Implantable Cardioverter-defibrillator Insertion Research Articles

Implantable cardioverter defibrillator insertion in a patient with Mustard procedure resulting in phrenic nerve stimulation.

Implantable cardioverter defibrillator insertion in a patient with Mustard procedure resulting in phrenic nerve stimulation.

ICD implantation and device therapy: Fabry vs hypertrophic cardiomyopathy

Abstract Background Cardiac involvement of Fabry disease (FD) includes left ventricular hypertrophy (LVH), inflammation, arrhythmia and sudden death. There are limited data regarding potential risk predictors and no definitive criteria exist to guide implantation of cardiac devices for primary prevention. Despite phenotypic similarities between FD and hypertrophic cardiomyopathy (HCM), FD is specifically excluded from the ESC sudden cardiac death risk prediction tool used for HCM. Purpose To evaluate differences in device implantation and arrhythmic burden between advanced Fabry cardiomyopathy and HCM. Methods This multi-centre, retrospective study including genetically confirmed FD and age/gender-matched HCM patients all of whom had an implantable cardioverter defibrillator (ICD). Data was collected prior to device implantation on disease characteristics, biomarkers and CMR imaging. Arrhythmia burden and changes in therapy were captured following implantation. Results Of the UK FD population under follow-up, 50/880 had an ICD implanted (80% males, 51% non-classical mutation, mean age at device implantation 57±12 years). A comparator group included 64 age- and gender-matched HCM patients (67% males, mean age at implant 46±39 years). Baseline LV mass was greater in FD (291±97g/m2 vs 218±78g/m2, p=0.012). FD patients had higher troponin (95 vs 19ng/l, p<0.001) but similar NT-pro-BNP (1687 vs 888ng/l, p=0.086) levels. Indications for ICD insertion in FD included: presumed HCM dual pathology 14%, symptomatic NSVT 18%, asymptomatic NSVT 24%, co-existing long QT 2%, CRT-D 14%, no clear indication (primary prevention in the presence of multiple potential arrhythmic risk factors) 28%. All HCM patients were risk stratified and underwent device implantation based on an estimated 5-year SCD risk >4%. All FD patients had a SCD risk >4% using this risk calculator. Arrhythmia were more common in FD over shorter follow-up (37/50, 74% over 4.3±3.0 years vs 28/64 in HCM, 44% over 6.5±2.9 years, p=0.001). Notably, VT requiring anti-tachycardia pacing (ATP) +/− defibrillation therapy from the ICD was more frequent (FD: 14/50, 28% vs HCM: 8/64, 12%, p=0.055), as was immediate shock therapy for sustained VT (p=0.009, figure panel B). FD patients with arrhythmia were often older, had greater LV mass, a larger left atrium and a broader QRS duration. These clinical features tended to occur more frequently in FD than in the HCM group. Conclusion This study has shown that delivery of device therapy in Fabry cardiomyopathy is higher than in HCM. Despite similar rates of asymptomatic NSVT, a higher rate of ventricular arrhythmia requiring ATP/defibrillation therapy occurred in FD. Although both FD and HCM had similar risk percentages according to the ESC calculator, active troponitis in FD was double that of HCM. Funding Acknowledgement Type of funding source: None

Baseline and Dynamic Risk Predictors of Appropriate Implantable Cardioverter Defibrillator Therapy.

BackgroundCurrent approaches fail to separate patients at high versus low risk for ventricular arrhythmias owing to overreliance on a snapshot left ventricular ejection fraction measure. We used statistical machine learning to identify important cardiac imaging and time‐varying risk predictors.Methods and ResultsThree hundred eighty‐two cardiomyopathy patients (left ventricular ejection fraction ≤35%) underwent cardiac magnetic resonance before primary prevention implantable cardioverter defibrillator insertion. The primary end point was appropriate implantable cardioverter defibrillator discharge or sudden death. Patient characteristics; serum biomarkers of inflammation, neurohormonal status, and injury; and cardiac magnetic resonance‐measured left ventricle and left atrial indices and myocardial scar burden were assessed at baseline. Time‐varying covariates comprised interval heart failure hospitalizations and left ventricular ejection fractions. A random forest statistical method for survival, longitudinal, and multivariable outcomes incorporating baseline and time‐varying variables was compared with (1) Seattle Heart Failure model scores and (2) random forest survival and Cox regression models incorporating baseline characteristics with and without imaging variables. Age averaged 57±13 years with 28% women, 66% white, 51% ischemic, and follow‐up time of 5.9±2.3 years. The primary end point (n=75) occurred at 3.3±2.4 years. Random forest statistical method for survival, longitudinal, and multivariable outcomes with baseline and time‐varying predictors had the highest area under the receiver operating curve, median 0.88 (95% CI, 0.75‐0.96). Top predictors comprised heart failure hospitalization, left ventricle scar, left ventricle and left atrial volumes, left atrial function, and interleukin‐6 level; heart failure accounted for 67% of the variation explained by the prediction, imaging 27%, and interleukin‐6 2%. Serial left ventricular ejection fraction was not a significant predictor.ConclusionsHospitalization for heart failure and baseline cardiac metrics substantially improve ventricular arrhythmic risk prediction.

