Utilization of Implantable Defibrillators in the Octogenarian Population

Review of the Registry's Second Year, Data Collected, and Plans to Add Lead and Pediatric ICD Procedures

Review of the ICD Registry's Third Year, Expansion to include Lead Data and Pediatric ICD Procedures, and Role for Measuring Performance

Appropriateness of implantable cardioverter-defibrillator device implants in the United States

MP-453086-1 THE USEFULNESS OF EPS TO PREDICT APPROPRIATE THERAPIES IN PRIMARY PREVENTION ICD PATIENTS

POSTER PRESENTATIONS

ORAL PRESENTATION

MADIT II like patients have not been compared to patients without an electrophysiological study, patients in whom ventricular tachycardia or fibrillation were induced in an electrophysiological study (EPS) and patients without an inducibility in EPS in one study.The multicenter automatic defibrillator implantation trial (MADIT) II showed a benefit of ICD implantation in patients with ischemic heart disease.We performed a retrospective analysis in 93 patients with an ischemic heart disease and an ejection fraction </=30% who had an ICD implanted with a follow-up at least an 18 months. Patients were divided into 3 groups according to the primary indication for ICD implantation: without EPS (group I), patients in whom ventricular tachycardia or fibrillation were inducible in EPS (group II) or patients without an inducibility in EPS (group III).During the mean follow-up of 32.9 +/- 16.1 months 289 appropriate ICD therapies and 10 deaths occurred. The incidence of appropriate ICD therapies did not differ significantly between the groups (group I 40%, group II 54% and group III 48% of patients). We found in group II a higher risk of appropriate ICD therapies with occurrence of a specific constellation of EPS values. These patients showed a 15-fold risk (P = 0.005) of an appropriate ICD therapy. Furthermore a brain natriuretic peptide value of 265 pg/ml also predicted an appropriate ICD therapy with a 3.5-fold risk (P = 0.017).In the present retrospective study the results of MADIT II were affirmed in the case of incidence of ventricular arrhythmias in patients with an EF < 30% and coronary heart disease. The prediction of an appropriate ICD therapy with EPS was only achieved in patients with inducibility in the EPS.

473 Abnormal electric phenomena after ICD implantation. Prevalence and diagnostic role in the ICD clinic

Background and aimsImplantable cardioverter‐defibrillators (ICDs) are frequently used to prevent sudden cardiac death in patients with high‐risk arrhythmias. However, the use of ICD therapy in elderly patients beyond the predicted age of life expectancy is still controversial. We aimed to evaluate the predictors of mortality and clinical outcomes following ICD implantation in elderly patients.MethodsWe conducted a retrospective analysis of 145 elderly patients aged 72 years and older who received ICD implantation between January 2010 and August 2015. We collected and analyzed baseline data, including clinical, demographic, and medical history, the reason for ICD therapy, procedural data, and echocardiography results. Follow‐up data included the development of complications and mortality. The predictors of mortality were identified using the univariate and multivariable Cox regression models.ResultsDuring the median follow‐up duration of 30.5 [18.0–48.0] months, 141 cases completed follow‐up (mean age = 76.0 ± 3.7 years). Forty‐four patients experienced at least one episode of ICD therapy. Inappropriate shock, recurrent shock, and device‐related infection were the most frequent complications observed in our study. Of the 145 patients, 42 died during the follow‐up period, with an average survival time of 22.4 months after ICD implantation. Among these patients, 11 received ICD for primary prevention, and 31 received it for secondary prevention. Cardiovascular problems were the leading cause of death. We found that a low baseline ejection fraction (EF) was an independent predictor of mortality (hazard ratio = 0.93, 95% confidence interval: 0.90–0.98; p = 0.008).ConclusionOur study suggests that ICD therapy is a valuable treatment option for elderly patients beyond their predicted age of life expectancy. The study highlights the importance of baseline EF as a significant predictor of mortality in these patients.

Aims Current guidelines recommend ICD implantation for primary prevention in patients with ischaemic heart disease and LVEF ≤35%. We aimed to access the value of the EP study in prediction of the arrhythmic events in ischaemic patients with reduced EF (≤35%) who underwent EPS and ICD implantation and do address the impact of ICD implantation on the all-cause mortality. Methods We compared the risk for all-cause mortality in ischaemic patients with negative and positive EPS with and without ICD implantation and compared the risk for appropriate therapy according to the results of the EP study of patients who underwent ICD implantation in our institution. The median follow-up was 84 months. Results Of 235 patients, who underwent EPS, 115 were negative (noninducible to VT). These patients were more likely to be female and did not differ in age, presence of diabetes, hypertension, atrial fibrillation or ejection fraction. Kaplan-Meier survival analysis showed that there was no difference in mortality between the 2 groups (49.6% vs 44.2%, p=0.419). ICD was implanted in 168 patients: there was no difference in mortality between them (47%) and patients without implanted ICD (46.6%), p=0.861. This was true for patients with negative and positive EPS (p=0.136 and p=0.554, respectively) Of 167 patients who underwent ICD implantation, 66 had negative EPS. Kaplan-Meier analysis showed that these patients were significantly less likely to receive appropriate therapy (7.6% vs 25.7%, p=0.003) and appropriate shock (0% vs 10.9%, p=0.004. The time to first appropriate ICD therapy was significantly longer in EPS negative patients (112 vs 93 months, p&amp;lt;0.001). The incidence of inappropriate therapies was similar in both groups (2.6% vs 5.8%, p=0.221). Conclusion ICD implantation does not reduce mortality in ischaemic patients with reduced EF and both positive and negative EPS. Patients with negative EPS and implanted ICD had much lower incidence of appropriate ICD therapies and no appropriate shocks. The policy of implanting ICDs to all ischaemic patients with EF&amp;lt;35% should be reconsidered.ICD shocks according to the EPS resultsMortality with and without ICD

