Use Of Implantable Cardioverter Defibrillators Research Articles

An international multicenter cohort study on implantable cardioverter-defibrillators for the treatment of symptomatic children with catecholaminergic polymorphic ventricular tachycardia

BackgroundCatecholaminergic polymorphic ventricular tachycardia (CPVT) may cause sudden cardiac death (SCD) despite medical therapy. Therefore, implantable cardioverter-defibrillators (ICDs) are commonly advised. However, there is limited data on the outcomes of ICD use in children. ObjectiveThe purpose of this study was to compare the risk of arrhythmic events in pediatric patients with CPVT with and without an ICD. MethodsWe compared the risk of SCD in patients with RYR2 (ryanodine receptor 2) variants and phenotype-positive symptomatic CPVT patients with and without an ICD who were younger than 19 years and had no history of sudden cardiac arrest at phenotype diagnosis. The primary outcome was SCD; secondary outcomes were composite end points of SCD, sudden cardiac arrest, or appropriate ICD shocks with or without arrhythmic syncope. ResultsThe study included 235 patients, 73 with an ICD (31.1%) and 162 without an ICD (68.9%). Over a median follow-up of 8.0 years (interquartile range 4.3–13.4 years), SCD occurred in 7 patients (3.0%), of whom 4 (57.1%) were noncompliant with medications and none had an ICD. Patients with ICD had a higher risk of both secondary composite outcomes (without syncope: hazard ratio 5.85; 95% confidence interval 3.40–10.09; P < .0001; with syncope: hazard ratio 2.55; 95% confidence interval 1.50–4.34; P = .0005). Thirty-one patients with ICD (42.5%) experienced appropriate shocks, 18 (24.7%) inappropriate shocks, and 21 (28.8%) device-related complications. ConclusionSCD events occurred only in patients without an ICD and mostly in those not on optimal medical therapy. Patients with an ICD had a high risk of appropriate and inappropriate shocks, which may be reduced with appropriate device programming. Severe ICD complications were common, and risks vs benefits of ICDs need to be considered.

Regional disparities and risk factors of mortality among patients at high risk of sudden cardiac death in emerging countries: a nonrandomized controlled trial

BackgroundComprehensive data on patients at high risk of sudden cardiac death (SCD) in emerging countries are lacking. The aim was to deepen our understanding of the SCD phenotype and identify risk factors for death among patients at high risk of SCD in emerging countries.MethodsPatients who met the class I indication for implantable cardioverter-defibrillator (ICD) implantation according to guideline recommendations in 17 countries and regions underrepresented in previous trials were enrolled. Countries were stratified by the WHO regional classification. Patients were or were not implanted with an ICD at their discretion. The outcomes were all-cause mortality and SCD.ResultsWe enrolled 4222 patients, and 3889 patients were included in the analysis. The mean follow-up period was 21.6 ± 10.2 months. There were 433 (11.1%) instances of all-cause mortality and 117 (3.0%) cases of SCD. All-cause mortality was highest in primary prevention (PP) patients from Southeast Asia and secondary prevention (SP) patients from the Middle East and Africa. The SCD rates among PP and SP patients were both highest in South Asia. Multivariate Cox regression modelling demonstrated that in addition to the independent predictors identified in previous studies, both geographic region and ICD use were associated with all-cause mortality in patients with high SCD risk. Primary prophylactic ICD implantation was associated with a 36% (HR = 0.64, 95% CI 0.531–0.802, p < 0.0001) lower all-cause mortality risk and an 80% (HR = 0.20, 95% CI = 0.116–0.343, p < 0.0001) lower SCD risk.ConclusionsThere was significant heterogeneity among patients with high SCD risk in emerging countries. The influences of geographic regions on patient characteristics and outcomes were significant. Improvement in increasing ICD utilization and uptake of guideline-directed medical therapy in emerging countries is urgent.Trial registrationClinicalTrials.gov, NCT02099721.

Characteristics, management, and outcomes in women and men with congestive heart failure in 40 countries at different economic levels: an analysis from the Global Congestive Heart Failure (G-CHF) registry