Efficacy of Implantable Cardioverter-defibrillators for Secondary Prevention of Sudden Cardiac Death in Patients with End-stage Renal Disease.

End-stage renal disease (ESRD) constitutes a major burden on the health-care system in the United States, with more than 300,000 patients nationwide being treated with renal replacement therapy. Very few studies to date have evaluated the benefit of implantable cardioverter-defibrillator (ICD) implantation for secondary prevention in patients with ESRD. In this study, we evaluated the efficacy of secondary-prevention ICDs in reducing all-cause mortality in patients on dialysis using the United States Renal Data System (USRDS) database. We queried the USRDS for relevant data between 2004 and 2010. Patients with diagnoses of ventricular fibrillation (VF), ventricular tachycardia (VT), or sudden cardiac arrest (SCA) were included in the study. Patients were excluded from the analysis if they were younger than 18 years; had missing age, sex, or race/ethnicity information; had experienced myocardial infarction; or had an ICD in situ at the time of VF, VT, or SCA diagnosis. The primary endpoint of this study was to determine the efficacy of secondary-prevention ICDs in reducing all-cause mortality in patients on dialysis. A total of 1,442 patients (3.4%) with ESRD had ICD insertion. Patients who received an ICD were predominantly younger, white males with lower Charlson Comorbidity Index and with fewer cardiovascular events. Survival at two years was 53% among those with an ICD relative to 27% among those without an ICD. In this study, we observed a substantial decrease in mortality in patients receiving an ICD for secondary prevention when compared with a cohort of similar patients with a history of VF, VT, or SCA.

Implantable cardioverter-defibrillator therapy to reduce sudden cardiac death in adults with congenital heart disease: A registry study.

The adult congenital heart disease (ACHD) population is rapidly expanding. However, a significant proportion of these patients suffer sudden cardiac death. Recommending implantable cardioverter-defibrillator (ICD) insertion requires balancing the need for appropriate therapy in malignant arrhythmia against the consequences of inappropriate therapy and procedural complications. Here we present long-term follow-up data for ICD insertion in patients with ACHD from a large Level 1 congenital cardiac center. All patients with ACHD undergoing ICD insertion over an 18-year period were identified. Data were extracted for baseline characteristics including demographics, initial diagnosis, ventricular function, relevant medication, and indication for ICD insertion. Details regarding device insertion were gathered along with follow-up data including appropriate and inappropriate therapy and complications. A total of 136 ICDs were implanted during this period: 79 for primary and 57 for secondary prevention. The most common congenital cardiac conditions in both groups were tetralogy of Fallot and transposition of the great arteries. Twenty-two individuals in the primary prevention group received appropriate antitachycardia pacing (ATP), 14 underwent appropriate cardioversion, 17 received inappropriate ATP, and 15 received inappropriate cardioversion. In the secondary prevention group, 18 individuals received appropriate ATP, 8 underwent appropriate cardioversion, 8 received inappropriate ATP, and 7 were inappropriately cardioverted. Our data demonstrate low complication rates, particularly with leads without advisories. ICD insertion in the ACHD population involves a careful balance of the risks and benefits. Our data show a significant proportion of patients receiving appropriate therapy indicating that ICDs were inserted appropriately.

