We know that cardiac implantable cardioverter-defibrillators (ICD)s save lives. The pivotal studies done around 20 years ago confirmed the value of these devices for both primary and secondary prevention of sudden cardiac death (SCD) and have led to guideline recommendations for their use in patients with prior episodes of life-threatening sustained ventricular arrhythmias (Class I) or heart failure and a left ventricular ejection fraction (LVEF) of ≤35 (Class I). The guidelines provide only limited recommendations for the select subset of patients with prior orthotopic heart transplant (OHT), stating that in the presence of "severe allograft vasculopathy with left ventricular (LV) dysfunction, an ICD may be reasonable" (Class MB). It has not been clear how the more general guidance applies to this group and there is an important caveat for all of these recommendations: that the patient has an expected meaningful survival of greater than 1 year.
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