There is a paucity of data on the clinical characteristics, management, and outcomes of women compared with men with heart failure in low-income and middle-income countries compared with high-income countries. We examined sex differences in risk factors, clinical characteristics, and treatments, and prospectively assessed the risk of heart failure hospitalisation and mortality in patients with heart failure in 40 high-income, middle-income, and low-income countries. Participants aged 18 years or older with heart failure were enrolled from Dec 20, 2016, to Sept 9, 2020 in the prospective Global Congestive Heart Failure (G-CHF) study from 257 centres in 40 high-income, middle-income, and low-income countries. Participants were followed up until May 25, 2023. We recorded the demographic characteristics, medical history, and treatments of participants. We prospectively recorded data on heart failure hospitalisation and mortality by sex in the overall study, according to country economic status, and according to level of left ventricular ejection fraction (LVEF). 23 341 participants (9119 [39·1%] women and 14 222 [60·1%] men) were recruited and followed up for a mean of 2·6 years (SD 1·4). The mean age of women in the study was 62 years (SD 17) compared with 64 years (14) in men. Fewer women than men had an LVEF of 40% or lower (51·7% women vs 66·2% men). By contrast, more women than men had an LVEF of 50% or higher (33·2% women vs 18·6% men). Hypertensive heart failure was the most common aetiology in women (25·5% women vs 16·8% men), whereas ischaemic heart failure was the most common aetiology in men (45·6% men vs 26·6% women). Signs and symptoms of congestion were more common in women than men: 42·6% of women had a New York Heart Association functional class of III or IV compared with 37·9% of men. The use of heart failure medications and cardiac tests did not differ systematically between the sexes, although implantable cardioverter defibrillator (ICD) implantation was lower among women than men (8·7% women vs 17·2% men). The adjusted risk of heart failure hospitalisation was similar in women and men (women-to-men adjusted hazard ratio [HR] 0·99 [95% CI 0·92-1·05]). This pattern was consistent within groups of countries categorised by economic status, geographical region, and by LVEF level. However, women had a lower adjusted risk of mortality (women-to-men adjusted HR 0·79 [95% CI 0·75-0·84]) despite adjustments for prognostic factors-a pattern which was consistently observed across groups of countries irrespective of economic status, geography, and LVEF levels of patients. The underlying cause of heart failure and ejection fraction phenotype differ between women and men, as do the severity of symptoms. Heart failure treatments (except ICD use) were not consistently in favour of one sex. Paradoxically, while the rates of hospitalisations were similar among women and men, the risk of death was lower among women. These patterns were consistent regardless of the economic status of the countries. The higher mortality among men is unexplained and warrants further study. Bayer.

Temporal trends in baseline characteristics of implantable cardioverter defibrillator recipients for primary prevention of sudden cardiac death- The DAIPP program

Abstract Introduction Since expanding the indication for implantable cardioverter defibrillators (ICD) to primary prevention, the patient population of ICD carriers continues to evolve over time. In pursuit of progressively decreasing the burden of sudden cardiac death, improved patient selection and risk-benefit assessment demand, among others, awareness of these temporal changes in clinical baseline characteristics of the ICD population. Purpose The aim was to explore the temporal differences in baseline characteristics of ICD recipients implanted for primary prevention of sudden cardiac death (SCD), and perioperative complications, to improve understanding of ICD population selection over the last two decades in a real-world setting. Methods The Primary Prevention ICD French Registry (DAI-PP program) was initiated in 2002 with an overall aim to assess the risk-benefit ratio of the introduction of ICD for primary prevention over a 20-year period, including a pilot evaluation that finished in 2012. The pilot study laid ground for the ongoing prospective DAIPP Consortium that started in 2018 and is aiming to follow 10000 patients under remote monitoring, using a specific integrational research platform. The two cohorts are in this study compared with regards to baseline characteristics as well as perioperative outcomes, i.e., early mortality and procedural complications. Results This study included 8432 participants, 5521 from the pilot study and 2211 from the prospective trial, with a median follow up of 2.36 (IQR 1.25-3.75) years. Median age was 64 (IQR 56-71) years, 17% female and 61% had ischemic heart disease. Baseline characteristics that remained stable over time were age, cancer burden. Compared to the 2002-2012 period, recent findings found a significant increase in the proportion of females (15 vs 20%, p &amp;lt;0.001), pauci-symptomatic patients (New York Heart Association Functional class-NYHA II, 41 vs. 57%, p &amp;lt;0.001), narrow QRS patients (31 vs. 43%, p&amp;lt;0.001), use of subcutaneous ICD (0 vs. 14%, P&amp;lt;0.001) and more comorbidities including an increase in diabetes, and slight increase in stroke. Regarding pharmacological treatment, there was an increase in use of 2 or 3 medications (2: 6.5% to 16% p&amp;lt;0.001; 3: 20% to 33%, p&amp;lt;0.001) where more received beta blockers and amiodarone in the contemporary study. Perioperative complications decreased over time (13% to 7.9% p&amp;lt;0.001) with a decrease in early reinterventions (1.3% to 0.1% p&amp;lt;0.001) and discrete fall in number of infections (0.7% to 0.1%, p&amp;lt;0.001) and pocket hematoma (4.4% to 3.0% p&amp;lt;0.001). A slight upward trend in number of lead dislodgements was seen over time (1.3% to 1.7% p&amp;lt;0.001). See Table 1 for perioperative complications. Conclusion The primary prevention ICD population has significantly changed over time. An increase in women, comorbidities, and use of 2-3 medications was seen, coupled with more participants receiving a subcutaneous ICD. Perioperative complications decreased over time.

