Outcomes following implantable cardioverter–defibrillator generator replacement in adults: A systematic review

Risk of Appropriate Implantable Cardioverter-Defibrillator Therapies and Sudden Cardiac Death in Patients With Heart Failure With Improved Left Ventricular Ejection Fraction

BACKGROUND

The benefit of implantable cardioverter-defibrillator (ICD) therapy is controversial in patients who have heart failure with improved left ventricular ejection fraction (EF) to >35% after implantation (HFimpEF).

METHODS

Databases (Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar) were queried for studies in patients with ICD that reported the association between HFimpEF and arrhythmic events (AEs), defined as the combined incidence of ventricular arrhythmias, appropriate ICD intervention, and sudden cardiac death (primary composite end point).

RESULTS

A total of 41 studies and 38,572 patients (11,135 with HFimpEF, 27,437 with persistent EF ≤35%) were included; mean follow-up was 43 months. HFimpEF was associated with decreased AEs (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.32 to 0.47; annual rate [AR] 4.1% vs 8%, p <0.01). Super-responders (EF ≥50%) had less risk of AEs than did patients with more modest reverse remodeling (EF >35% and <50%, OR 0.25, 95% CI 0.14 to 0.46, AR 2.7% vs 6.2%, p <0.01). Patients with HFimpEF who had an initial primary-prevention indication had less risk of AEs (OR 0.43, 95% CI 0.3 to 0.61, AR 5.1% vs 10.3%, p <0.01). Among patients with primary prevention who had never received appropriate ICD therapy at the time of generator change, HFimpEF was associated with decreased subsequent AEs (OR 0.26, 95% CI 0.12 to 0.59, AR 1.6% vs 4.8%, p <0.01). In conclusion, HFimpEF is associated with reduced, but not eliminated, risk for AEs in patients with ICDs. The decision to replace an ICD in subgroups at less risk should incorporate shared decision making based on risks for subsequent AEs and procedural complications.

Lights and shadows of subcutaneous implantable cardioverter-defibrillator in Brugada syndrome

Currently the cornerstone of therapy for ventricular arrhythmic complications and sudden cardiac death prevention in Brugada syndrome (BrS) is an implantable cardioverter-defibrillator (ICD). BrS patient population differs from the majority of patients with an ICD implanted for structural heart disease, and as widely known, transvenous ICD (TV-ICD) systems have been associated with high complication rates in patients with BrS. Technological evolution of these devices has certainly reduced complications due to the device itself, but a careful preimplant screening of these patients is still essential. To date, criteria for an adequate screening process to select suitable candidates for a subcutaneous implantable cardioverter-defibrillator (S-ICD) from patients with BrS are sometimes nonstandardized and often lack important precautions that are instead fundamental to select the most suitable type of ICD for these patients. To better select suitable candidates for an S-ICD from patients with BrS, a full screening process should include screening during or immediately after an exercise test and after a drug provocation challenge test. We report an analysis of the "lights and shadows" of S-ICD for a correct use of this device in patients with BrS.

Recall devices: Defects at initial visit and during remote monitoring supported follow-up

BACKGROUND AND AIM

In March 2021, Biotronik informed about the risk of premature battery depletion in a group of implantable cardioverter-defibrillators. Following the manufacturers' recommendation, our center executed a recall and introduced remote monitoring in patients with susceptible devices.This study reports the rate of premature battery depletion in our center and events found in RM-supported follow-up.

METHODS

Single-centre observational study.

RESULTS

Out of the 206 susceptible implanted devices, 125 patients appeared for the visit and remote monitoring was introduced in 107 (83%) patients. Until the visit, 3 (2.4%) devices required replacement due to battery depletion, and a further 3 (2.4%) devices had unexpected battery depletion during follow-up.

CONCLUSIONS

The recalled devices had a higher rate of battery exhaustion than expected, while other device or lead defects were less common. This article is protected by copyright. All rights reserved.

Prospective evaluation of health status, quality of life and clinical outcomes following implantable defibrillator generator exchange

BACKGROUND

Little is known about health status and quality of life (QoL) after implantable cardioverter-defibrillator (ICD) generator exchange (GE).

METHODS

We prospectively followed patients undergoing first-time ICD GE. Serial assessments of health status were performed by administering the 36-Item Short Form Survey (SF-36).

