3/23/2018. Complications of VAD Therapy: Arrhythmias. Disclosures. Agenda. I have no relevant disclosures

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1 March 23, 2018 Complications of VAD Therapy: Arrhythmias Sandeep M. Jani, MD, MPH Associate Directory of Advanced Heart Failure and Population Health MedStar Heart and Vascular Institute - Baltimore Sandeep M. Jani, MD, MPH 1 Disclosures I have no relevant disclosures March 23, Agenda Atrial Fibrillation Ventricular Arrhythmias Device Therapy 3 1

2 Themes Arrhythmias pre-date VAD implant Arrhythmias are better tolerated in patient with a VAD than in patients without a VAD Arrhythmia effects on the RV is important March 23, Atrial Arrhythmias in VAD patient Atrial fibrillation Importance begins prior to VAD implantation Common after VAD implantation March 23, Atrial Fibrillation: Incidence 25%->50% of patients have atrial fibrillation prior or after VAD Majority of patients seem to have atrial fib prior to VAD 50 of 55 patients in Mount Sinai HeartMate II experience Less common to develop new atrial fib after VAD 5 of 55 patient in Mount Sinai HeartMate II experience (excluding immediate post op period) Of those with atrial fib 2/3 Paroxysmal 1/3 Persistent or permanent afib 6 Enriquez AD, Calenda B, et al. Clinical Impact of Atrial fibrillation in Patients with the HeartMate II Left Ventricular Assist Device. JACC. 2014;64:

3 Atrial Fibrillation: Population Atrial fib and VAD population are sicker INTERMACS Data: Atrial fib patients were: Older (58% > age 60 vs 49% in sinus group) More likely to be male (83% vs 78%) More likely to have prior stroke (8% vs 3%) More likely to have severe DM (14% vs 8%) More likely to have kidney disease (42% vs 17%) More likely to have PVD, pulmonary disease, pulmonary hypertension, liver dysfunction, chronic coagulatopathy, GI ulcers, smoking, or other comorbidities 7 Xia Y, Stern D, et al. Preoperative atrial fibrillation may not increase thromboembolic events in left ventricular assist device recipients on midterm follow-up. J Heart Lung Transplant 2016;35: Atrial Fibrillation: Risk of Thromboembolism Stulack JM, Deo S, Schirger J, Aaronson KD, et al. Preoperative atrial fibrillation increases risk of thromboembolic events after left ventricular assist device implantation. Ann Thorac Surg 2013; 96: Atrial Fibrillation: Risk of Thromboembolism INTERMACS data from May 2012-Dec 2013 History of atrial fib or No history of atrial fib 3909 patients 3071 (78.6%) without history of atrial fib 838 (21.4%) with history of atrial fib Atrial fib patients older and had more comorbid conditions Followed for median 8.5 months Xia Y, Stern D, et al. Preoperative atrial fibrillation may not increase thromboembolic events in left ventricular assist device recipients on midterm follow-up. J Heart Lung Transplant 2016;35:

4 Atrial Fibrillation: Risk of Thromboembolism Xia Y, Stern D, et al. Preoperative atrial fibrillation may not increase thromboembolic events in left ventricular assist device recipients on midterm follow-up. J Heart Lung Transplant 2016;35: Atrial Fibrillation: Risk of Thromboembolism March 23, Xia Y, Stern D, et al. Preoperative atrial fibrillation may not increase thromboembolic events in left ventricular assist device recipients on midterm follow-up. J Heart Lung Transplant 2016;35: Atrial Fibrillation: Survival March 23, Xia Y, Stern D, et al. Preoperative atrial fibrillation may not increase thromboembolic events in left ventricular assist device recipients on midterm follow-up. J Heart Lung Transplant 2016;35:

