Implantable Cardioverter-defibrillator Placement Research Articles

Long-term follow-up of patients with Brugada syndrome: Foremost risk factors associated with overall arrhythmic events.

Brugada syndrome (BS) is characterized by ST segment elevation in right precordial leads (V1-V3), ventricular tachycardia (VT), ventricular fibrillation (VF), and sudden cardiac death (SCD) in individuals without structural heart disease. The aim of this study is to contribute to the controversial issue of finding the most valuable marker that can predict poor prognosis during follow-up in patients with a diagnosis of BS. A total of 68 patients diagnosed with BS or had Brugada-type ECG change between January 1997 and July 2012 at the Department of Cardiology of Başkent University Faculty of Medicine, Ankara, Turkey, were included in this cohort study. Patients were screened every 6 months for arrhythmia-related syncope, SCD, appropriate and inappropriate defibrillation (shock), AF development and death; collectively defined as "arrhythmic events" and were the primary endpoints. Patients with and without arrhythmic events were compared. The mean age was 34.9 ± 12.2 years (9-71 years), and 52 (76.5%) patients were male. Mean follow-up was 49.6 ± 37.6 months (4-188 months). Univariate analysis showed that male sex (P = .004), type 1 electrocardiographic pattern (P = .008), SCD (P = .036), VT/VF history (P = .046), requirement for electrophysiological studies (P = .034), implantable cardioverter-defibrillator placement (P = .014) were found to demonstrate significant differences in patients with and without arrhythmic events. In multivariable analyzes, spontaneous type 1 ECG presence (HR = 8.54, 95% CI: 0.38-26.37; P = .003) and VT/VF history (HR = 9.21, 95% CI: 0.004-1.88; P = .002) were found to be independently associated with arrhythmic events. We found the presence of spontaneous type 1 ECG and a history of VT/VF to be associated with increased likelihood of overall arrhythmic events in BS. Given the higher risk of poor prognosis, we recommend additional measures in patients with BS who have these features.

Defibrillator Lead Perforation Leading to Concerning Electrocardiogram Findings: Case Report

Introduction: Implantable cardioverter-defibrillator (ICD) lead perforation through the myocardium may result in chest pain and electrocardiogram (ECG) changes concerning for ST-segment elevation myocardial infarction. The clinical context of the ECG aids in appropriate management.Case Report: We report the case of a 71-year-old woman experiencing chest pain after an ICD placement two weeks earlier. On presentation, she exhibited ST-segment elevation on her ECG. Computed tomography confirmed ICD lead migration. The patient’s hemodynamics were normal, and she was discharged home after a five-day hospital stay following a lead revision.Conclusion: Although rare, ICD lead perforation is a potential cause of chest pain and ischemic ECG changes. Emergency physicians should consider lead perforation as a potential differential diagnosis when evaluating chest pain in patients with ICDs, taking into account the potential complications of coronary angiography.

Peri-Operative Outcomes Associated With the Placement of Implantable Cardioverter-Defibrillators in Patients With Sarcoidosis: A Nationwide Database Analysis.

Rationale Sarcoidosis with cardiac involvement can be associated with serious life-threatening arrhythmias and an increased risk of sudden cardiac death. Implantable cardiac defibrillators (ICDs) have been used for primary and secondary prevention of sudden death in patients with cardiac sarcoidosis (CS).Post-ICD placement complications have been shown to be higher in patients with CS. However, data comparing postoperative ICD complications among sarcoidosis patients with the general population is limited. Here, we evaluated the association of postoperative complications with implantable cardioverter-defibrillators in sarcoidosis. Methods Using the NIS database, we identified cases of adults aged ≥ 18 years undergoing surgical placement of implantable cardioverter-defibrillators between 2010 and 2019. Using ICD-9 and ICD-10 codes, we identified patients with sarcoidosis. In all statistical analyses, we applied weights provided by HCUP to produce results representative of national estimates. We compared categorical and continuous covariates in the baseline characteristics using the chi-square test and analysis of variance, respectively. We employed multivariable logistic and linear regression to compare binomial and continuous outcomes to assess differences in mortality rates. Results We analyzed 114073 patients during the study period. Of these, 1012 (0.9%) had sarcoidosis and were found to be significantly younger and female compared to patients without sarcoidosis (56.4 ±11.5 years vs. 65.6 ± 13.9 years, p <0.001) and (39.4% vs. 28.3%, p<0.001) respectively. Further, patients with sarcoidosis were more likely to be African American (45% vs. 16.3%), have private insurance (45.4% vs. 23.8%), and less likely to have Medicare (34.9% vs. 60.9%). Overall, post-ICD placement complications such as lead complications (4.2% vs. 6.9%, p = 0.03), post-procedure hemorrhage (4.1% vs. 5.5%, p=0.048), and requirement for transfusion (2.3% vs. 4.4%) were less likely in patients with sarcoidosis. Regarding post-ICD placement inpatient mortality, sarcoidosis was not associated with any difference(OR: 0.71, 95% CI 0.18-2.88 p=0.634). Conclusions Placement of implantable cardioverter-defibrillators in patients with sarcoidosis is a safe procedure and is associated with significantly lower rates of lead complications, post-procedure hemorrhage, and requirement for transfusion. This is of great importance as it is known that patients with underlying sarcoidosis are predisposed to developing more cardiac complications.

