In patients with left ventricular assist devices (LVADs), atrial fibrillation (AF) is fairly common, according to a retrospective study published in JACC: Clinical Electrophysiology.
To document AF, researchers reviewed electronic medical records (EMR) of patients (n=249; mean age: 58 years; 81% male) who underwent LVAD placement between 2008 and 2014 at Columbia University Medical Center. Patients were followed through October 2015 via EMR to determine AF incidence and treatment post-LVAD implantation.
In 45% of patients LVADs were implanted as a bridge to transplantation and in 55% of patients as a destination therapy. Following implantation, patients were followed for a mean of 20 months.
AF was classified by using American Heart Association/American College of Cardiology AF guidelines and standard definitions. Short-term AF was considered less than 2 weeks, intermediate-term was considered between 2 weeks to 3 months, and long-term AF was considered longer than 3 months.
Researchers determined the relationship between measures of occurrence of AF after LVAD placement (presence of AF and development of new AF) by univariate logistic regression. Potential predictors of these measures, including age, gender clinical history, cardiovascular risk factors, medications, AF prior to LVAD placement, and echocardiographic assessments, were also evaluated. Multivariable logistic regression was used to determine potential interactions and other predictors between AF prior to LVAD placement..
AF was documented in 80 patients after LVAD implantation. Prior to the procedure, 182 patients had no history of AF while 67 patients did. Among those patients who did have AF history, 56 continued to experience AF following LVAD placement, and 24 patients without history of AF developed AF after LVAD placement. Short-term AF occurred in 39 patients, intermediate-term in 6 patients, and long-term in 35 patients.
Some patients had experienced prior myocardial infarction (MI), undergone valve surgery, or had an implantable cardioverter-defibrillator (ICD). Others had diabetes, hypertension, dyslipidemia, and/or history of smoking.
Ischemic etiology, history of tobacco use, ICD placement, beta blocker or amiodarone use prior to insertion, and a history of previous AF were the variables associated with an increased likelihood of AF following LVAD insertion by univariate logistic regression.
However, by multivariable logistic regression, the only variable associated with an increased likelihood of AF following LVAD placement was a history of previous AF (18% vs 85%; odds ratio [OR]: 18.54; 95% confidence limit [CL]: 6.63-51.84; P<.001). Interestingly, women had an increased likelihood of developing a de novo AF following LVAD placement if they did not have a history of previous AF. Female gender was associated with an increased likelihood of developing AF by multivariable logistic regression (29% vs 9%; OR: 4.06; 95% CL: 1.61-10.27; P=.003).
A total of 73 patients died during the follow-up period and 11 experienced a stroke, but neither a history of previous AF prior to LAVD placement (hazard ratio [HR]: 1.17; 95% confidence interval [CI]: 0.64-2.12; P=.61) nor presence of AF following LVAD placement (HR: 1.38; 95% CI: 0.79-2.40; P=.26) was related to mortality.
Only prior MI was significantly related to risk of death, according to univariate analysis (HR: 1.85; 95% CI: 1.09-3.15; P=.024). However, by multivariable analysis, female gender was associated with an increased risk of death (HR: 2.14; 95% CI: 1.14-4.03; P=.018).
Ultimately, there were no significant differences in risk of stroke or death for patients with AF prior to or after LVAD placement.
“Clinical implications include the fact that aggressive treatment of AF with maintenance of sinus rhythm as the therapeutic goal may not be warranted in this setting and may have higher than usual incidence of adverse effects,” researchers wrote. “Prospective studies that further examine the frequency, type, treatment, and impact of AF before and after LVAD placement using long-term internal cardiac monitoring are warranted.”
Hickey KT, Garan H, Mancini D, et al. Atrial fibrillation in patients with left ventricular assist devices: incidence, predictors, and clinical outcomes. JACC Clin Electrophysiol. 2016. doi:10.1016/j.jacep.2016.03.009.