# Prediction of Late Ventricular Arrhythmias in Patients with Left Ventricular Assist Device: Insights from the VT-LVAD Consortium

Raphaël Martins, Vincent Galand, Erwan Flécher, Pierre Groussin, K Bode, E Efimova, A Dashkevich, J Liang, J Larson, Blandine Mondésert, et al.

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Raphaël Martins, Vincent Galand, Erwan Flécher, Pierre Groussin, K Bode, et al.. Prediction of Late Ventricular Arrhythmias in Patients with Left Ventricular Assist Device: Insights from the VT-LVAD Consortium. EP-Europace, 2025, 27 (12), pp.euaf297. 10.1093/europace/euaf297. hal-05390776

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Distributed under a Creative Commons Attribution 4.0 International License
# Prediction of late ventricular arrhythmias in patients with left ventricular assist device: insights from the VT-LVAD consortium

Raphael Martins<fnref n="1" />, Vincent Galand², Erwan Flecher<fnref n="1" />, Pierre Groussin<fnref n="1" />,
Kerstin Bode³, Elena Efimova³, Alexey Dashkevich⁴, Jackson Liang⁵,
John Larson⁶, Blandine Mondesert⁷, Jacinthe Boulet⁷,
Pierre-Emmanuel Noly⁷, Frederic Sacher⁸, Jean Luc Pasquié⁹,
Jean-Baptiste Gourraud¹⁰, Sandro Ninni¹¹, Laurence Jesel¹²,
Alexandre Sebestyen¹³, Vincent Algalarrondo¹⁴, Jean-Claude Deharo¹⁵,
Frederic Anselme¹⁶, Laure Champ-Rigot¹⁷, Charles Guenancia¹⁸,
Bertrand Pierre¹⁹, Romain Eschalier²⁰, Mathieu Echivard²¹,
Pierre Baudinaud²²,²³, Nicolas Lellouche²⁴, Kevin Gardey²⁵,
Karim Benali²⁶, Paul Gautier²⁷, Clément Delmas²⁷, and Miloud Cherbi²⁸*

Received 30 October 2025; accepted after revision 31 October 2025; online publish-ahead-of-print 17 November 2025

**Keywords**

Left ventricular assist device • Ventricular arrhythmia • Ventricular tachycardia • Ventricular fibrillation • Electrical storm • Heartmate • Heartware

Ventricular arrhythmias (VAs) are highly prevalent complications in left ventricular assist device (LVAD) recipients, with late VAs—occurring beyond 30 days post-implantation—affecting 20–50% of patients at 1 year.<fnref n="1" />,² Unlike early VAs, which are often triggered by acute perioperative factors such as electrolyte disturbances or suction events, late VAs primarily arise from the underlying arrhythmogenic substrate of the

cardiomyopathy.<fnref n="1" />,³,⁴ Despite their substantial clinical burden, data on late VA characteristics and risk prediction remain limited, and management strategies are poorly standardized. The VT-LVAD score⁴,⁵ was recently proposed as a simple tool to identify patients at risk of late VAs based on six readily available clinical variables: early VAs (≤30 days) after implantation, prior VA history, absence of angiotensin-