Abstract 15099: Sex Disparities in Patients With Cardiac Sarcoidosis Undergoing Implantable Cardioverter-Defibrillators Implantation in the United States

Introduction: In patients with cardiac sarcoidosis (CS), implantable cardioverter-defibrillators (ICDs) are utilized to avoid sudden cardiac death. We aimed to compare the sex disparities in CS patients undergoing ICD implantation.Hypothesis:Higher ICD implantation would be observed in male CS patients as compared to females. Methods: Males and females with CS receiving ICD were identified and compared from the 2016-2020 National Inpatient Sample (NIS) database whilst adjusting for confounders via logistic regression models. Results: Of the 760 cardiac sarcoidosis patients undergoing ICD implantation, 505 (66.4%) were males and 255 (33.6%) were females. Around 94.1% of all procedures (715 cases) were conducted in urban teaching centres. In comparison to females, males were younger (55.0 vs 56.9 years, p&lt;0.01) with higher prevalence of diabetes (31.7% vs 21.6% p&lt;0.01) and chronic kidney disease (CKD) (16.8% vs 7.8% p&lt;0.01) and a lower occurrence of reported depression (5.0 vs 19.6 p&lt;0.01). Atrial fibrillation (AF) (23.5% vs 11.9%, p&lt;0.01), sick sinus syndrome (SSS) (7.8% vs 4.0%, p=0.024) and ventricular fibrillation (VF) (15.7% vs 9.9%, p=0.02) were more prevalent in female CS receiving ICD. The percentages of ICD use in those with a history of hypertension, smoking, obesity, lipid disorder, previous myocardial infarction, supraventricular tachycardia, ventricular tachycardia, 2nd degree AV block and complete AV block were similar for both male and female CS patients. Following ICD implantation, the mean length of stay and mean hospital charges were comparable between the two groups. Incidence of acute kidney injury (AKI) post-ICD was more common in males (23.8% vs 15.7%, p=0.01) (Table 1). Conclusion: AF, SSS and VF are more prevalent in female CS patients with ICD. However, ICD use in CS patients is generally more common in males who also have a greater prevalence of diabetes, CKD and post-ICD AKI.

Abstract 15327: Clinical Outcomes of Methamphetamine-Associated Cardiomyopathy Compared to Ischemic Cardiomyopathy: A Single Institution Retrospective Longitudinal Study

Background: Methamphetamine-associated cardiomyopathy (MAC) leads to significant morbidity and mortality. The benefit of implantable cardioverter-defibrillator (ICD) in this population is poorly characterized. Aims: To evaluate ICD use and outcomes in patients with MAC compared to ischemic cardiomyopathy (ICM). Methods: Electronic health record (EHR) was queried for all heart failure hospitalizations using ICD-9 codes between 2011 and 2019. Patients with an EF ≤ 35% were included. The MAC cohort was derived from this population and defined by ICD-9 code or positive urine toxicology and compared to ICM cohort. Baseline characteristics and outcomes were extracted from the EHR. MACE was defined as death, ventricular tachycardia, cardiac arrest, rehospitalization, atrial fibrillation (AF) or stroke. Results: The study included 294 patients in the MAC group and 373 patients in the ICM group. MAC patients were younger (56 vs 61 years, p&lt;0.001) compared to ICM (table 1). Readmission rates for heart failure at one year were similar (13% vs 11.2%, p=ns). Significantly fewer patients with MAC had ICD for primary prevention (15.0% vs 27.9%, p&lt;0.001). Mortality and AF were lower in MAC compared to ICM, however VT (2.38% vs 5.09%, p=0.072) and cardiac arrest (6.1% vs 7.8%, p=0.408) were similar between the two groups. MACE outcomes were worse in the ICM cohort (38.3% vs 21.1%, p=0.012) than MAC. In the MAC cohort, ICD presence was associated with 56.82% incidence of MACE compared to 40.00% without ICD (OR = 1.97, CI 1.032-3.77, p = 0.040) mainly due to higher AF hospitalization (22% vs 8%, p=0.01). Conclusion: ICM patients had higher mortality and atrial fibrillation compared to MAC. ICD implantation for primary prevention was not associated with reduced mortality, however this cohort had higher AF hospitalization. We need further studies to assess the benefit of ICD in MAC.

Hypertrophic Cardiomyopathy in Underrepresented Populations: Clinical and Genetic Landscape Based on a Russian Single-Center Cohort Study.