RESULTS

Mean age was 67.5 ± 14.3 years, left ventricle ejection fraction (LVEF) was 36.5% ± 15.0% and over 40% of the cohort had improved LVEF to > 35% at the time of GE. SF-36 scores were significantly worse in physical/general health domains compared to domains of emotional/social well-being ( P < 0.001 for each comparison). Physical health scores were significantly worse among those with medical comorbidities including diabetes, chronic obstructive pulmonary disease and atrial fibrillation. Mean follow-up was 1.6 ± 0.5 years after GE. Overall SF-36 scores remained stable across all domains during follow-up. Survival at 3 years post-GE was estimated at 80%. Five patients died during follow-up and most deaths were adjudicated as non-arrhythmic in origin. Four patients experienced appropriate ICD shocks after GE, three of whom had LVEF which remains impaired LVEF (i.e., < 35%) at the time of GE.

CONCLUSION

Patients undergoing ICD GE have significantly worse physical health compared to emotional/social well-being, which is associated with the presence of medical comorbidities. In terms of clinical outcomes, the incidence of appropriate shocks after GE among those with improvement in LVEF is very low, and most deaths post-procedure appear to be non-arrhythmic in origin. These data represent an attempt to more fully characterize the spectrum of QoL and clinical outcomes after GE.

Neuromuscular Blockade and Reversal Agent Practice Variability in the US Inpatient Surgical Settings

Introduction

The management of neuromuscular blockade (NMB) has evolved over time and remains a critical component of general anesthesia. However, NMB use varies by patient and procedural characteristics, clinical practices, protocols, and drug access. National utilization patterns are unknown. We describe changes in NMB and NMB reversal agent administration in surgical inpatients since the US introduction of sugammadex in December 2015.

Methods

In a retrospective observational study of inpatients involving NMB with rocuronium or vecuronium in the Premier Healthcare Database, we estimate associations between factors related to choice of (1) active NMB reversal versus spontaneous recovery and (2) sugammadex versus neostigmine as the reversal agent.

Results

Among 4.3 million adult inpatient encounters involving rocuronium or vecuronium, the most widely administered NMB agent was rocuronium alone (86%). Over time, gradual declines in both neostigmine use and spontaneous reversal were observed (64% and 36% in 2014 to 38% and 28%, respectively in the first half of 2019). Several factors were independently associated with use of active versus spontaneous NMB recovery including years since 2016, patient (age, race, comorbidities), and procedure (admission and surgery type) characteristics. Among those actively reversed, these and other factors were independently associated with choice of reversal agent administered, including size and teaching affiliation of hospital. While both impacted choices in treatment, the direction and magnitude of effect of patient comorbidities and procedure type varied in their impact on choice of mode (pharmacologic vs. spontaneous) and agent (neostigmine vs. sugammadex) of NMB reversal independent of other factors and each other. Sites which adopted sugammadex earlier were more likely to choose sugammadex over neostigmine compared with later adopters independent of other factors.

Conclusions

Among US adult inpatients administered NMBs, we observed complex relationships between patient, site, procedural characteristics, and NMB management choices as NMBA choice and active reversal options among inpatient cases changed over time.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01835-2.

Neuromuscular blocking agents, medications that temporarily paralyze muscles, are used frequently during surgical procedures to facilitate intubation and patient immobility. Over time, muscle function can return spontaneously or through pharmacological reversal agents. This study looked at how the use of reversal agents in inpatients undergoing surgical procedures changed after a new reversal agent, sugammadex, became available for use in the USA in December 2015.

Medical records of 4.3 million adult patients treated with neuromuscular blocking agents (rocuronium or vecuronium) in the USA were studied. In 2014 (before sugammadex was available), one-third of patients (36%) recovered spontaneously from a neuromuscular blocking agent and two-thirds (64%) were treated with the reversal agent neostigmine. The use of both neostigmine and spontaneous recovery reduced gradually after sugammadex became available, so that by the first half of 2019, 38% of patients were treated with neostigmine and 28% of patients recovered spontaneously.

Whether or not a patient was treated with a reversal agent and what type of agent was chosen were affected by the length of time since 2016, patient characteristics, the type of surgical procedure that was performed as well as local hospital characteristics and practice differences.

Ongoing Risk of Ventricular Arrhythmias and All-Cause Mortality at Implantable Cardioverter Defibrillator Generator Change: A Systematic Review and Meta-Analysis

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Risk of ventricular arrhythmia in cardiac resynchronization therapy responders and super-responders: a systematic review and meta-analysis

AIMS

Response to cardiac resynchronization therapy (CRT) is associated with improved survival, and reduction in heart failure hospitalization, and ventricular arrhythmia (VA) risk. However, the impact of CRT super-response [CRT-SR, increase in left ventricular ejection fraction (LVEF) to ≥ 50%] on VA remains unclear.