5 Atrial Fibrillation: Survival No Afib Afib March 23, Xuereb L, Go PH, Kaur B, et al. Impact of Preoperative Atrial Fibrillation on Postoperative Thromboembolic Events after Left Ventricular Assist Device Implantation. Ann Thorac Surg 2016;102: Post-Operative Atrial Fibrillation Minimal Data Can be symptomatic and/or clinically significant Fatigue and palpitations RV failure Lower VAD flows Inappropriate ICD shocks Series of 8 patient with HMII and atrial flutter Immediate improvement in symptoms and right heart failure from atrial flutter ablation Hottigoudar RU, Deam AG, et al. Catheter ablation of atrial flutter in patient with left ventricular assist devices improves symptoms of right heart failure. Congest Heart Fail. 2013;19: Post-VAD Atrial Fibrillation Treatment Individualized to the Patient Rate control with Beta-Blockers, Digoxin Amiodarone or dofetalide Cardioversion AV nodal Ablation Atrial flutter or atrial fib ablation Anticoagulation Our practice is goal INR of 2-3 for VAD patients Kadado AJ, Akar JG, Hummel JP. Arrhythmias after left ventricular assist device implantation: incidence and management. Trends in Cardiovascular Medicine. 28(2018):

6 Atrial Fibrillation: Summary Atrial fibrillation is common pre and post LVAD Atrial fib Pre-VAD, likely to have it Post-VAD Pre-VAD atrial fib unlikely to cause increase thromboembolic events or increase mortality Post-VAD atrial fib can be clinically significant due to RV dysfunction Treat postop atrial fib with rate control, antiarrhytmics, cardioversion or rarely AV nodal ablation or Atrial flutter/fib ablations 16 Ventricular Arrhythmias 17 Ventricular Arrhythmias: Incidence Common to have Vent Arrhythmias after VAD 22-59% of patients Definition of Vent Arrhythmias and type of VAD vary 18 Kadado AJ, et al. Trends in Cardiovascular Medicine. 28(2018): Nakahara S, et al. Circ Arrhythm Electrophysiol 2013;6:

7 Ventricular Arrhythmias: Incidence Randomized Trials Ventricular Arrhythmias requiring Defibrillation Trial HMII BTT % HeartWare BTT Advance Trial % Momentum (HMIII) 2 yr outcomes % % Patient with Vent Arrhythmia req. Defib Miller LW, et al. N Engl J Med 2007;357: Slaughter MS, et al. J Heart Lung Transplant 2013;32: Mehra MR, et al. N Engl J Med Published online March 11, Ventricular Arrhythmias: Incidence ICD studies University of Leipzig May 2011-Dec 2013 All patients had an ICD HeartWare (85 pts) and HMII (13 pts) Monomorphic VT or VF lasting > 30 sec or appropriate shock from ICD 49% had ventricular arrhythmias Mostly monomorphic VT, less likely VF 20 Efimova E, Fischer J, et al. Predictors of ventricular arrhythmia after left ventricular assist device implantation: a large-single center observational study. Heart Rhythm 2017;14: Ventricular Arrhythmias: Clinical Consequences Generally much better tolerated than in patient without VAD Sometimes tolerated for weeks Dizziness, shortness of breath, palpitations ICD shocks Low flows on VAD RV may become impaired RV failure Worsening Renal Failure, Liver dysfunction 21 Nakahara S, Chien C, et al. Ventricular Arrhythmias after Left Ventricular Assist Device. Circ Arrhythm Electophysiol. 2013;6:

8 Ventricular Arrhythmias: Effect on Survival Meta-analysis of 9 observational studies 1179 patients Evaluate association of post-lvad Vent Arrhythmias on all-cause mortality at 60, 120, 180 days VT >30 sec, VF, or needing ATP or defibrillation Mix of continuous flow VADs and pulsatile VADs Makki N, Mesubi O, et al. Meta-Analysis of the Relation of Ventricular Arrhythmias to All-Cause Mortality after Implantation of a Left Ventricular Assist Device. Am J Cardiol 2015;116: Ventricular Arrhythmias: Effect on Survival Time Point Adjusted OR 95% Confidence Interval Pulsatile and CF VAD p-value 60 days days days CF VADs only 60 days days days Makki N, Mesubi O, et al. Meta-Analysis of the Relation of Ventricular Arrhythmias to All-Cause Mortality after Implantation of a Left Ventricular Assist Device. Am J Cardiol 2015;116: Causes of Ventricular Arrhythmias after VAD Mostly from scar in the LV myocardium Macro-rentry accounted for 95% Rarely from around the inflow cannula 9% of ventricular arrhythmias Mechanical irritation of the LVAD inflow cannula on LV myocardial wall (suction events) LVAD implant seems to cause repolarization abnormalities 24 Nakahara S, Chien C, et al. Ventricular Arrhythmias after Left Ventricular Assist Device. Circ Arrhythm Electophysiol. 2013;6: Sacher F, Reichlin T, et al. Characteristics of Ventricular Tachycardia Ablation in Patient with Continuous Flow Left Ventricular Assist Devices. Circ Arrhythm Electrophysiol. 2015;8:

