Cardiac implantable electronic devices in end-stage renal disease patients: preservation of central venous circulation

Abstract

Cardiovascular disease is the leading cause of death in patients with end-stage renal disease (ESRD). In the United States Renal Data System database, 25–29.7% of cardiac deaths are attributable to arrhythmic mechanisms [1, 2]. Ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT) likely remain the most common initiating and potentially reversible mechanisms of outof-hospital sudden cardiac death (SCD). Defibrillation is the only predictably effective therapy for reverting VF and pulseless VT to an effective rhythm for restoration of blood flow [3]. The expanding indications of implantable cardioverter-defibrillator (ICD) therapy for primary and secondary prevention of SCD have significantly increased the patient population with cardiac implantable electronic devices (CIEDs) [4]. A meta-analysis of secondary prevention trials showed a 28% relative risk reduction (RRR) in all-cause mortality (p0 0.0006) with ICD therapy that was due almost entirely to a 50% RRR in arrhythmic death (p<0.0001); similarly, primary prevention trials showed a 28% reduction in the risk of death in the ICD-treated patients as compared with the conventionally treated patients and an overall absolute 2year mortality reduction of 3% [3]. Despite the high incidence of SCD among patients with ESRD and the proven survival benefits of ICD therapy, the benefit of ICD therapy in this patient population has been questioned. This is probably due to the fact that all major ICD trials excluded patients with advanced renal dysfunction and transvenous ICD therapy is associated with higher complications rates in this patient group; especially, on hemodialysis (HD) patients. Our current knowledge regarding the efficacy of ICD therapy in this population relies on observational data and secondary post hoc analyses of major ICD trials [5–11]. Initially, ICDs were implanted via thoracotomy, which was associated with mortality rates of 3% to 5.4%. The development of transvenous ICD systems in the early 1990s was associated with an operative mortality of <1%, lower costs, and shorter hospital stays [12–14]. For these reasons, the transvenous route has become the most frequently used method for implantation of CIEDs. However, the use of the transvenous CIEDs can be associated with significant complications in chronic HD patients including central venous stenosis, tricuspid regurgitation (TR), and device infection [15–31]. Varies degrees of central venous stenosis have been reported in 23% to 67% patients with transvenous CIEDs [15–17]. This complication is asymptomatic in most patients. However, the situation is different in patients on G. Lopera : R. Carrillo Division of Cardiology, University of Miami, Miller School of Medicine, Miami, FL, USA