management of ventricular tachycardia in advanced heart failure
TRANSCRIPT
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