Abstract 9500: Patients’ Perspectives Regarding Generator Exchanges of Implantable Cardioverter-Defibrillators

Abstract

Background: Shared decision-making (SDM) is mandated for patients receiving primary prevention implantable cardioverter-defibrillators (ICD). Less attention has been paid to ICD generator exchange (GE) decisions. At the time of GE, patients’ risk of sudden cardiac death (SCD), risk of procedural complications, quality of life, or prognosis may have changed. This study was designed to explore how patients view GE decisions. Methods: In-depth interviews about perspectives regarding GE decisions were conducted with patients who had primary prevention ICDs implanted at Emory Healthcare from 2013-2021. Patients were also presented a hypothetical scenario where their ICD battery was depleted but their risk of SCD over 5 years at the time of battery depletion varied (10%, 5%, 1%). Patients were asked about their willingness to undergo GE under each of these conditions. Transcribed interview text was qualitatively coded using a multilevel template analytic method. Results: Fifty patients were interviewed, of whom 19 had a prior GE, 16 had no prior ICD therapies and 14 had improved left ventricular ejection fraction. Overall, even with low SCD risk, patients’ willingness to undergo a GE remained high (Figure). If their doctor recommended deferring GE, 15/49 patients still would not defer a GE. Many patients reported not relying on risk/benefit estimates to make GE decisions. Most also reported deferring the decision to their doctor, and many exhibited significant therapeutic inertia. One patient stated, “since I’m already wired for it⋯wouldn’t make sense to disregard it.” Conclusion: Strong default preferences push patients towards a GE. Risk stratifying patients for SCD at the time of GE may facilitate SDM and may reduce GE in very low-risk patients. However, even at 1% risk of SCD, which would not meet thresholds for ICD therapy, most patients would choose GE. This highlights provision of risk information alone seems unlikely to drive substantially different GE decisions.