[Whether to implant a defibrillator or not? The Possibility of Using the MADIT-ICD Benefit Score Calculator in Real Practice].

To study the predictive capabilities of the MADIT-ICD Benefit Score calculator in assessing the benefit of implantable cardioverter defibrillator (ICD) placement for the primary prevention of sudden cardiac death (SCD). This study included 388 patients with NYHA II-IV functional class chronic heart failure (CHF) with a left ventricular ejection fraction (LVEF) ≤35 % who underwent ICD placement for the primary prevention of SCD. Patients were followed up for two years to record the endpoints of first-time paroxysmal sustained ventricular tachyarrhythmia (VT) or non-arrhythmic death. According to the results of calculation with the MADIT-ICD Benefit Score calculator, 276 (71 %) patients had a high risk of VT (score ≥7) and 150 (39 %) had a high risk of non-arrhythmic death (score ≥3). 336 (94%) patients would benefit from an ICD: 148 (38 %) with a high level of probability and 218 (56 %) with a medium level of probability. According to the incidence of endpoints, VT episodes predominated in the low-ICD benefit group (36%), while the high-ICD benefit group had a relatively high incidence of non-arrhythmic death (12%). The results obtained for a cohort of Russian patients with CHF and reduced LVEF indicated that the use of the MADIT-ICD Benefit Score in routine clinical practice does not improve the stratification of SCD risk compared to the traditional approach to selecting patients with CHF for ICD based on the LVEF value.

Implantable loop recorder in Brugada syndrome: Insights from a single-center experience

BackgroundThis study aimed to investigate the characteristics and outcomes of patients diagnosed with Brugada syndrome (BrS) who underwent implantable loop recorder (ILR) insertion during routine clinical activity. MethodsWe conducted a comprehensive screening of all consecutive patients diagnosed with BrS at our institution. We analyzed baseline clinical characteristics, arrhythmic findings, and outcomes. ResultsOut of 147 BrS patients, 42 (29 %) received an ILR, 13 (9 %) underwent implantable cardioverter-defibrillator (ICD) placement, and 92 patients (63 %) continued regular cardiological follow-up. Patients who received an ILR had a higher prevalence of suspected arrhythmic syncope (43 % vs. 22 %, p = 0.012) and tended to be younger (median age 38 years, interquartile range 30–52, vs. 43 years, 35–55, p = 0.044) with a higher presence of SCN5A gene mutations (17 % vs. 6 %, p = 0.066) compared to those who continued regular follow-up. Additionally, compared to patients with an ICD, those with an ILR had a significantly lower frequency of positive programmed ventricular stimulation (0 % vs. 91 %, p < 0.001). During a median follow-up period of 14.7 months (4.7–44.8), no deaths occurred among the patients with ILR. Eight individuals (19 %) were diagnosed with arrhythmic findings through continuous ILR monitoring, primarily atrial fibrillation, and asystolic pauses. The median time from insertion to the occurrence of these events was 8.7 months (3.6–46.4). No adverse events related to ILR were reported. ConclusionContinuous monitoring with ILR may facilitate the timely detection of non-malignant rhythm disorders in BrS patients with risk factors but without an indication for primary prevention ICD implantation.

