Abstract 17896: Implantable Cardioverter Defibrillator in Cardiac Resynchronization Therapy Recipients With Advanced Chronic Kidney Disease

Abstract

Introduction: The effectiveness of the implantable cardioverter defibrillator (ICD) in preventing sudden cardiac death (SCD) is well-established in heart failure patients with reduced ejection fraction (HFrEF). However, the benefit of the ICD in advanced chronic kidney disease (CKD) patients remains elusive, particularly in those who are cardiac resynchronization therapy (CRT) recipients. Hypothesis: In CRT recipients with CKD, the benefit of the ICD may be attenuated due to the competing risk of mortality before experiencing an arrhythmia. Methods: A total of 1015 patients receiving CRT with defibrillator (CRT-D) for primary prevention of SCD were included from the MADIT-CRT and RAID trials. Patients were categorized into two groups based on kidney disease (KD) stage: Stage 1-3a (S1-S3a) CKD and Stage 3b-5 (S3b-S5) CKD. The primary endpoint was the occurrence of ventricular tachycardia (VT) or ventricular fibrillation (VF). Results: The cumulative incidence of any VT/VF was 23.5% in patients with (S1-S3a)KD and 12.6% in those with (S3b-S5)KD (p<0.001 [Figure left panel]). Death without VT/VF occurred in 6.6% of patients with (S1-S3a)KD and 21.6% of patients with( S3b-S5)KD (p<0.001 [Figure right panel]). A multivariate competing risk regression model revealed that patients with (S3b-S5)KD had a 43% lower risk of experiencing any VT/VF compared to those with (S1-S3a)KD (HR=0.56, 95% CI [0.33-0.94], p=0.03). Over two years of follow-up, patients with (S3b-S5)KD had nearly a five-fold increased risk of death without VT/VF compared to those with (S1-S3a)KD (HR=4.63, 95% CI [2.46-8.72], p for interaction with time=0.012). Conclusions: The benefit of the ICD may be attenuated in CRT recipients with advanced CKD due to a lower incidence of arrhythmias and a higher risk of non-arrhythmic death. Future prospective trials should investigate whether CRT without a defibrillator is more suitable for these patients.