Hypertrophic cardiomyopathy (HCM) is a common inherited cardiac disorder characterized by marked clinical and genetic heterogeneity. Ethnic groups underrepresented in studies may have distinctive characteristics. We sought to evaluate the clinical and genetic landscape of Russian HCM patients. A total of 193 patients (52% male; 95% Eastern Slavic origin; median age 56 years) were clinically evaluated, including genetic testing, and prospectively followed to document outcomes. As a result, 48% had obstructive HCM, 25% had HCM in family, 21% were asymptomatic, and 68% had comorbidities. During 2.8 years of follow-up, the all-cause mortality rate was 2.86%/year. A total of 5.7% received an implantable cardioverter-defibrillator (ICD), and 21% had septal reduction therapy. A sequencing analysis of 176 probands identified 64 causative variants in 66 patients (38%); recurrent variants were MYBPC3 p.Q1233* (8), MYBPC3 p.R346H (2), MYH7 p.A729P (2), TPM1 p.Q210R (3), and FLNC p.H1834Y (2); 10 were multiple variant carriers (5.7%); 5 had non-sarcomeric HCM, ALPK3, TRIM63, and FLNC. Thin filament variant carriers had a worse prognosis for heart failure (HR = 7.9, p = 0.007). In conclusion, in the Russian HCM population, the low use of ICD and relatively high mortality should be noted by clinicians; some distinct recurrent variants are suspected to have a founder effect; and family studies on some rare variants enriched worldwide knowledge in HCM.

Outcomes Following Implantable Cardioverter-Defibrillator Insertion in Patients 80 Years of Age or Older: A Statewide Population Cohort Study

BackgroundPatients ≥ 80 years of age are underrepresented in major implantable cardioverter-defibrillator (ICD) trials, and real-world data are lacking. In this study, we sought to assess ICD utilisation, outcomes, and their predictors, in an unselected statewide population including patients ≥ 80 years old. MethodsWe extracted details of ICDs implanted from 2009 to 2018 in New South Wales (NSW), Australia from the Centre for Health Record Linkage administrative data sets. Analysis was stratified into age groups of < 60 years, 60-79 years, and ≥ 80 years. ResultsA total of 9304 patients (mean age 66.1 ± 13.1 years; 12.1% ≥ 80 years) had de novo ICD placement at an average rate of 1163 ± 122 patients per annum, with more implants in men in all age groups. After adjusting for NSW population size by sex, age group, and calendar year, mean implantation rates were 5.5 ± 0.6, 63.2 ± 8.6, and 52.7 ± 10.8 per 100,000 persons per annum in patients aged < 60 years, 60-79 years, and ≥ 80 years, respectively. In-hospital mortality was 0.4% and did not differ among age groups. However, 1-year mortality was 2.1%, 5.9%, and 10.7%, in those < 60 years, 60-79 years, and ≥ 80 years of age, respectively (P < 0.001), with hazard ratios for those aged ≥ 80 years of 4.3 (95% confidence interval [CI] 3.1-6.0) and those aged 60-79 years of 2.6 (95% CI 1.9-3.5) relative to those aged < 60 years (both P < 0.001) after adjusting for ICD indications, sex, implantation year, referral source, and comorbidities. In those aged ≥ 80 years, age > 83 years, congestive cardiac failure, chronic renal failure, neurodegenerative disease, and a higher Charlson comorbidity index score were each independent predictors of 1-year mortality. ConclusionsICD use in patients aged ≥ 80 years and 60-79 years was 10-fold that in patients aged < 60 years, and perioperative outcomes were good in all ages, but there was substantially increased 1-year mortality in those aged ≥ 80 years. Careful selection based on age and comorbidity may further reduce 1-year mortality in patients ≥ 80 years old receiving ICDs.

The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing - Report 2022

The Pacemaker (PM) and Implantable Cardioverter-Defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the voluntary Italian collaborating centers. For the year 2022 main data about national PM and ICD implantation activity were obtained on the basis of European Cards and subsequently analyzed to create a standard report. PM Registry: data about 17 800 PM implantations were collected (14 191 first implants and 3609 replacements). The number of collaborating centers was 152. Median age of treated patients was 81 years (75 quartile I; 86 quartile III). Main ECG indications included atrioventricular conduction disorders in 46.0% of first PM implants, sick sinus syndrome in 17.7%, atrial fibrillation plus bradycardia in 7.7%, other unspecified ECG and electrophysiological abnormalities in 43.0%. For first PM implants, pacing in DDDR mode was reported in 42.2%, followed by DDD mode (20.6%), VVIR mode (25.1%), VVI mode (11.1%) and finally VDD-VDDR (5.1%). Median value of longevity of explanted PMs was 8.3 years. ICD Registry: data about 5210 ICD implantations were obtained (3656 first implants and 1554 replacements). The number of collaborating centers was 301. Median age of treated patients was 72 years (63 quartile I; 79 quartile III). Primary prevention indication was reported in 72.4% of first implants, secondary prevention in 27.6% (cardiac arrest in 4.6% of records). A single-chamber ICD was used in 30.3% of first implants, dual-chamber ICD in 30.0% and biventricular ICD in 39.7%. Median value of longevity of explanted ICDs was 7.0 years. In the calendar year 2022, the Italian PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The ICD Registry documented a large use of prophylactic and biventricular ICDs, reflecting a favorable adherence in clinical practice to trials and guidelines. The ICD longevity and the number of recalls demonstrated a favorable trend.