Association of Device-Detected Atrial High-Rate Episodes With Long-term Cardiovascular and All-Cause Mortality: A Cohort Study

BackgroundDevice-detected atrial high-rate episodes (AHREs) were associated with an increased thromboembolic risk. Although limited data regarding the long-term prognosis of patients with AHRE were controversial, this study aimed to identify the association of device-detected AHRE with mortality. MethodsThis observational study included patients with implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) placement and no history of atrial fibrillation (AF), atrial flutter (AFL), or atrial tachycardia (AT). During follow-up, patients with at least 1 day of AHRE duration ≥ 15 minutes were identified. The primary endpoint was cardiovascular mortality, and the secondary endpoint was all-cause mortality. ResultsDuring a mean follow-up period of 4.2 years, AHREs were detected in 124 of 343 (36.2%) patients. Of these, 44 deaths (35.5%) occurred in 124 patients with AHREs, which was significantly higher than those without AHREs (43 of 219; 19.6%; P = 0.001). The multivariate analysis revealed that patients with AHRE had a significantly higher risk of cardiovascular (hazard ratio [HR], 2.40; 95% confidence interval [CI], 1.23-4.67; P = 0.010), and all-cause mortality (HR, 2.31; 95% CI, 1.49-3.59; P < 0.001). Further analysis indicated that this association remained significant in patients with higher burden (≥ 6 hours) but not in patients with lower burden (≥ 15 minutes to 6 hours). Notably, even after excluding the patients diagnosed with clinical AF during follow-up, the remaining patients with AHREs still exhibited a higher risk of cardiovascular and all-cause mortality compared with patients without AHREs. ConclusionsAHREs were prevalent in ICD or CRT-D recipients with no history of clinical AF, AFL, or AT and were associated with more than twice the risk of cardiovascular and all-cause mortality. Clinical Trial RegistrationNo. ChiCTR-ONRC-13003695.

Challenges and Applications of Genetic Testing in Dilated Cardiomyopathy: Genotype, Phenotype and Clinical Implications.

Genetic tests for dilated cardiomyopathy (DCM) have a diagnostic yield of up to 40%, but there is significant genetic heterogeneity and other challenges, such as variable expressivity and incomplete penetrance. Pedigree analysis is essential for distinguishing between sporadic and familial DCM cases by assessing family history. Familial DCM yields higher results in genetic testing, but sporadic DCM does not rule out the possibility of a genetic cause. Some genes have specific phenotypes, with the Lamin gene ( LMNA ) being associated with a phenotype of malignant arrhythmias and advanced heart failure (HF). The presence of a causal genetic variant can also aid in prognostic evaluation, identifying more severe cases with lower rates of reverse remodeling (RR) compared to individuals with a negative genotype. Current guidelines recommend genetic evaluation and counseling for individuals with DCM, along with cascade screening in first-degree relatives in cases where one or more variants are identified, offering an opportunity for early diagnosis and treatment. Relatives with a positive genotype and negative phenotype are candidates for serial evaluation, with frequency varying by age. Genotype also assists in individualized recommendations for implantable cardioverter-defibrillator (ICD) placement and advice regarding physical activity and family planning. Ongoing studies are progressively elucidating the details of genotype/phenotype relationships for a large number of variants, making molecular genetics increasingly integrated into clinical practice.

Abstract 16140: Utility of Cardiovascular Magnetic Resonance Imaging in Clinical Decision Making for Children and Adolescents With Hypertrophic Cardiomyopathy

Introduction: Cardiovascular magnetic resonance (CMR) imaging is recommended for surveillance and risk stratification in patients with hypertrophic cardiomyopathy (HCM), but the role of CMR findings in clinical decision making has not been described in a pediatric population. Methods: In this single center retrospective study we identified all patients with HCM who underwent CMR. We then determined if there was a clinical management change based on CMR findings. Results: We identified 136 patients with an HCM diagnosis from 2005-2022. Of these, 55 patients (40%) underwent 76 CMR studies. The HCM etiology was genetic or familial in 31 (56%), idiopathic in 21 (38%), and syndromic in 3 (5%); 34% of patients were female; and the median age (and IQR) of included patients at first CMR was 12 (9-15) years old. Ten patients underwent more than one CMR. Both awake and sedated CMRs were included and there were no complications. Management changes included confirmation of HCM diagnosis in 9 patients (16%), change in medical therapy for 3 (5%), myectomy recommendation in 1 (2%), and implantable cardioverter defibrillator (ICD) placement recommendation in 11 (20%). Of those recommended for ICD placement, 8 were a result of new late gadolinium enhancement and 3 had massive septal hypertrophy (median Z-score 30) discovered or confirmed by CMR. To date, no ICDs have discharged any shocks. Altogether, changes in clinical management were made based on CMR findings for 22 patients (40%), representing a change in management as a result of 29% of the total CMRs performed. Conclusion: CMR is an important contributor to clinical decision making in the management of children and adolescents with HCM. Specifically, CMR in this population was especially useful in defining the diagnosis of HCM in the presence of an equivocal echocardiogram and deciding to place an ICD. Fewer CMRs contributed to decision making regarding medical therapy and septal myectomy.