9 Ventricular Arrhythmias: Therapy Similar to patients without VAD Treat underlying causes Replete Electrolytes Beta Blockers Antiarrhythmics Amiodarone Lidocaine Mexilitine Nakahara S, Chien C, et al. Ventricular Arrhythmias after Left Ventricular Assist Device. Circ Arrhythm Electophysiol. 2013;6: \ 25 Ventricular Arrhythmias: Treatment Echocardiogram Evaluate LV size, inflow cannula position Cardiac CT Evaluate inflow cannula position IV fluids Reduce VAD speed Ablation ICD or external cardioversion March 23, Kadado AJ, Akar JG, Hummel JP. Arrhythmias after left ventricular assist device implantation: incidence and management. Trends in Cardiovascular Medicine. 28(2018): Ventricular Arrhythmia Ablation Several series show success with VT/VF ablation post VAD Columbia Experience 7 VAD patient between 2008 and 2012 Recurrent ICD firings or refractory vent arrhythmias causing RV failure 19 VTs induced, 13 ablated 5 of 7 had reduced burden of ventricular arrhythmias 1 was cured until transplant 2 did not have reduction in VT burden 1 groin hematoma 27 Garan AR, Iyer V, et al. Catheter Ablation for Ventricular Tachyarrhythmias in Patient Supported by Continuous-Flow Left Ventricular Assist Devices. ASAIO Journal 2014;60:

10 Ventricular Arrhythmia Ablation 9 tertiary EP centers pooled data 34 HMII LVAD patients between Outcomes 7 transplanted and 10 died (non-arrhythmia related) Of remaining 17, 13 arrhythmia free at 25+/-15 months March 23, Sacher F, Reichlin T, et al. Characteristics of Ventricular Tachycardia Ablation in Patients with Continous Flow Left Ventricular Assist Devices. Circ Arrhythm Electrophysiol. 2015;8: ICD Therapy Most but not all patients will already have an ICD Columbia Experience 77 patients with ICD, 17 without ICD 1 patient had ICD placed after VAD due to VF ~25% had ventricular arrhythmias 98 ventricular arrhythmias, 1.2 VAs per patient year 6 patient had sustained vent arrhythmias not treated by ICD or did not have an ICD Slow VT, failure to cardiovert 1 patient died of refractory VT/VF leading to RV failure No difference in mortality between ICD and no ICD No deaths in patient discharged with an ICD 29 Garan AR, Yuzefpolskaya M, et al. Ventricular Arrhythmias and Implantable Cardioverter- Defibrillator Therapy in Patients with Continuous Flow Left Ventricular Assist Devices. J Am Coll Cardiol. 2013;61: ICD Therapy Large Propensity matched cohort from UNOS CF LVAD patients as BTT from (83%) with ICD, 515 (17%) without ICD 30 Clerkin KJ, Topkara VK, et al. The role of implantable cardioverter defibrillators in patients bridged to transplantation with a continous-flow left ventricular assist device: A propensity score matched analysis. J Heart Lung Transplant 2017;36;

11 ICD Therapy 31 Clerkin KJ J Heart Lung Transplant 2017;36; ICD Therapy Transplanted Death/Delisted March 23, Clerkin KJ J Heart Lung Transplant 2017;36; Clinical Approach to ICD in VAD Patients March 23, Garan AR, Yuzefpolskaya M, et al.j Am Coll Cardiol. 2013;61:

12 Ventricular Arrhythmia: Summary Common after VAD Generally tolerated but can become symptomatic ICD shocks, RV failure May be a marker of sicker patients Treat Medically Consider VAD positioning and speed Ablation has been successful No data that ICDs improve overall survival in VAD patients Consider ICDs for secondary prevention Arrhythmias Post VAD Atrial fibrillation/ventricular arrhythmias are common Best predictors of post-vad arrhythmias are pre- VAD arrhythmias Arrhythmias are better tolerated in VAD patients than patients without mechanical support Arrhythmia clinical effect is often dependant on the RV Both supraventricular and ventricular arrhythmias are treatable Thank you March 23,