Sudden Death Risk Assessment in Hypertrophic Cardiomyopathy Across the Lifespan: Reconciling the American and European Approaches.

Hypertrophic cardiomyopathy (HCM) is the most prevalent inherited cardiac disease. Since the modern description of HCM more than seven decades ago, great focus has been placed on preventing its most catastrophic complication: sudden cardiac death (SCD). Implantable cardioverter-defibrillators (ICD) have been recognized to provide effective prophylactic therapy. Over the years, two leading societies, the European Society of Cardiology (ESC) and the American Heart Association/American College of Cardiology (AHA/ACC), have proposed risk stratification models to assess SCD in adults. European guidelines rely on a risk calculator, the HCM Risk-SCD, while American guidelines propose a stand-alone risk factor approach. Recently, risk prediction models were also developed in the pediatric population. This article reviews the latest recommendations on the risk stratification of SCD in HCM and summarises current indications for ICD use.

Imaging modality for left ventricular ejection fraction estimation and effect of implantable cardioverter-defibrillator on mortality in patients with heart failure

Implantable cardioverter-defibrillators (ICDs) improve outcomes in patients with heart failure (HF) with left ventricular ejection fraction (LVEF) ≤35%. Less is known about whether outcomes varied between the 2 noninvasive imaging modalities used to estimate LVEF-2-dimensional echocardiography (2DE) and multigated acquisition radionuclide ventriculography (MUGA)-which use different principles (geometric vs count-based, respectively). The purpose of this study was to examine whether the effect of ICD on mortality in patients with HF and LVEF ≤35% varied on the basis of LVEF measured by 2DE or MUGA. Of the 2521 patients with HF with LVEF ≤35% in the Sudden Cardiac Death in Heart Failure Trial, 1676 were randomized to either placebo or ICD, of whom 1386 had LVEF measured by 2DE (n = 971) or MUGA (n = 415). Hazard ratios (HRs) and 97.5% confidence intervals (CIs) for mortality associated with ICD use were estimated overall, checking for interaction, and within the 2 imaging subgroups. Of the 1386 patients in the present analysis, all-cause mortality occurred in 23.1% (160 of 692) and 29.7% (206 of 694) of patients randomized to ICD or placebo, respectively (HR 0.77; 97.5% CI 0.61-0.97), which is consistent with that in 1676 patients in the original report. HRs (97.5% CIs) for all-cause mortality in the 2DE and MUGA subgroups were 0.79 (0.60-1.04) and 0.72 (0.46-1.11), respectively (P = .693 for interaction). Similar associations were observed for cardiac and arrhythmic mortalities. We found no evidence that in patients with HF and LVEF ≤35%, the effect of ICD on mortality varied by the noninvasive imaging method used to measure LVEF.

HeartFailure Burden by Autopsy, Guideline-Directed Medical Therapy, and ICD Utilization Among Sudden Deaths.

Studies of heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF) report high sudden cardiac death (SCD) rates but presume cardiac cause. Underlying causes, guideline-directed medical therapy (GDMT), and implantable cardioverter-defibrillator (ICD) use in community sudden deaths with heart failure (HF) are unknown. This study aims to assess the burden of HF, GDMT, and ICD use among autopsied sudden deaths in the POST SCD (Postmortem Systematic Investigation of Sudden Cardiac Death) study, a countywide postmortem study of all presumed SCDs. Incident WHO-defined (presumed) SCDs for individuals of ages 18 to 90 years were autopsied via prospective surveillance of consecutive out-of-hospital deaths in San Francisco County from February 1, 2011, to March 1, 2014. Sudden arrhythmic deaths (SADs) had no identifiable nonarrhythmic cause (eg, pulmonary embolism), and are thus considered potentially rescuable with ICD. Of 525 presumed SCDs, 100 (19%) had HF. There were 85 patients with known HF (31 HFpEF, 54 HFrEF) and 15 with subclinical HF (postmortem evidence of cardiomyopathy and pulmonary edema without HF diagnosis). SADs comprised 56% (293 of 525) of all presumed SCDs, and 69% (69 of 100) of HF SCDs. The rates were similar in HFrEF (40 of 54 [74%]) and HFpEF (19 of 31 [61%], P=0.45). Four SAD patients (4%) had ICDs, 3 of which experienced device failure. Twenty-eight SCDs had ejection fraction≤35%: 22 (79%) with arrhythmic and 6 (21%) with noncardiac causes. Of the 22 SAD patients, 8 (36%) had no identifiable barrier to ICD referral. Complete use of GDMT in HFrEF was 6%. One in 5 community sudden deaths had HF; two-thirds had autopsy-confirmed arrhythmic causes. ICD prevention criteria captured only 8% (22 of 293) of all SAD cases countywide; GDMT and ICD use remain important targets for HF sudden death prevention.