Abstract 14514: Hypertrophic Cardiomyopathy - Genotype Distribution and Genotype-Phenotype Correlations - A Unique Perspective From a Single Center Study

Background: The role of genotype in risk stratification of hypertrophic cardiomyopathy (HCM) is unclear. Hypothesis: Genotype status affects phenotype and associated outcomes. Aims: To evaluate genotype-phenotype correlations in all adult HCM patients seen at our Cardiac Specialty Center over 13 years and associated outcomes. Methods: We evaluated genotype-phenotype correlations, all-cause mortality, and a composite outcome, including mortality, stroke, implantable cardioverter-defibrillator placement, heart failure hospitalization, LV assist device implantation, heart transplant, septal myectomy, and alcohol septal ablation. Results: Of 827 HCM patients, genotyping was completed in 754 (91.2%), which included 27% genotype-positive (Gen-P), 22% variants of unknown significance (VUS), and 51% genotype-negative (Gen-N) patients with a mean age of 47, 57, and 58 years, respectively. The most common gene implicated was MYBPC3 (63%). LV hypertrophy on electrocardiogram was more frequent in Gen-N than Gen-P patients. Gen-P patients had more frequent non-sustained ventricular tachycardia on Holter monitoring (25% vs 10%), grade III diastolic dysfunction (12% vs 7%), elevated ProBNP (71% vs 61%), and lower ejection fraction (66% vs 69%) than Gen-N patients (P &lt;.05 for all comparisons). All heart transplantations (N=5) were performed in Gen-P patients. LVOT obstruction was more frequent in Gen-N than Gen-P patients (48% vs 26%, P &lt;.01). Distribution of outcomes is shown in Panels A-H. The composite outcome was worse in Gen-P vs Gen-N patients (HR 1.84, P &lt;.01). The other independent predictors of poor composite outcome were old age, male sex, obesity, and atrial fibrillation. A separate analysis of mortality showed similar survival in all groups. Conclusion: Differences exist in phenotype and outcomes based on the genotype status, with more severe phenotype and poorer outcomes in Gen-P patients in our single-state single-center experience.

Abstract 16037: Vaping Associated Sudden Cardiac Arrest in a Young Healthy Patient

Introduction and Importance: While the use of vaping has increased significantly among young individuals, the effects of the various vape aerosol chemical contents on cardiac electrophysiological dynamics remain unknown. Case Presentation: A 22-year-old female with a history of energy vaping but no significant past medical history presented with cardiac arrest. Found to have no pulse, CPR was started and initial rhythm of ventricular tachycardia was obtained. Shock was administered with follow-up rhythm of ventricular fibrillation. Patient was shocked again and entered atrial fibrillation with rapid ventricular response. She later cardioverted into sinus tachycardia and was intubated. Transthoracic echocardiogram showed normal ejection fraction but was otherwise unremarkable. Patient was extubated on day four of hospitalization. Left heart catheterization and cardiac MRI were completely unremarkable. Toxicology, urine analysis, and troponins were all negative. Patient was discharged with metoprolol tartrate, and a life-vest with outpatient follow-ups for possible implantable cardioverter-defibrillator placement in the setting of negative work up for sudden cardiac arrest. Clinical Discussion: Vaping-induced sudden cardiac arrest may be attributed to a reduction in cardiac repolarization reserve. Exposure to vegetable glycerin and propylene glycol, substances present in nearly all vape products, have been found to incite arrhythmias and disrupt cardiac conduction in animals. Acrolein,a byproduct of glycerin, has also been found to induce arrhythmias due to autonomic dysfunction. Increased prevalence of ventricular arrhythmias have also been noted with exposure to aerosols containing nicotine-free propylene glycol (PG).This likely stems from the impact of PG aerosols on the transient outward potassium current, which plays a significant role in early cardiac repolarization. Conclusion: The effects of inhaling vape aerosols remain not fully understood. While there is a perceived notion that nicotine-free aerosols may not be harmful, that remains unclear.Further studies should be conducted to evaluate for pro-arrhythmogenic effects and autonomic dysfunction from the various chemical substances present in vape aerosols.