In-hospital and long-term outcomes among patients with spontaneous coronary artery dissection presenting with ventricular tachycardia/fibrillation

Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in young to middle-age women. Ventricular tachycardia/ventricular fibrillation (VT/VF) may complicate acute SCAD presentations, and the long-term outcomes are unknown. The purpose of this study was to report the outcomes of SCAD patients presenting with VT/VF. We analyzed our prospective Canadian SCAD registries for patients presenting with VT/VF during index hospitalization. Long-term outcomes including VT/VF and cardiac arrest were collected. Univariate and multivariable analyses were performed to identify predictors of VT/VF at follow-up. Among 1056 consecutive SCAD patients, 84 (8.0%) presented with VT/VF, and 8 underwent implantable cardioverter-defibrillator (ICD) insertion. Patients with VT/VF during index hospitalization were younger (49.3 vs 52.0 years; P = .019) and were more likely to have ST-elevation MI, lower left ventricular ejection fraction (LVEF), and left main dissection (all P <.001). Initial VT/VF was associated with in-hospital events, including recurrent MI, unplanned revascularization, heart failure, ICD insertion, and in-hospital death (all P <.05). At mean follow-up of 4.8 ± 3.3 years, 8 patients suffered VT/VF (time to event 5.2 ± 6.2 years); 5 of 8 patients had VT/VF on initial SCAD presentation, and 1 of 8 had undergone ICD insertion. Predictors of VT/VF during follow-up included LVEF <50%, LVEF <35%, peripartum SCAD, unplanned revascularization, repeat MI, heart failure, and initial VT/VF. Multivariable analysis showed initial VT/VF (odds ratio [OR] 9.5; 95% confidence interval [CI] 2.0-44; P = .004) and LVEF <50% (OR 12.9; 95% CI 1.5-111; P = .019) were independent predictors of VT/VF at follow-up. SCAD patients presenting with VT/VF were at greater risk for in-hospital events and recurrent VF/VT at follow-up. Both VT/VF and LVEF <50% were independent predictors of subsequent VT/VF.

Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) Study

BackgroundCurrent guidelines recommend 4 weeks of private driving restriction after implantation of a primary-prevention implantable cardioverter-defibrillator (ICD). These driving restrictions result in significant inconvenience and social implications. Advances in medical treatment and ICD programming have lowered the overall rate of device therapies. The objective of this study was to assess the incidence of ICD therapies at 30, 60, and 180 days after implantation. MethodsDriving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) was a retrospective cohort study conducted at 2 Canadian university centres enrolling patients with new implantation of a primary-prevention ICD. Device programming was standardised according to current guidelines. A total of 803 patients were enrolled. ResultsThe cumulative rates of appropriate ICD therapies at 30, 60, and 180 days were 0.12%, 0.50%, and 0.75%, respectively. There was no syncope during the first 6 months. The median duration to the first appropriate ICD therapy was 208 (range 23-1109) days after implantation. The rate of inappropriate ICD therapies at 30 days was only 0.2%. Overall, < 13.6% of all appropriate ICD therapies occurred within the first 6 months after implantation. ConclusionsThe rate of appropriate ICD therapies within the first 30 days after device insertion is extremely low in contemporary primary prevention cohorts with guideline-concordant device programming. There was no increased risk for ventricular arrhythmia early after ICD insertion. The results of DREAM-ICD suggest the need for a revision of the existing driving restrictions for primary-prevention ICD recipients.

A Validated Model for Sudden Cardiac Death Risk Prediction in Pediatric Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy is the leading cause of sudden cardiac death (SCD) in children and young adults. Our objective was to develop and validate a SCD risk prediction model in pediatric hypertrophic cardiomyopathy to guide SCD prevention strategies. In an international multicenter observational cohort study, phenotype-positive patients with isolated hypertrophic cardiomyopathy <18 years of age at diagnosis were eligible. The primary outcome variable was the time from diagnosis to a composite of SCD events at 5-year follow-up: SCD, resuscitated sudden cardiac arrest, and aborted SCD, that is, appropriate shock following primary prevention implantable cardioverter defibrillators. Competing risk models with cause-specific hazard regression were used to identify and quantify clinical and genetic factors associated with SCD. The cause-specific regression model was implemented using boosting, and tuned with 10 repeated 4-fold cross-validations. The final model was fitted using all data with the tuned hyperparameter value that maximizes the c-statistic, and its performance was characterized by using the c-statistic for competing risk models. The final model was validated in an independent external cohort (SHaRe [Sarcomeric Human Cardiomyopathy Registry], n=285). Overall, 572 patients met eligibility criteria with 2855 patient-years of follow-up. The 5-year cumulative proportion of SCD events was 9.1% (14 SCD, 25 resuscitated sudden cardiac arrests, and 14 aborted SCD). Risk predictors included age at diagnosis, documented nonsustained ventricular tachycardia, unexplained syncope, septal diameter z-score, left ventricular posterior wall diameter z score, left atrial diameter z score, peak left ventricular outflow tract gradient, and presence of a pathogenic variant. Unlike in adults, left ventricular outflow tract gradient had an inverse association, and family history of SCD had no association with SCD. Clinical and clinical/genetic models were developed to predict 5-year freedom from SCD. Both models adequately discriminated between patients with and without SCD events with a c-statistic of 0.75 and 0.76, respectively, and demonstrated good agreement between predicted and observed events in the primary and validation cohorts (validation c-statistic 0.71 and 0.72, respectively). Our study provides a validated SCD risk prediction model with >70% prediction accuracy and incorporates risk factors that are unique to pediatric hypertrophic cardiomyopathy. An individualized risk prediction model has the potential to improve the application of clinical practice guidelines and shared decision making for implantable cardioverter defibrillator insertion. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT0403679.