The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing - Report 2021

The Pacemaker (PM) and Implantable Cardioverter-Defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the voluntary Italian collaborating centers. For the year 2021 main data about national PM and ICD implantation activity were obtained on the basis of European Cards and subsequently analyzed to create a standard report. PM Registry: data about 18 631 PM implantations were collected (15879 first implants and 2752 replacements). The number of collaborating centers was 121. Median age of treated patients was 82 years (76 quartile I; 87 quartile III). Main ECG indications included atrioventricular conduction disorders in 26.8% of first PM implants, sick sinus syndrome in 12.2%, atrial fibrillation plus bradycardia in 9.6%, other unspecified ECG and electrophysiological abnormalities in 43.0%. For first PM implants, pacing in DDDR mode was reported in 46.5%, followed by DDD mode (20.6%), VVIR mode (15.0%), VVI mode (9.0%) and finally VDD-VDDR (5.8%). Median value of longevity of explanted PMs was 8.9 years. ICD Registry: data about 6878 ICD implantations were obtained (4708 first implants and 2170 replacements). The number of collaborating centers was 345. Median age of treated patients was 72 years (70 quartile I; 75 quartile III). Primary prevention indication was reported in 86.3% of first implants, secondary prevention in 13.7% (cardiac arrest in 4.4% of records). A single-chamber ICD was used in 32.1% of first implants, dual-chamber ICD in 30.3% and biventricular ICD in 37.6%. Median value of longevity of explanted ICDs was 6.9 years. In the calendar year 2021, the Italian PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The ICD Registry documented a large use of prophylactic and biventricular ICDs, reflecting a favorable adherence in the clinical practice to trials and guidelines. The ICD longevity and the number of recalls demonstrated a favorable trend. In order to increase and optimize the cooperation of Italian PM and ICD implanting centers, the online data entry (https://www.aiac.it/riprid) should be adopted at large scale.

Experience of using the of subcutaneous cardioverter-defibrillators in the world practice: review

The article provides a review of international clinical studies on the use of a subcutaneous implantable cardioverter-defibrillator (ICD) in comparison with classical intravenous defibrillation systems. Subcutaneous ICDs have shown themselves to be a worthy alternative to intravenous defibrillating systems for the primary prevention of sudden cardiac death, when the patient is not indicated for anti-tachy stimulation and anti-brady stimulation. World experience on the use of subcutaneous ICDs proves the safety and effectiveness of the functioning of the subcutaneous ICD system, excluding from the patient’s life the formidable risks associated with the implantation procedure and further functioning of the classical intravenous ICD system.

Inter-American Society of Cardiology (CIFACAH-ELECTROSIAC) and Latin-American Heart Rhythm Society (LAHRS): multidisciplinary review on the appropriate use of implantable cardiodefibrillator in heart failure with reduced ejection fraction

BackgroundOur main objective was to present a multidisciplinary review on the epidemiology of sudden cardiac death (SCD) and the tools that could be used to identify malignant ventricular arrhythmias (VAs) and to perform risk stratification. In addition, indications and contraindications for the use of implantable cardioverter defibrillator (ICD) in general and in special populations including the elderly and patients with chronic kidney disease (CKD) are also given.MethodsAn expert group from the Inter American Society of Cardiology (IASC), through their HF Council (CIFACAH) and Electrocardiology Council (ElectroSIAC), together with the Latin American Heart Rhythm Society (LAHRS), reviewed and discussed the literature regarding the appropriate use of an ICD in people with heart failure (HF) with reduced ejection fraction (HFpEF). Indications and contraindications for the use of ICD are presented in this multidisciplinary review.ResultsNumerous clinical studies have demonstrated the usefulness of ICD in both primary and secondary prevention of SCD in HFpEF. There are currently precise indications and contraindications for the use of these devices.ConclusionsIn some Latin American countries, a low rate of implantation is correlated with low incomes, but this is not the case for all Latin America. Determinants of the low rates of ICD implantation in many Latin American countries are still a matter of research. VA remains one of the most common causes of cardiovascular death associated with HFrEF and different tools are available for stratifying the risk of SCD in this population.