Abstract 15634: Primary Prevention Defibrillator Use in a Safety-Net Setting

Introduction: Disparities in use of implantable cardioverter-defibrillators (ICD) for primary prevention have been documented; however, whether ICDs may be underutilized within a safety-net healthcare system has not been studied. Methods: Using an electronic health record cohort of all patients with heart failure (HF) who received care within the public safety-net system in San Francisco from 2001-2018 linked to device implantation records from two health systems, we identified all patients with ICD implantation (adjudicated with manual chart review) and primary prevention ICD-eligible with no indication for secondary prevention ICD, EF&lt;35% on 2 echocardiograms at least 90 days apart, HF hospitalization (to increase specificity for symptomatic HF), and prescribed beta blocker and ACEi/ARB. For exploratory survival analysis, eligibility and follow up started at the second echocardiogram. Results: Out of 14,230 patients with HF, at least 384 patients were potentially eligible for primary prevention ICD, but only 9 (2.3%) had an ICD implanted (2 CRT-D, 7 ICD). Of these 6 were nonischemic, and 3 had revascularized ischemic cardiomyopathy. Those who received ICD were younger (47 years vs 55 years; p=0.05), with lower rates of substance use (Table). Among 4 patients who died after ICD, median survival after device placement was 2.8 years (range 0.73 to 7.3); among 5 still alive, median follow up is 6.2 years (range 5.5 to 7.0). In an exploratory analysis, survival did not greatly differ by ICD placement (logrank p=0.53; age-adjusted HR 1.55; 95%CI 0.57-4.24). Conclusion: Among individuals receiving care at a safety-net system in San Francisco, even acknowledging that not all barriers to ICD placement are measured, very few guideline-eligible patients received primary prevention ICD. Additional studies are needed to identify patient-level and systems-level barriers to referral and implantation specific to a diverse, publicly insured patient population.

Abstract 18348: Causes and Predictors of 30-Day Readmissions Following Permanent Pacemaker Implantation in Patients With Cardiac Amyloidosis: From National Readmission Database (2016-2020)

Introduction: Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy where local deposition of amyloid fibrils causes heart failure, arrhythmias, and conduction system abnormalities. Involvement of the AV nodal and infra-hisian conduction system increases the need for a permanent pacemaker (PPM). Studies have noted worse outcomes in patients with implantable-cardioverter defibrillator placement in amyloidosis, but a comparison with PPM is lacking. We sought to analyze readmissions in CA patients following PPM placement utilizing National Readmission Database (NRD). Methods: NRD (2016 to 2020) was queried to identify adults with a diagnosis of CA who underwent PPM implantation using ICD-10 CM and PCS codes. The primary outcome was a 30-day readmission rate. Secondary outcomes were in-hospital mortality, length of stay (LOS), total hospital charge (THC), and predictors of readmission. Multivariate/univariate logistic and linear regression analyses were used to analyze the outcomes and adjust for possible confounders. Results: A total of 1,027 encounters of CA who underwent PPM were identified, of which 975 were discharged alive. Within 30 days from discharge, 141 (14.5%) were readmitted. Those readmitted had a longer LOS and higher burden of comorbidities while were similar in age, sex, hospital characteristics, and household income status. Readmissions lead to an additional mean THC of $55,079 and a mean LOS of 6.3 days. The top five causes of readmissions were heart failure (23%), sepsis (6.6%), hypertensive heart disease (4%), bradycardia (3.5%), and acute kidney injury (3.2%). Figure-1 shows the forest plot of a multivariate analysis of independent factors associated with readmissions. Conclusions: Our findings show that up to 15% of patients with CA who undergo PPM implantation get readmitted with heart failure being the most common etiology. Optimizing comorbidities with PPM implantation in CA may provide better outcomes and reduce admissions.

Polypharmacy, Gender Disparities, and Ethnic and Racial Predispositions in Long QT Syndrome: An In-Depth Review.