<footnote n="1">¹Cardiology Department, University of Rennes, CHU Rennes, CIC 1414, INSERM, LTSI-UMR 1099, Rennes F-35000, France; ²Interventional Cardiology Department, Saint Joseph Clinic, Trélazé, France; ³Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany; ⁴Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany; ⁵Division of Cardiology, University of Michigan, Ann Arbor, MI, USA; ⁶Department of Cardiovascular Disease, Emory University, Atlanta, GA, USA; ⁷Montreal Heart Institute, Department of Medicine, Division of Cardiology, Université de Montréal, Montreal, QC, Canada; ⁸IHU LIRYC, CHU Bordeaux, Bordeaux University, INSERM 1045, Bordeaux F33000, France; ⁹Department of Cardiology, University Hospital of Montpellier, Montpellier, France; ¹⁰Department of Cardiology, CHU Nantes, Nantes, France; ¹¹University of Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France; ¹²Department of Cardiology, University Hospital of Strasbourg, Strasbourg, France; ¹³Department of Cardiac Surgery, University Hospital of Grenoble Alpes, Grenoble, France; ¹⁴Department of Cardiology, CHU Bichat, APHP, Paris, France; ¹⁵Assistance Publique-Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, France and Aix Marseille Université, C2VN, Cardiologie-Hôpital La Timone, Boulevard Jean Moulin, Marseille 13005, France; ¹⁶Department of Cardiology, Rouen University Hospital and UNIROUEN, INSERM U1096, Rouen, France; ¹⁷Department of Cardiology, Caen University Hospital, Normandie University, UniCaen, Caen, France; ¹⁸Cardiology Department, University Hospital, Dijon, France; ¹⁹Department of Cardiology, University Hospital of Tours, Tours, France; ²⁰Cardiology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France; ²¹Department of Cardiology, CHRU Nancy, Vandoeuvre-les-Nancy, France; ²²Division of Cardiology, European Georges Pompidou Hospital, Paris, France; ²³Université Paris Cité, INSERM U970, Paris Cardiovascular Research Centre, Paris, France; ²⁴Department of Cardiology, Hôpital Henri Mondor, Creteil, France; ²⁵Cardiac Electrophysiology Department, Institut cardiologique de Lyon, Hôpital cardiologique Louis-Pradel, Hospices civils de Lyon, Université Claude-Bernard Lyon 1, Bron 69500, France; ²⁶CHU Saint-Étienne, Université Jean Monnet, Mines Saint-Étienne, Inserm U1059, SAINBIOSE, Saint-Étienne, France; ²⁷Cardiology Department, Toulouse University Hospital, Toulouse, France; and ²⁸Department of Cardiology, AZ Sint-Jan Hospital, Ruddershove 10, Bruges 8000, Belgium</footnote>

<footnote>* Corresponding author. Tel: +33561323535. E-mail address: cherbi.miloud@gmail.com
© The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.</footnote>
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<figure><img src="image_3.png" /><figcaption>**Figure 1** Risk stratification and prediction of late ventricular arrhythmias according to the VT-LVAD score. (A) Kaplan-Meier curves showing freedom from late VAs across VT-LVAD risk groups over 3-year follow-up. (B) Relationship between VT-LVAD score and late VA risk. AIC, Akaike information criterion; HR, hazard ratio; LVAD, left ventricular assist device; VA, ventricular arrhythmia.</figcaption></figure>

converting enzyme inhibitor therapy, heart failure duration > 12 months, pre-implantation atrial fibrillation, and idiopathic dilated cardiomyopathy. However, this score has never been validated in large multicentre cohorts. Therefore, this study aimed to validate the performance of the VT-LVAD score in predicting late VA occurrence using data from an international, multicentre LVAD registry.

The VT-LVAD Consortium is an international, retrospective, multicentre study including LVAD patients implanted with durable continuous-flow devices between 2006 and 2019 across tertiary centres in France, Germany, the USA, and Canada. Patients were stratified into four risk groups according to their VT-LVAD score⁴: low (0–1 point), intermediate (2–4 points), high (5–6 points), and very high (7–10 points). The primary endpoint was the occurrence of late VAs (occurring more than 30 days after LVAD implantation) at 3-year follow-up, defined as sustained (>30 s) ventricular tachycardia or ventricular fibrillation, or shorter episodes if treated medically, by external electrical shock, or by appropriate implantable cardioverter-defibrillator (ICD) therapy. Kaplan-Meier survival analysis was performed to assess freedom from late VAs across risk groups, with hazard ratios (HRs) computed through multivariate Cox regression adjusted for age, gender, pre-LVAD ejection fraction, LVAD device type, LVAD strategy (bridge-to-transplantation vs. destination therapy), heart failure medications after implantation (beta-blockers, angiotensin receptor blockers, mineralocorticoid receptor antagonists), and presence of ICD prior to implantation. The relationship between the VT-LVAD score and late VA risk was further assessed using fractional polynomial analysis to evaluate linearity. All tests were two-tailed with *P* ≤ 0.05 accepted as statistically significant. Analyses were performed using R

(v4.3.2). This study was approved by the institutional review board or ethics committee of each participating centre.