Optimizing exercise testing-based risk stratification to predict poor prognosis after acute heart failure.

The timely selection of severe heart failure (HF) patients for cardiac transplantation and advanced HF therapy is challenging. Peak oxygen consumption (VO2 ) values obtained by the cardiopulmonary exercise testing are used to determine the transplant recipient list. This study reassessed the prognostic predictability of peak VO2 and compared it with the Heart Failure Survival Score (HFSS) in the modern optimized guideline-directed medical therapy (GDMT) era. We retrospectively selected 377 acute HF patients discharged from the hospital. The primary outcome was a composite of all-cause mortality, or urgent cardiac transplantation. We divided these patients into the more GDMT (two or more types of GDMT) and less GDMT groups (fewer than two types of GDMT) and compared the performance of their peak VO2 and HFSS in predicting primary outcomes. The median follow-up period was 3.3years. The primary outcome occurred in 57 participants. Peak VO2 outperformed HFSS when predicting 1year (0.81 vs. 0.61; P=0.017) and 2year (0.78 vs. 0.58; P<0.001) major outcomes. The cutoff peak VO2 for predicting a 20% risk of a major outcome within 2years was 10.2 (11.8-7.0) for the total cohort. Multivariate Cox regression analyses showed that peak VO2 , sodium, previous implantable cardioverter defibrillator (ICD) implantation, and estimated glomerular filtration rate were significant predictors of major outcomes. Optimizing the cutoff value of peak VO2 is required in the current GDMT era for advanced HF therapy. Other clinical factors such as ICD use, hyponatraemia, and chronic kidney disease could also be used to predict poor prognosis. The improvement of resource allocation and patient outcomes could be achieved by careful selection of appropriate patients for advanced HF therapies, such as cardiac transplantation.

Abstract 15205: Cardiovascular Outcomes With Use of Primary Prevention Implantable Cardioverter Defibrillators in Patients With Non-Ischemic Cardiomyopathy: A Meta-Analysis and Meta-Regression Analysis

Introduction: Guidelines recommend use of implantable cardioverter defibrillator (ICD) in all patients with non-ischemic cardiomyopathy (NICM) and ejection fraction (EF) &lt; 35% for primary prevention of sudden cardiac death (SCD) and hence reduction of overall mortality. Contemporary randomized clinical trials (RCTs) with longer follow up duration have thrown into question this beneficial effect of ICDs. Hypothesis: Prophylactic use of ICDs in addition to optimal medical therapy (OMT) does not reduce adverse outcomes in patients with NICM and EF &lt; 35% compared to OMT alone. Methods: Six RCTs (n=4541) comparing ICD + OMT vs OMT alone were selected from MEDLINE and EMBASE databases from inception through March 2022. Meta-analysis was performed using random effects model. Meta-regression analysis was performed with inverse-variance weighting and Knapp and Hartung adjustments for all-cause mortality. Results: ICDs did not reduce risk of all-cause mortality (Relative Risk (RR) 0.87, [95% confidence interval, 0.75-1.00], cardiovascular mortality (RR, 0.80 [0.49-1.31]), non-cardiovascular mortality (RR, 0.66 [0.13-3.34]) or non-sudden cardiac death (RR, 1.03 [0.51-2.08]). ICDs reduced the risk of sudden cardiac death (HR, 0.49 [0.26-0.92]). Meta-regression analysis did not show any association between all-cause mortality and follow up duration (p=0.09). Conclusions: ICDs reduce risk of SCD however this does not translate into meaningful improvement in long term cardiovascular outcomes.

Rates of implantable cardioverter defibrillator implantation and outcomes in octogenarians or older compared to non-octogenarians in a statewide cohort from 2009 to 2018