Anesthetic management of a child with catecholaminergic polymorphic ventricular tachycardia undergoing insertion of implantable cardioverter defibrillator : a case report

BackgroundCatecholaminergic polymorphic ventricular tachycardia (CPVT) is a fatal cardiac ion channelopathy that causes sudden unexpected death in the young.Case presentationThe patient was a 3-year-old girl with CPVT. Insertion of an implantable cardioverter defibrillator (ICD) using epicardial pacing was scheduled. After premedication of rectal midazolam was given, general anesthesia was induced with midazolam, fentanyl, and rocuronium, and maintained with midazolam, fentanyl, remifentanil, and rocuronium. The operation was performed without any complications. Dexmedetomidine and fentanyl were continuously infused after the operation until she was extubated in the morning of postoperative day 1. Fatal arrhythmia due to perioperative stress did not occur.ConclusionsWe report the anesthetic management of a child with CPVT who underwent insertion of an ICD. CPVT-induced fatal arrhythmia did not occur perioperatively by carefully avoiding perioperative stress with premedication and post-operative sedation.

Programming implantable cardioverter–defibrillator in primary prevention: Guideline concordance and outcomes

Inappropriate therapy is a common adverse effect in patients with an implantable cardioverter-defibrillator (ICD) that may be prevented by appropriate programming. The purpose of this study was to assess the outcomes of device programming based on a 2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement and a 2019 focused update on optimal ICD programming and testing. Consecutive patients who underwent ICD insertion for primary prevention from 2014-2016 at 3 centers were included in the retrospective analysis. Patients were classified into 2 groups based on the tachycardia programming at the time of implant: guideline concordant group (GC) and non-guideline concordant group (NGC). Kaplan-Meier analysis and Cox proportional hazard models were used to estimate freedom from ICD therapy (antitachycardia pacing or shock), ICD shock, and death. A total of 772 patients were included in the study (mean age 63.3 ± 13.8 years). Of this total, 258 patients (33.4%) were in the GC group and 514 patients (66.6%) were in the NGC group. During mean follow-up of 2.02 ± 0.91 years, guideline concordant programming was associated with a 53% reduction in ICD therapy (P<.01) and 50% reduction in ICD shock (P = .02). There were no significant differences in mortality (6% in GC group vs11% in NGC group; P = .22). Only one-third of the studied population had an ICD device programmed in concordance with current guidelines. ICD programming based on the current guidelines was associated with a significantly lower rate of ICD therapy and shock without changes in mortality during intermediate-term follow-up.

Clinical and genetic characteristics and course of congenital long QT syndrome in children: A nine-year single-center experience.

Long QT syndrome (LQTS) is an inherited primary arrhythmia syndrome associated with life-threatening ventricular arrhythmias and sudden death. This study aimed to report the clinical and genetic characteristics and outcomes of children diagnosed as having LQTS in a tertiary pediatric cardiology center in Turkey. This was a retrospective review of pediatric patients diagnosed as having LQTS at our center from January 2011 to April 2020. A total of 145 patients (76 males) were included, with a mean age of 9.2±4.5 years and a mean weight of 35.7±18.5 kg; 38 (26.2%) were identified as having LQTS during family screening, whereas a significant proportion of patients were asymptomatic at presentation, 15 patients (10.3%) were diagnosed after previous cardiac arrest, and 26 patients (18%) had syncope. The mean Schwartz score was 4.5 points (range, 3-7.5 points). Furthermore, 107 patients (82%) were confirmed to have a pathogenic mutation for LQTS genes. All patients received beta-blockers. Implantable cardioverter-defibrillator insertion was performed in 34 patients (23.4%). Left or bilateral cardiac sympathetic denervation was performed in 9 patients (6.2%). Median follow-up time was 35.6±25.8 months. Five (3.4%) patients died during the follow-up. Statistical analyses of risk factors for major cardiac events revealed that the QTc was >500 ms and that T wave alternans, high Schwartz score, and Jervell and Lange-Nielsen syndrome were strong and significant predictors of cardiac events. LQTS has a variety of clinical manifestations. Patients' symptoms ranged between asymptomatic and sudden cardiac death (SCD). By raising the awareness of physicians regarding the disease, SCD might be prevented in the early period.

