

– ICD

– Lifevest

• Lifevest – Presented to the ED several times with Lifevest

warning of impending ICD shock

– Elective DCCV in the ER with sedation

• Subsequently transplanted and doing well

Possible ICD strategy - LVADs JACC 2013;61:2542

• It is uncertain if ICD are life saving in LVAD patients.

• It is uncertain whether a patient without an ICD should have

an ICD placed after LVAD.

• Program ICDs to minimize ICD shocks as they likely are not

life saving.

• Consider VT ablation to avoid repeated ICD shocks

LVADs & ICDs

• Mode of death in Stage D heart failure – Pump Failure is predominant

• Does all VT/VF need therapy in LVAD patients? – No. Many resolve without therapy

• Are ICDs life saving in LVAD patients? – Unknown

• Should ICDs be programmed differently in patients with an LVAD? – Yes. Long detection intervals