INFLUENCE OF AGE AND SEX ON VENTRICULAR ARRHYTHMIA IN AN ICD POPULATION

BackgroundImplantable cardioverter-defibrillator (ICD) therapy is well established for secondary prevention, but studies on the efficacy and safety in elderly patients are still lacking. This retrospective study compared the outcome after ICD implantation between octogenarians and other age groups.MethodsData were obtained from a local ICD registry. Patients who received ICD implantation for secondary prevention at our department were included. All-cause mortality, appropriate ICD therapy and acute adverse events requiring surgical intervention were compared between different age groups.Results519 patients were enrolled, 34 of whom were aged ≥ 80 years. During the median follow-up of 35 months after ICD implantation 129 patients (annual mortality rate 5.0%) had died, including 16 patients aged ≥ 80 years (annual mortality rate 9.4%). The mortality rate of patients aged ≥ 80 years was significantly higher than that of patients aged ≤ 69 years (p < 0.001), but similar to that of patients aged 70–79 years. Age at the time of ICD implantation was an independent predictor of all-cause mortality (p < 0.001). 29.7% of patients had appropriate ICD therapy with no difference between age groups. Acute adverse events leading to surgical intervention were low (n = 13) and not age-related.ConclusionAge is an independent predictor of mortality after ICD implantation for secondary prevention. Mortality rates did not differ significantly between octogenarians and other elderly aged 70–79 years. Appropriate ICD therapy and acute adverse events leading to surgical intervention were not age-related. Implantable cardioverter-defibrillator therapy for secondary prevention seems to be an effective and safe treatment modality in octogenarians.

Background: There are no upper age restrictions for ICD implantation, though guidelines state that placement should be reserved for those with expected survival of &gt; 1 year. In octogenarians, competing comorbidities may limit the mortality benefit of ICDs. Methods: A retrospective cohort study was used to identify octogenarians who received ICD implantation and follow-up at Northwestern Memorial Hospital or Tufts New England Medical Center between 1990 and 2006. The primary endpoint was death within 1 year of implant. Results: The study identified 241 octogenarians. Mean age 83.3 ± 3.1 years, 79% male, 87% coronary disease and 35% implanted for primary prophylaxis. Mean EF 31 ± 13%, creatinine 1.49 ± 0.71 mg/dl, and mean survival was 3.9 ± 0.3 years. Death within 1 year of implant occurred in 32 (13.2%) patients. Univariate predictors of 1-year mortality included EF ≤ 20% and creatinine ≥ 1.5 mg/dl (p &lt; 0.01 and 0.04, respectively). Cox proportional analysis demonstrated that EF ≤ 20% was the only independent predictor of death within 1 year of ICD implant [Hazard Ratio = 3.2 (95% CI 1.5– 6.5; p&lt;0.002)] and was associated with a 48% 1-year mortality. Of these patients, 6 (19%) received appropriate ICD therapy prior to death; the mean time from therapy to death was 3 months. Conclusion: Octogenarians with EF ≤ 20% have a very high 1-year mortality despite ICD implantation. A minority of these patients will receive appropriate ICD therapy during this time. These results would be expected to have significant impact on the cost-effectiveness of ICDs and should be considered when evaluating device implantation in this population.

<i>Circulation: Arrhythmia and Electrophysiology</i> Editors’ Picks

The prospective observational Nippon Storm Study aggregated clinical data from Japanese patients receiving implantable cardioverter-defibrillator (ICD) therapy. This study investigated the usefulness of prophylactic ICD therapy in patients with non-ischemic heart failure (NIHF) enrolled in the study.Methods and Results: We analyzed 540 NIHF patients with systolic dysfunction (left ventricular ejection fraction <50%). Propensity score matching was used to select patient subgroups for comparison; 126 patients were analyzed in each of the primary (PP) and secondary (SP) prophylaxis groups. The incidence of appropriate ICD therapy during follow-up in the PP and SP groups was 21.4% and 31.7%, respectively (P=0.044). The incidence of electrical storm (ES) was higher in SP than PP patients (P=0.024). Cox proportional hazard analysis revealed that increased serum creatinine in SP patients (hazard ratio [HR] 1.18; 95% confidence interval [CI] 1.02-1.33; P=0.013) and anemia in PP patients (HR 0.92; 95% CI 0.86-0.98; P=0.008) increased the likelihood of appropriate ICD therapy, whereas long-lasting atrial fibrillation in PP patients (HR, 0.64 [95% CI, 0.45-0.91], P=0.013) decreased that likelihood. In propensity score-matched Japanese NIHF patients, the incidence of appropriate ICD therapy and ES was significantly higher in SP than PP patients. Impaired renal function in SP patients and anemia in PP patients increased the likelihood of appropriate ICD therapy, whereas long-lasting atrial fibrillation reduced that likelihood in PP patients.