Who benefits from implantable cardioverter defibrillator therapy, and who pays the price?

Children with heart transplants: Lessons learned from 774 visits at a primary community clinic

Aims Unexpected decompensation of PHTRs may surprise, when the patient is at home. If the PHTR lives a distance from transplant center, the task of identifying risk factors of allograft rejection/dysfunction falls primarily on the PCP in the PCC, whether or not they are knowledgeable toward pediatric heart-transplantation. Methods We reviewed the medical reports of three heart-transplanted children in our periphery clinic between the years 2005 and 2019. Results The unexpected death of one patient, hours after he left our health facility, was the impetus for writing this article. Another heart transplant child attended our periphery clinic for 774 visits. Majority of visits were casual, others were scheduled, and the rest were for administrative affairs. We referred the PHTR to the transplantation center in 9% of all visits. In remaining 91% visits, we handled problems locally. Conclusions One of the important lessons we have learned through handling the PHTR at the PCC is that, during daily workflows and dealing with the occasional visits of a heart transplant child, related critical clinical information to allograft rejection or its dysfunction can easily evade from awareness of the attending physician. Through this study, we demonstrated that a program of summoning the PHTR to "initiated monthly visits" at the PCC enables the PCP to be maximally aware of critical clinical information, in addition to limiting futile referrals of 91% of the visits to specialized centers, without adversely affecting the prognosis.

[The subcutaneous cardioverter-defibrillator: When less is more]

INTRODUCTION

In the last few decades, defibrillator therapy has revolutionized treatment of patients at risk for sudden cardiac death. Multiple clinical trials have shown the benefit of implantable cardioverter-defibrillators (ICD) for primary and secondary prevention of sudden cardiac death. Being an entirely subcutaneous system, the S-ICD® avoids important periprocedural and long-term complications associated with transvenous implantable cardioverter-defibrillator (TV-ICD) systems as well as the need for fluoroscopy during implant surgery.

METHODS AND RESULTS

In patients with challenging anatomic conditions or after infection, the S-ICD® might be reasonable. In multicenter studies and registries efficacy and safety of the S-ICD® was equal or better to transvenous implantable defibrillators. The cardiac rhythm is detected by the use of 1 of the 3 potential vectors. The S-ICD® automatically selects the most suitable vector for rhythm detection. If ventricular tachyarrhythmia is detected, the device is able to deliver up to five shocks of 80 J, while postshock pacing is available at 50 bpm for 30 s. The implantation technique is different from that of conventional ICDs, but easily learnable by experienced cardiologists. Initially observed hurdles (e.g., inappropriate shocks or infections) have been overcome by standardized implantation techniques, operator learning curves, and modification of algorithms.

CONCLUSIONS

The S-ICD® predominately might be suitable in all patients with ICD indication except patients with pacing or cardiac resynchronization therapy (CRT) indication, ventricular tachycardia < 170 bpm, negative screening, or in the occasional patient whose arrhythmia might be suppressed by overdrive pacing. The system received CE certification in 2009 and was approved by the FDA in 2012. Currently, in Germany the S-ICD® has been integrated into the DRG system and can be reimbursed as a single chamber ICD.