ICD use may be appropriate in high-risk heart transplant patients

1 May 2009

MedWire News: Implantable cardioverter defibrillator (ICD) therapy may be appropriate in some patients after cardiac transplantation, say US researchers, and should be considered in individuals with graft atherosclerosis who are at high risk for sudden death.

The results come from a retrospective analysis of multicenter registry data for all adult orthotopic heart transplant survivors at five transplant centers, by Vivian Tsai (Stanford University, California, USA) and colleagues.

“Unlike the general population, there is little documented experience on the use of ICDs in cardiac transplant patients,” they note. “While clinical experience suggests that ICDs may be useful in certain patients with allograft vasculopathy, its role in heart transplantation has not been well established.”

The researchers looked at the outcomes of 36 high-risk patients, out of the total of 2612 patients, who received ICDs. The indications for ICD therapy were history of cardiac arrest (eight patients), left ventricular ejection fraction 35% or lower (seven patients), severe allograft vasculopathy (12 patients), or unexplained syncope (nine patients).

Tsai and co-authors report in the journal Circulation: Heart Failure that 10 (28%) of the patients received a total of 22 shocks, of whom eight (80%) received 12 appropriate shocks for 11 episodes of either rapid ventricular tachycardia or ventricular fibrillation.

Three (8%) patients received 10 inappropriate shocks on three occasions.

Allograft vasculopathy was present in all eight (100%) patients who received appropriate shocks compared with 18 (64%) patients who did not.

At the end of follow-up (average 51 months), 32 (89%) of the patients were alive, of who three (8%) had undergone a second heart transplantation. Seven (88%) of the eight patients who received appropriate ICD therapy were alive at the end of the study.

“Compared to conventional ICD recipients, a relatively high percentage of the orthotopic heart transplant group benefited from ICD therapy,” remark the authors.

“This finding seems to suggest that in patients with allograft vasculopathy, sustained ventricular arrhythmias in the orthotopic heart transplant population are not uncommon. Indeed, there appears to be a group of patients after cardiac transplant who are at significant risk for arrhythmic death, and in whom ICD therapy would be beneficial.”

Circulation: Heart Fail 2009; Advance online publication