Prophylactic Implantable Cardioverter Defibrillator Treatment in Patients With End-Stage Heart Failure Awaiting Heart Transplantation

Study Questions:

What is the role of implantable cardioverter-defibrillator (ICD) therapy for the primary and secondary prevention of sudden cardiac death in patients listed for heart transplantation?

Methods:

This was a retrospective, observational, multicenter study; 1,089 consecutive patients listed for heart transplantation in two tertiary heart transplant centers were enrolled. Of 550 patients (51%) on the transplant list with an ICD, 216 had received their ICD for the primary prevention of sudden cardiac death and 334 for secondary prevention; 539 patients did not receive an ICD. Treatment with or without an ICD was left to the discretion of the heart failure specialist. The main outcome measure was all-cause mortality.

Results:

ICDs appear to be associated with a reduction in all-cause mortality in patients implanted with the device for primary and secondary prevention compared to those without an ICD despite a median time on the waiting list of only 8 months (estimated 1-year: 88 ± 3% vs. 77 ± 3% vs. 67 ± 3%; p = 0.0001). A Cox regressional hazard model (corrected for age, sex, underlying heart disease, atrial fibrillation, cardiac resynchronization therapy, New York Heart Association class, ejection fraction, co-medication, and year of listing) suggested an independent beneficial effect of ICDs that was most pronounced in patients who had received an ICD for primary prevention (hazard ratio, 0.4; 95% confidence interval, 0.19-0.85; p = 0.016).

Conclusions:

The authors concluded that ICD implantation appears to be associated with an immediate and sustained survival benefit for patients awaiting heart transplantation.

Perspective:

This observational study reported that ICD implantation results in a reduction in sudden cardiac death, leading to an immediate and sustained survival benefit for candidates listed for heart transplantation despite a median time on the waiting list of only 8 months. Patients who received the ICD for primary prevention before listing, as well as patients receiving an ICD (primary and secondary prevention) after being listed for transplantation, appear to derive the greatest benefit. Based on these results, patients listed for heart transplantation for whom in-hospital rhythm monitoring cannot be guaranteed until transplantation, may be considered for ICD implantation, taking into account the clinical equipoise of ICD therapy, while prospective randomized trials are conducted to validate these findings.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant

Keywords: Outcome Assessment (Health Care), Macrophage Colony-Stimulating Factor, Granulocyte-Macrophage Colony-Stimulating Factor, New York, Primary Prevention, Heart Transplantation, Cardiac Resynchronization Therapy, Heart Diseases, Incidence, Heart Failure, Defibrillators, Implantable, Death, Sudden, Cardiac


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