Prognostic Impact of Ischemic Mitral Regurgitation Severity and Myocardial Infarct Quantification by Cardiovascular Magnetic Resonance

ObjectivesThis study sought to evaluate the role of cardiac magnetic resonance (CMR) for the quantification of ischemic mitral regurgitation (IMR) and myocardial infarct size (MIS) in patients with ischemic cardiomyopathy (ICM). This study also sought to explore the interaction between IMR severity and MIS and its association with outcomes in patients with ICM. BackgroundIMR occurs secondary to a disease of the left ventricle and is associated with poor outcomes. The role of CMR for the evaluation and risk stratification of patients with ICM and IMR remains uncertain. MethodsConsecutive patients with ICM who underwent baseline CMR were included. MIS was quantified on late gadolinium enhancement imaging as the proportion of left ventricular mass. IMR was quantified with CMR by calculating the mitral regurgitant fraction (MRFraction). Cox proportional hazards models were built to assess the association of IMR and MIS quantification with the combined endpoint of all-cause death or heart transplant. ResultsWe evaluated 578 patients (mean age: 62 ± 11 years, 76% males). The mean left ventricular ejection fraction was 25 ± 11%, with an MIS of 24 ± 16% and MRFraction of 18 ± 17%. Over a median follow-up time of 4.9 years, 198 (34%) patients experienced death or cardiac transplant. On multivariable analysis, after comprehensive medical risk score, subsequent revascularization, implantable cardioverter-defibrillator insertion, and surgical mitral valve intervention were controlled for, the interaction of IMR severity and MIS emerged as a powerful predictor of adverse outcomes (p = 0.008). For patients with significant IMR (MRFraction: ≥35%), the hazard ratio comparing moderate MIS (15% to 29%) versus small MIS (<15%) was 1.51 (0.57 to 3.98), and the hazard ratio comparing large MIS (≥30%) versus small MIS was 5.41 (2.34 to 12.7). ConclusionsRisk associated with IMR is more comprehensively described as an interaction between IMR severity and MIS. Further studies in patients IMR using comprehensive CMR evaluation are needed to verify whether this approach can improve patient selection and procedural outcomes to address IMR.

Shoulder Function After Cardioverter-Defibrillator Implantation: 5-Year Follow-up

Implantable cardioverter-defibrillator (ICD) represents the main tool for prevention of sudden cardiac death. Different kinds of postimplant complications have been described; however, little is known about shoulder functional impairment and its impact on quality of life. Patients with standard indications for elective prepectoral subcutaneous ICD insertion were enrolled during a 1-year period. The impact of ICD implantation on shoulder motility, pain, general disability, and quality of life was evaluated prospectively at baseline, and after 2 weeks, 3 months, 1 year, and 5 years using the Constant score, the Numeric Pain Rating Scale, the Disabilities of the Arm, Shoulder, and Hand scale, and the Short Form-36 Health Survey questionnaire. A total of 50 patients underwent insertion of single, dual chamber, or biventricular ICDs. Two weeks after implantation, functional impairment and mild pain were observed in ipsilateral shoulder movements, with a reduction in the Short Form-36 Health Survey score. Shoulder functional impairment improved at the third-month evaluations, with almost normalization at 1-year and 5-year assessments, as well as pain and quality of life. Prepectoral subcutaneous ICD implantation may be associated with ipsilateral shoulder functional impairment that regresses partially after 3 months and completely at 1-year and 5-year assessments. The less invasive implantation technique and the relatively small size of modern ICDs, independently from types and volumes, may be relevant to the degree of postimplantation shoulder functional impairment and recovery time. Shoulder function should be assessed at routine checks, especially soon after ICD implantation because of potential functional impairment and subsequent impact on quality of life.

