Utilization of Implantable Cardioverter-Defibrillators in Patients With Heart Transplant (from National Inpatient Sample Database)

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Heart transplant (HT) recipients represent a unique and vulnerable population in whom medium and long-term outcomes are significantly affected by the risk of arrhythmias and sudden cardiac death. The use of implantable cardioverter-defibrillators (ICDs) in this population remains debated. A retrospective analysis of the National Inpatient Sample data between 2009 and 2018 was conducted. Hospitalization data on patients who underwent HT, or who had a preexisting HT, and who received a new ICD were included (excluding the preexisting ICD). Outcomes assessed included inpatient mortality, length of stay, and inflation-adjusted costs. We explored temporal trends in ICD placement and mean length of stay, and predictors of ICD placement. Between 2009 and 2018, 22,673 hospitalizations were recorded for HT, during which patients either received a concurrent new ICD placement (n = 70 [0.31%]) or no new ICD placement (n = 22,603 [99.7%]). During the same period, 146,555 admissions were recorded in patients with a history of HT. ICD placement in patients with a preexisting HT was associated with significantly higher inflation-adjusted costs ($55,680.7 vs $17,219.2; p <0.001). Predictors of ICD placement in preexisting patients with HT included cardiac arrest during hospitalization (odds ratio [OR]:14.3 [3.5 to 58.6]), drug abuse (OR:6.0 [1.3 to 27.1]), and previous PCI (OR:6.0 [2.1 to 17.3]). In conclusion, ICD placement in patients with HT history was associated with significantly higher inflation-adjusted costs. In patients with HT history, factors predicting ICD placement included cardiac arrest at hospitalization, previous PCI, and drug abuse.

Introduction

In its 2011 registry of approximately 70,000 heart transplant (HT) recipients worldwide, the International Society of Heart and Lung Transplantation demonstrated a median survival after first-time transplantation of roughly 11 years.1 Sudden cardiac death (SCD) has been recognized as a major cause of death in this population, with mortality rates ranging from 10% to 35%.2,3 Implantable cardioverter-defibrillators (ICDs) are routinely implanted for patients with left ventricular systolic function <35% to prevent SCD. However, there exists limited observational evidence regarding the role of ICDs in the setting of HT.2,4 The current American College of Cardiology/American Heart Association guidelines recommend ICD as a reasonable strategy for primary prevention after HT with severe allograft vasculopathy and graft dysfunction (class IIB).2 Given the limited evidence and uncertain benefit, clinical practice patterns of ICD placement have depended on physician judgment.5 We sought to evaluate the current trends in new ICD placement in the HT patient population, patient outcomes, and predictors of ICD placement. This was done through a retrospective analysis of all HT admissions receiving an ICD using the National Inpatient Sample (NIS) database.

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Methods

This was a retrospective analysis of discharge data from the NIS from 2009 to 2018. The NIS is an all-payer database that approximates a 20% stratified sample of discharges from the United States community hospitals participating in the Healthcare Cost and Utilization Project (HCUP), sponsored by the Agency for Healthcare Research and Quality.6 It includes de-identified clinical and nonclinical elements such as primary and secondary diagnoses, patient demographics, payment source, length of

Results

Between 2009 and 2018, 22,673 hospitalizations were reported for heart transplantation, during which patients either received a concurrent new ICD placement (n = 70 [0.31%]) or no new ICD placement (n = 22,603 [99.7%]) (Table 1). The mean age of the cohort studied was 53.3 (SE:0.22), and 5,997 (26.5%) of hospitalizations were female (Table 1). Baseline and clinical characteristics did not significantly differ between groups.

An overall non-significant decline was observed in the unadjusted

Discussion

This large, retrospective, and multicenter analysis provides an overview regarding the implantation of ICD in HT patients, either concurrently at the time of HT or in patients with a history of HT. In both groups, a temporal analysis of ICD placement rates and mean LOS did not show a significant trend from 2009 to 2018. However, results should be interpreted with caution because of the small cell counts and limited data points available. During this period, a mortality benefit, or harm, from

Disclosures

The authors have no conflicts of interest to declare.

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