Long QT syndrome (LQTS) is a complex disorder of cardiac electrophysiology. It is characterized by delayed myocardial polarization leading to QT prolongation and alterations on the ST segment and Twave visible on electrocardiogram (ECG). Syncope is a common manifestation, and torsade de pointes (TdP) can lead to sudden cardiac death. Three major LQTS genes (KCI31, KCNH2, and SCN5) lead to most of the cases of LQTS. Lifestyle modifications, beta blockers, and implantable cardioverterdefibrillator(ICD) placement are the main treatments for LQTS. Polypharmacy, including QT-prolonging drugs, has been shown to worsen LQTS. The impact on potassium channels and the human ether-a-go-go-related gene (hERG) is the mechanism behind the QT interval prolongation caused by these medications. There is an increased incidence of LQTS among African-American men and women as compared to Caucasians. Women with LQTS tend to have a higher mortality rate from the condition, especially during menstruation and shortly after giving birth. Genetic testing is reserved to those patientswho exhibit either a strong clinical index of suspicion or experience persistent QT prolongation despite their lack of symptoms. Knowing the genetics, racial, and gender discrepancies can help improve patient management and a better comprehension on each case. Proper understanding of how ion channels function and their interaction with medications will lead to a better comprehension and to develop effective forms to treat those patients.

Racial differences in setting of implantable cardioverter-defibrillator placement in older adults with heart failure and association with disparate post-implant outcomes.

Implantable cardioverter-defibrillator (ICD) placement in heart failure (HF) patients during or early after (≤90 days) unplanned cardiovascular hospitalizations has been associated with poor outcomes. Racial and ethnic differences in this "peri-hospitalization" ICD placement have not been well described. Using a 20% random sample of Medicare beneficiaries, we identified older (≥66 years) patients with HF who underwent ICD placement for primary prevention from 2008 to 2018. We investigated racial and ethnic differences in frequency of peri-hospitalization ICD placement using modified Poisson regression. We utilized Kaplan-Meier analyses and Cox regression to investigate the association of peri-hospitalization ICD placement with differences in all-cause mortality and hospitalization (HF, cardiovascular and all-cause) within and between race and ethnicity groups for up to 5-year follow-up. Among the 61,710 beneficiaries receiving ICDs (35% female, 82% White, 10% Black, 6% Hispanic), 44% were implanted peri-hospitalization. Black [adjusted rate ratio (RR) 95% Confidence Interval (95% CI): 1.16 (1.12, 1.20)] and Hispanic [RR (95% CI): 1.10 (1.06, 1.14)] beneficiaries were more likely than White beneficiaries to have ICD placement peri-hospitalization. Peri-hospitalization ICD placement was associated with an at least 1.5× increased risk of death, 1.5× increased risk of re-hospitalization and 1.7× increased risk of HF hospitalization during 3-year follow-up in fully adjusted models. Although beneficiaries with peri-hospitalization placement had the highest mortality and readmission rates 1- and 3-year post-implant (log-rank p < 0.0001), the magnitude of the associated risk did not differ significantly by race and ethnicity (p = NS for interaction). ICD implantation occurring during the peri-hospitalization period was associated with worse prognosis and occurred at higher rates among Black and Hispanic compared to White Medicare beneficiaries with HF during the period under study. The risk associated with peri-hospitalization ICD placement did not differ by race and ethnicity. Future paradigms aimed at enhancing real-world effectiveness of ICD therapy and addressing disparate outcomes should consider timing and setting of ICD placement in HFrEF patients who otherwise meet guideline eligibility.

Using a Modified Delphi Panel to Estimate Health Service Utilization for Patients with Advanced and Non-Advanced Systemic Light Chain Amyloidosis.

Patients with diagnosed with systemic light chain (AL) amyloidosis at advanced Mayo stages have greater morbidity and mortality than those diagnosed at non-advanced stages. Estimating service use by severity is difficult because Mayo stage is not available in many secondary databases. We used an expert panel to estimate healthcare utilization among advanced and non-advanced AL amyloidosis patients. Using the RAND/UCLA modified Delphi method, expert panelists completed 180 healthcare utilization estimates, consisting of inpatient and outpatient visits, testing, chemotherapy, and procedures by disease severity and organ involvement during two treatment phases (the 1 year after starting first line [1L] therapy and 1 year following treatment [post-1L]). Estimates were also provided for post-1L by hematologic treatment response (complete or very good partial response [CR/VGPR], partial, no response or relapse [PR/NR/R]). Areas of disagreement were discussed during a meeting, after which ratings were completed a second time. During 1L therapy, 55% of advanced patients had ≥1 hospitalization and 38% had ≥2 admissions. Rates of hematopoietic stem cell transplant (HSCT) in advanced patients were 5%, while pacemaker or implantable cardioverter defibrillator (ICD) placement were 15%. During post-1L therapy, rates of hospitalization in advanced patients remained high (≥1 hospitalization: 20-43%, ≥2 hospitalizations: 10-20%), and up to 10% of advanced patients had a HSCT. Ten percent of these patients underwent pacemaker/ICD placement. Experts estimated advanced patients, who would not be good candidates for HSCT, would have high rates of hospitalization (traditionally the most expensive type of healthcare utilization) and other health service use. The development of new treatment options that can facilitate organ recovery and improve function may lead to decreased utilization.