When is an implantable cardioverter-defibrillator controversial?

When is an implantable cardioverter-defibrillator controversial?

Family screening for hypertrophic cardiomyopathy: Is it time to change practice guidelines?

AimsCurrent guidelines recommend initiating family screening for hypertrophic cardiomyopathy (HCM) after age 10 or 12 years unless early screening criteria are met. The aim was to evaluate if current screening guidelines miss early onset disease.Methods and resultsChildren who underwent family screening for HCM before age 18 years were analysed. Major cardiac events (MaCEs) were defined as death, sudden cardiac death (SCD), or need for major cardiac interventions (myectomy, implantable cardioverter-defibrillator insertion, transplantation). Of 524 children screened, 331 were under 10 years of age, 9.9% had echocardiographic evidence of HCM, and 1.1% were symptomatic at first screening. The median (interquartile range) age at HCM onset was 8.9 (4.7–13.4) years, and at MaCE was 10.9 (8.5–14.3) years with a median time to MaCE from HCM onset of 1.5 (0.5–4.1) years. About 52.5% phenotype-positive children and 41% with MaCEs were <10 years old. Only 69% children with early HCM met early screening criteria. Cox regression identified male gender, family history of SCD, and pathogenic variants in MYH7/MYBPC3 as a predictor of early onset HCM and MaCEs.ConclusionA third of children not eligible for early screening by current guidelines had phenotype-positive HCM. MYH7 and MYBC3 mutation-positive patients were at highest risk for developing early HCM and experiencing an event or requiring a major intervention. Our findings suggest that younger family members should be considered for early clinical and genetic screening to identify the subset in need of closer monitoring and interventions.

Implications of Neurological Status on Defibrillator Therapy and Long-Term Mortality of Sudden Cardiac Arrest Survivors.

This study sought to investigate the impact of the neurological status of sudden cardiac arrest (SCA) survivors on implantable cardioverter-defibrillator (ICD) insertion and long-term mortality. The neurological status of SCA survivors may impact the decision to insert an ICD insertion and influence long-term survival. In 1,433 survivors of SCA between 2002 and 2012, we examined the neurological status immediately afterthe arrest using the Pittsburgh Cardiac Arrest Category (PCAC) and prior to hospital discharge using the cerebral performance category (CPC) score. Patients were followed up to the endpoints of ICD implantation and all-cause mortality. Over a median follow-up period of 3.6 years, 389 (27%) patients received an ICD, and 674 (47%) died. The PCAC (adjusted hazard ratio [HR]: 0.79; 95% confidence interval [CI]: 0.69 to 0.90) and CPC (adjusted HR: 0.73; 95%CI: 0.64 to 0.84) scores were highly predictive of the time to ICD insertion and of all-cause mortality (PCAC score, adjusted HR: 1.39; 95%CI: 1.24 to 1.57; CPC score, adjusted HR: 2.03; 95%CI: 1.77 to 2.34). ICD therapy was associated with better survival even after adjusting for neurological status (HR: 0.56; 95%CI: 0.43 to 0.73). A significant proportion of patients in the worse CPC categories had a >1-year survival after the index SCA. In SCA survivors, worse neurological performance was associated with lower likelihood of ICD insertion and higher mortality. ICD insertion was associated with improved survival even after accounting for neurological performance. ICD discussion should therefore not be omitted in these patients.

Right ventricular pacing is associated with increased rates of appropriate implantable cardioverter defibrillator shocks.

Right ventricular (RV) pacing has been associated with increased risk of pacemaker-induced cardiomyopathy, hospitalization and death among patients with implantable cardioverter defibrillators (ICDs). Little is known about its association with ventricular tachyarrhythmias. We hypothesize that RV pacing is associated with increased incidence of appropriate ICD shocks and death. Retrospective study of consecutive patients with de novo ICD insertion (excluding cardiac resynchronization therapy devices) from a single tertiary care center. Patients were classified into <10% RV pacing (low-pace group) and ≥10% RV pacing (high-pace group). Data were compared using two-tailed t tests and Fisher's exact test. Binomial logistic regression was performed to identify predictors of appropriate ICD therapies. A total of 178 patients (54 high paced and 124 low paced) were included. Mean follow-up was 43±11months. Appropriate shocks occurred in 27 patients (15%) and were significantly higher in the high-pace group (35% vs. 10%, p=0.008), as the number of deaths (31% vs. 11%, p=0.001). Binary logistic regression showed a significantly increased risk of shock (OR 2.99, p=0.01) and death (OR 3.61, p=0.002) in high-paced patients. Multivariable analysis showed no difference in risk of shocks based on age, sex or ejection fraction. Older patients had higher risk of death. In this population of ICD patients, those with a high prevalence of RV pacing experienced more shocks for VF/VT and had higher mortality. Further studies should be done to determine whether minimizing RV pacing reduces arrhythmias, shock burden and death in patients with ICDs.