The analysis included 1146 LVAD patients with a median follow-up of 20.6 months. Based on the VT-LVAD score, 114 patients (9.9%) were classified as low risk, 425 (37.1%) as intermediate, 319 (27.8%) as high, and 288 (25.1%) as very high risk. The median age was 59.4 years and 84.6% were men. Patients in higher risk groups were older and had more comorbidities including diabetes and hypertension and lower ejection fraction. Overall, 311 patients (27.1%) experienced late VAs after a median time of 12.4 months, with event rates of 7.9% in the low-risk, 13.6% in intermediate, 34.5% in high, and 46.5% in very high-risk groups. Kaplan-Meier analysis demonstrated clear risk stratification across groups (Figure 1A), with adjusted HRs of 1.77 (0.88–3.57) for intermediate, 4.84 (2.45–9.55) for high, and 7.39 (3.76–14.51) for very high-risk groups compared with the low-risk reference (P for trend < 0.01). When analysed as a continuous variable, the VT-LVAD score demonstrated a strong linear relationship with late VA risk (C-index = 0.7, *P* for non-linearity ≥ 0.99), with each point increase associated with 30% higher VA risk [HR 1.32 (1.26–1.39)], and a clear threshold effect observed around score 5 above which hazard ratios consistently exceeded 1.0 (Figure 1B).

To date, this represents the largest international study validating the VT-LVAD score for predicting late VAs in LVAD recipients. Our main findings are as follows: (i) the cumulative incidence of late VAs reaches 27.1%, confirming this as a common complication; (ii) the VT-LVAD score, based on six easily accessible clinical variables, demonstrated good performance in risk stratification; and (iii) each 1-point increase in the score was associated with 30% higher late VA risk, with a clear threshold effect around score 5.
These results have important clinical implications for individualizing pa-
tient management. Specifically, while the survival benefit of ICD therapy in
this population remains unproven,¹,⁵ ICD implantation is widespread with
nearly 50% of LVAD patients having ICDs prior to device placement,⁵ mak-
ing risk-based decision-making guided by the VT-LVAD score particularly
relevant. Rather than a generalized approach, our findings suggest indivi-
dualized decision-making based on intrinsic arrhythmic risk assessment,
where ICD therapy should be strongly considered in patients classified
as high or very high risk (score ≥ 5), whereas those with low scores may
not benefit from ICD therapy since, beyond the lack of demonstrated sur-
vival benefit, ICD in LVAD recipients is associated with high risks of poten-
tial complications including inappropriate shocks, electromagnetic
interference, infections, and pocket haematomas.¹,⁵,⁶ Beyond ICDs, the
VT-LVAD score may also help identify candidates for prophylactic catheter
ablation at the time of LVAD implantation, a strategy currently being eval-
uated in the PIVATAL trial.⁷ Future prospective studies should determine
whether risk-stratified management strategies guided by this score can im-
prove patient outcomes and optimize therapeutic decisions.

Our study has several limitations. First, the retrospective design may
have introduced selection bias, and patients without ICDs may have ex-
perienced undetected self-terminating VAs, though this reflects real-
world practice. Moreover, we lacked detailed data on antiarrhythmic
therapies and catheter ablation during follow-up.

In conclusion, this large international multicentre study validates the
VT-LVAD score as a reliable tool for predicting late VA risk in LVAD
recipients. The score demonstrated good discrimination and can be
used to individualize risk stratification in clinical practice. Future studies
should evaluate whether risk-stratified management strategies guided
by this score can optimize therapeutic decisions, particularly regarding
ICD implantation and prophylactic catheter ablation.

Acknowledgements

None declared.

Funding

No funding was received for this study.

**Conflict of interest.** None declared.

Data availability

The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.

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