Impact of late gadolinium-enhanced cardiac MRI on arrhythmic and mortality outcomes in nonischemic dilated cardiomyopathy: updated systematic review and meta-analysis

Risk stratification based mainly on the impairment of left ventricular ejection fraction has limited performance in patients with nonischemic dilated cardiomyopathy (NIDCM). Evidence is rapidly growing for the impact of myocardial scar identified by late gadolinium enhancement (LGE) cardiac magnetic resonance imaging (CMR) on cardiovascular events. We aim to assess the prognostic value of LGE on long-term arrhythmic and mortality outcomes in patients with NIDCM. PubMed, Scopus, and Cochrane databases were searched from inception to January 21, 2022. Studies that included disease-specific subpopulations of NIDCM were excluded. Data were independently extracted and combined via random-effects meta-analysis using a generic inverse-variance strategy. Data from 60 studies comprising 15,217 patients were analyzed with a 3-year median follow-up. The presence of LGE was associated with major ventricular arrhythmic events (pooled OR: 3.99; 95% CI 3.08, 5.16), all-cause mortality (pooled OR: 2.14; 95% CI 1.81, 2.52), cardiovascular mortality (pooled OR 2.83; 95% CI 2.23, 3.60), and heart failure hospitalization (pooled OR: 2.53; 95% CI 1.78, 3.59). Real-world evidence suggests that the presence of LGE on CMR was a strong predictor of adverse long-term outcomes in patients with NIDCM. Scar assessment should be incorporated as a primary determinant in the patient selection criteria for primary prophylactic implantable cardioverter-defibrillator placement.

Initial Experience With Intercostal Insertion of an Extravascular ICD Lead Compatible With Existing Pulse Generators.

This study assessed safety and feasibility of a novel extravascular implantable cardioverter defibrillator (ICD) lead when inserted anteriorly through a rib space and connected to various commercially available ICD pulse generators (PGs) placed in either a left mid-axillary or left pectoral pocket. Currently available or investigational, extravascular-ICDs include a subcutaneous or subxiphoid lead connected to customized extravascular-ICD PGs. This novel extravascular-ICD (AtaCor Medical Inc, San Clemente, CA) employs a unique intercostal implant technique and is designed to function with commercial DF-4 ICD PGs. In this nonrandomized, single-center, acute study, 36 de novo or replacement ICD (transvenous ICD) patients enrolled to receive a concomitant extravascular-ICD lead inserted through an intercostal space along the left parasternal margin. extravascular-ICD leads were connected to DF-4 compatible ICD PGs positioned in either a left mid-axillary or pectoral pocket for acute sensing and defibrillation testing. Defibrillation testing started at 30 Joules (J) and stepped up or down in 5 to 10 joule increments depending on the success and limitations of the generator used. Successful acute defibrillation using ≤35 J was noted in 100% of left mid-axillary PG subjects (n=27, mean 16.3±8.6 J) and 83% of left pectoral PG subjects (n=6, mean 21.0±8.4 J). Furthermore, 24 of 27 (89%) of patients tested with a left, mid-axillary intermuscular PG had successful VF conversion with defibrillation energies at least 10 J below the maximum delivered output of the device. All evaluable episodes (n=93) were automatically sensed, detected, and shocked. No serious device-related intraoperative adverse events were observed. This first-in-human study documented the safe and reliable placement of a novel extravascular ICD lead with effective sensing and defibrillation of induced ventricular fibrillation using commercial DF-4 ICD PGs.