Abstract Background Octogenarians are underrepresented or excluded in major implantable cardioverter defibrillator (ICD) trials. The deployment of ICDs and their real-world outcomes in octogenarians is unclear. Purpose To investigate the prevalence and outcomes of ICD implantation in octogenarian or older vs non-octogenarian. Methods We extracted details of all ICD implanted statewide from 2009–2018 including patient's characteristics, in-hospital complications and mortality using the Centre-for-Health-Record-Linkage administrative datasets. Implantation rates were adjusted for the population size by sex, age-groups in decade and calendar-year. Analysis was stratified by age &amp;lt;80 vs ≥80yo. Results There were 9304 admissions (12.1% ≥80yo) for de novo ICD implantation (mean±SD implantation: 1163±122 cases per-annum). The mean age for ≥80 vs &amp;lt;80yo groups was 83.5±2.9yo vs 66.2±12.1yo respectively (overall cohort mean age 66.1±13.1yo). Total ICD implantations increased by 8.4±12.4% vs 1.8±8.4% per-annum for ≥80 vs &amp;lt;80yo groups. The mean implantation rates were 52.7±10.8 vs 22.0±2.8 per-100,000-persons in ≥80yo compared to &amp;lt;80yo, respectively, with rates increasing at 7.7±18.3% per-100,000-persons-per-annum in ≥80yo. In contrast, implantation rates declined slightly by 0.2±12.4% per-100,000-persons-per-annum in &amp;lt;80yo groups. There was a non-significant trend towards more in-hospital non-fatal complications in ≥80yo compared to &amp;lt;80yo (10.8% vs 9.0% respectively, p=0.054), with no difference in in-hospital mortality (0.6% vs 0.4% respectively, p=0.32). The 1-year mortality was 10.7% in ≥80yo compared to 4.7% in &amp;lt;80yo (p&amp;lt;0.001), and 2-year mortality was 20.2% vs 8.8% respectively (p&amp;lt;0.001). The 1-yr and 2-yr mortality hazard ratio for ≥80yo was 2.0 (95% confidence interval [CI] 1.6–2.5, p&amp;lt;0.001) and 2.2 (95% CI 1.8–2.5, p&amp;lt;0.001) respectively after adjusting for sex, year of implantation, referral source, indications for ICD, and comorbidities. Overall, the annual rates of total in-hospital non-fatal complications and mortality did not alter significantly during the study period. Conclusion Despite limited clinical trials data on efficacy of ICD use in octogenarians or older, implantation rate was more than double that of &amp;lt;80yo age-groups, with the implantation rate observed to be increasing in ≥80yo. There was no significant difference in in-hospital mortality between the two age-groups, however the 1-year and 2-year mortality rates were significantly higher in the ≥80yo. Funding Acknowledgement Type of funding sources: None.

Implantable defibrillator therapy and mortality in patients with non-ischaemic dilated cardiomyopathy : Anupdated meta-analysis and effect on Dutch clinical practice by the Task Force of the Dutch Society of Cardiology.

Primary prophylactic implantable cardioverter-defibrillators (ICDs) in patients with non-ischaemic cardiomyopathy (NICMP) remains controversial. This study sought to assess the benefit of ICD therapy with or without cardiac resynchronisation therapy (CRT) in patients with NICMP. In addition, data were compared with real-world clinical data to perform arisk/benefit analysis. Relevant randomised clinical trials (RCTs) published in meta-analyses since DANISH, and in PubMed, EMBASE and Cochrane databases from 2016 to 2020 were identified. The benefit of ICD therapy stratified by CRT use was assessed using random effects meta-analysis techniques. Six RCTs were included in the meta-analysis. Among patients without CRT, ICD use was associated with a24% reduction in mortality (hazard ratio [HR]: 0.76; 95% confidence interval [CI]: 0.62-0.93; P = 0.008). In contrast, among patients with CRT, aCRT-defibrillator was not associated with reduced mortality (HR: 0.74, 95% CI 0.47-1.16; P = 0.19). For ICD therapy without CRT, absolute risk reduction at 3‑years follow-up was 3.7% yielding anumber needed to treat of27. ICD use significantly improved survival among patients with NICMP who are not eligible for CRT. Considering CRT, the addition of defibrillator therapy was not significantly associated with mortality benefit compared with CRT pacemaker.

Prevention of sudden death in heart failure with reduced ejection fraction: do we still needan implantable cardioverter-defibrillator for primary prevention?

Sudden death is a devastating complication of heart failure (HF). Current guidelines recommend an implantable cardioverter-defibrillator (ICD) for prevention of sudden death in patients with HF and reduced ejection fraction (HFrEF) specifically those with a left ventricular ejection fraction ≤35% after at least 3 months of optimized HF treatment. The benefit of ICD in patients with symptomatic HFrEF caused by coronary artery disease has been well documented; however, the evidence for a benefit of prophylactic ICD implantation in patients with HFrEF of non-ischaemic aetiology is less strong. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta-blockers (BB), and mineralocorticoid receptor antagonists (MRA) block the deleterious actions of angiotensin II, norepinephrine, and aldosterone, respectively. Neprilysin inhibition potentiates the actions of endogenous natriuretic peptides that mitigate adverse ventricular remodelling. BB, MRA, angiotensin receptor-neprilysin inhibitor (ARNI) have a favourable effect on reduction of sudden cardiac death in HFrEF. Recent data suggest a beneficial effect of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in reducing serious ventricular arrhythmias and sudden cardiac death in patients with HFrEF. So, in the current era of new drugs for HFrEF and with the optimal use of disease-modifying therapies (BB, MRA, ARNI and SGLT2i), we might need to reconsider the need and timing for use of ICD as primary prevention of sudden death, especially in HF of non-ischaemic aetiology.