Perceived control and quality of life among recipients of implantable cardioverter defibrillator

BackgroundPerceived control is strongly associated with health-related quality of life (HRQOL) among patients with chronic conditions, and it is possible to increase perceived control with appropriate intervention. Little is known about the relationship between perceived control and HRQOL in implantable cardioverter defibrillator (ICD) recipients. ObjectivesTo determine the relationship of perceived control with quality of life in ICD recipients and to determine predictors of perceived control in this population. MethodsA total of 263 ICD recipients (63% male, age 61 ± 14 years) completed the Control Attitude Scale-Revised to measure perceived control and completed self-reported measures on potential correlates of perceived control (i.e., depressive symptoms, anxiety, social support, and ICD concerns). The EuroQol-5D was used to measure HRQOL. Regression analysis was used to determine predictors of perceived control and its relationship to HRQOL, controlling for covariates. ResultsLower perceived control (β = 0.30, p < .01), and higher levels of depression (β = −0.30, p < .01) and anxiety (β = −0.18, p < .05) predicted lower levels of HRQOL. Higher anxiety (β = −0.17, p < .05), higher depression (β = −0.23, p < .05), lower social support (β = 0.26, p < .01), and higher ICD-related concerns (β = −0.16, p < .05) independently predicted lower perceived control. ConclusionsInterventions targeting patients' ICD concerns and psychosocial factors before, and continuing after, ICD insertion are needed to improve ICD recipients' perceived control and, in turn, their HRQOL.

Implantable cardioverter-defibrillator therapy in Australia, 2002-2015.

To quantify the number of implantable cardioverter-defibrillator (ICD) procedures in Australia by year, patient age and sex, and to estimate age group-specific population rates and the associated costs. Design, setting: Retrospective observational study; analysis of Australian National Hospital Morbidity Database hospital procedures data. Patients with an ICD insertion, replacement, adjustment, or removal procedure code, July 2002 - June 2015. Number of ICD procedures by procedure year, patient age (0-34, 35-69, 70 years or more) and sex; age group-specific population procedure rates; number of procedures associated with complications. The number of ICD procedures increased from 1844 in 2002-03 to 6504 in 2014-15; more than 75% of procedures were in men. In 2014-15, the ICD insertion rate for people aged 70 years or more was 78.1 per 100 000 population, 22 per 100 000 for those aged 35-69 years, and 1.40 per 100 000 people under 35. The reported complication rate decreased from 45% in 2002-03 to 19% in 2014-15, partly because of a change in the coding of complications. The number of removals corresponded to at least 4% of the number of insertions each year. The aggregate cost of hospitalisations with an ICD procedure during 2011-14 was $445 644 566. ICD procedures are becoming more frequent in Australia, particularly in people aged 70 or more. Patterns of care associated with ICD therapy, particularly patient- and hospital-related factors associated with adverse events, should be investigated to better understand and improve patient outcomes.

Evaluacija i lečenje pacijenata sa sinkopom - prikaz slučaja i pregled ACC/AHA/HRS preporuka iz 2017

Introduction: Syncope is frequent symptom with different etiologies. Reported prevalence in general population was as high as 41%. If the etiology of syncope remain undefined after initial evaluation then an additional diagnostic tests are indicated based on clinical assessment. Case report: We present a 57 year old female with ischemic cardiomyopathy with mildly reduced systolic left ventricular function who presented with recurrent syncope. The diagnosis of sustained monomorphic ventricular tachycardia was confirmed after insertion of implantable cardiac rhythm monitor and implantable cardioverter-defibrillator was implanted. Conclusion: Treatment of syncope due to cardiac causes depends on the specific cause and should be based on relevant guidelines. Sometimes clinical guidelines miss selected patient groups due to lack of data, and in these cases clinical judgement is the most important part of decision making.