Wearable defibrillator use in patients with high risk of sudden cardiac death: a brief report from a single center

Devices such as implantable cardioverter defibrillators (ICDs) and wearable cardioverter defibrillators (WCDs) have opened up new paths in the treatment of Sudden Cardiac Death. Guidelines advocate ICD placement for primary prevention after at least three months of optimal medical therapy following the first diagnosis of heart failure with reduced FE from any cause, and at least 40 days after an acute myocardial infarction with FE 35% notwithstanding medication. In these and other cases documented in the guidelines, the use of a wearable defibrillator (WCD), a noninvasive device that guards against malignant arrhythmias while waiting for arrhythmic risk to be defined and medication therapy to be optimized, may be considered. In our Cardiology/Utic Department, we treated 26 patients with a preliminary indication for ICD implantation: the use of the WCD allowed us to swiftly put them in clinical safety, avoiding potentially fatal arrhythmias while waiting for pharmacological therapy to be optimized. At the end of the periodic follow-up, FE had normalized in ten patients, allowing them to avoid ICD. Only 10 of the 26 participants with WCD had a proven indication for final implantation. There were no fatalities or problems in any of the patients.

Perioperative and postoperative pain in patients undergoing subcutaneous implantable cardioverter-defibrillator placement

Abstract Funding Acknowledgements Type of funding sources: None. Background The recent Avoiding Transvenous Leads in Appropriate Subjects (ATLAS) Trial demonstrated that the subcutaneous implantable cardioverter–defibrillator (S-ICD) reduces lead-related complications without significantly compromising the effectiveness of ICD shocks, but with more early postoperative pain. Purpose To assess the perioperative and postoperative pain during S-ICD implantation in current clinical practice and evaluate the influence of implantation techniques. Methods We analyzed 255 consecutive patients (84% male, 52±16 years, body mass index 26±4 Kg/m², ejection fraction 42±16%) who had undergone S-ICD implantation from 2017 to 2022. The primary endpoint was pain during S-ICD placement. The secondary outcome measure included static and dynamic pain intensity 6 hours after the end of the procedure. Patients were asked to rate pain intensity on a 10-point visual analogue scale from 0 (no pain) to 10 (worst imaginable pain). Results The mean procedure duration was 62±22 minutes. The serratus anterior plane block (SAPB) was performed in 161 (63%) patients for anesthesia/analgesia, and 161 (63%) patients underwent the defibrillation testing. Implantation success was reported in all patients with no operative complications. In the overall group, the pain intensity was 2 [range: 1-8] during the implantation procedure, and 1 [1-7] for both static and dynamic pain, 6 hours after the end of the procedure. Significantly lower values were recorded during implantation in the SAPB group (p=0.010) and among those who did not undergo the defibrillation testing (p=0.008). The adoption of the SAPB (coefficient: -0.54, p=0.047) and the omission of defibrillation testing (coefficient: -0.70, p=0.028) remained associated with less pain during implantation after correction for age, sex, body habitus, ejection fraction. Six hours after the end of the procedure the static and dynamic pain intensity remained lower among those with omitted testing (p=0.018 and 0.004, respectively). Conclusions In current clinical practice, S-ICD implantation is associated with very little discomfort. The adoption of novel anesthetic techniques and the omission of defibrillation testing is associated with lower pain levels.

Outcomes of Ventricular Tachycardia Catheter Ablation in Patients Who Underwent Cardiac Defibrillator Implantation Nationwide Readmission Database Analysis

The timing of when to perform ventricular tachycardia (VT) ablation while receiving an implantable cardioverter defibrillator (ICD) during the same hospitalization has not been explored. This study aimed to investigate the use and outcomes of VT catheter ablation in patients with sustained VT receiving ICD in the same hospital stay. The Nationwide Readmission Database 2016 to 2019 was queried for all hospitalizations with a primary diagnosis of VT with subsequent ICD during the same admission. Hospitalizations were later stratified according to whether a VT ablation was performed. All catheter ablation of VT were performed before ICD implantation. The outcomes of interest were in-hospital mortality and 90-day readmission. A total of 29,385 VT hospitalizations were included. VT ablation was performed with subsequent ICD placement in 2,255 (7.6%), whereas 27,130 (92.3%) received an ICD only. No differences were found regarding in-hospital mortality (adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.35 to 1.9, p=0.67) and all-cause 90-day readmission rate (aOR 1.1, 95% CI 0.95 to 1.3, p=0.16). An increase in readmission because of recurrent VT was noted in the VT ablation group (aOR 1.53, 8% vs 5% CI 1.2 to 1.9, p <0.01); the VT ablation group encompassed a higher number of patients with heart failure with reduced ejection fraction (p <0.01), cardiogenic shock (p <0.01), and mechanical circulatory support use (p <0.01). In conclusion, the use of VT ablation in patients admitted with sustained VT is low and reserved for higher risk patients with significant co-morbidities. Despite the higher risk profile of VT ablation cohort, no differences were found in the short-term mortality and readmission rate between the groups.