METHODS AND RESULTS

We undertook a meta-analysis aimed at determining the impact of CRT response and CRT-SR on risk of VA and all-cause mortality. Systematic search of PubMed, EMBASE, and Cochrane databases, identifying all relevant English articles published until 31 December 2019. A total of 34 studies (7605 patients for VA and 5874 patients for all-cause mortality) were retained for the meta-analysis. The pooled cumulative incidence of appropriate implantable cardioverter-defibrillator therapy for VA was significantly lower at 13.0% (4.5% per annum) in CRT-responders, vs. 29.0% (annualized rate of 10.0%) in CRT non-responders, relative risk (RR) 0.47 [95% confidence interval (CI) 0.39-0.56, P < 0.0001]; all-cause mortality 3.5% vs. 9.1% per annum, RR of 0.38 (95% CI 0.30-0.49, P < 0.0001). The pooled incidence of VA was significantly lower in CRT-SR compared with CRT non-super-responders (non-responders + responders) at 0.9% vs. 3.8% per annum, respectively, RR 0.22 (95% CI 0.12-0.40, P < 0.0001); as well as all-cause mortality at 2.0% vs. 4.3%, respectively, RR 0.47 (95% CI 0.33-0.66, P < 0.0001).

CONCLUSIONS

Cardiac resynchronization therapy super-responders have low absolute risk of VA and all-cause mortality. However, there remains a non-trivial residual absolute risk of these adverse outcomes in CRT responders. These findings suggest that among CRT responders, there may be a continued clinical benefit of defibrillators.

Comparison of depression and anxiety among pacemaker and implantable cardioverter-defibrillator recipients: A cross-sectional study

INTRODUCTION

Anxiety and depression among implantable cardioverter-defibrillator (ICD) recipients can lead to physical or psychological consequences and reduce the quality of life of these patients. Few studies have compared the frequency and severity of depressive and anxiety disorders in the pacemaker (PM) and ICD recipients. The aim of the present study was to compare depression and anxiety among PM and ICD recipients.

METHODS

This cross-sectional study was performed on 296 patients referred to a specialized cardiology teaching hospital from October 1, 2019 to July 1, 2020. Patients were selected using convenience sampling method.

RESULTS

Regarding anxiety, the results showed that the overall prevalence of anxiety in PM, ICD, and control groups was 23.5%, 28%, and 8%, respectively. Results showed no significant difference between PM and ICD recipients regarding the anxiety prevalence (p = .46). With regard to depression, the results showed that the overall prevalence of depression in the PM, ICD, and control groups was 7.1%, 23%, and 4.1%, respectively. The results showed a significant difference between PM and ICD recipients in terms of depression prevalence (p = .03). The results also showed that the prevalence of depression was significantly higher among PM and ICD recipients than the control group (p = .01).

CONCLUSION

Considering the results of the present study and the high prevalence of anxiety and depression, it seems necessary to focus more on educating patients about the effectiveness of PM and ICD devices in reducing anxiety and depression.

Mortality after cardioverter-defibrillator replacement: Results of the DECODE survival score index

BACKGROUND

Device replacement is the ideal time to reassess health care goals regarding continuing implantable cardioverter-defibrillator (ICD) therapy. Only few data are available on the decision making at this time.

OBJECTIVES

The goals of this study were to identify factors associated with poor prognosis at the time of ICD replacement and to develop a prognostic index able to stratify those patients at risk of dying early.

METHODS

DEtect long-term COmplications after implantable cardioverter-DEfibrillator replacement (DECODE) was a prospective, single-arm, multicenter cohort study aimed at estimating long-term complications in a large population of patients who underwent ICD/cardiac resynchronization therapy - defibrillator replacement. Potential predictors of death were investigated, and all these factors were gathered into a survival score index (SUSCI).

RESULTS

We included 983 consecutive patients (median age 71 years (63-78)); 750 (76%) were men, 537 (55%) had ischemic cardiomyopathy; 460 (47%) were implanted with cardiac resynchronization therapy - defibrillator. During a median follow-up period of 761 days (interquartile range 628-904 days), 114 patients (12%) died. In multivariate Cox regression analysis, New York Heart Association class III/IV, ischemic cardiomyopathy, body mass index < 26 kg/m², insulin administration, age ≥ 75 years, history of atrial fibrillation, and hospitalization within 30 days before ICD replacement remained associated with death. The survival score index showed a good discriminatory power with a hazard ratio of 2.6 (95% confidence interval 2.2-3.1; P < .0001). The risk of death increased according to the severity of the risk profile ranging from 0% (low risk) to 47% (high risk).

CONCLUSION

A simple score that includes a limited set of variables appears to be predictive of total mortality in an unselected real-world population undergoing ICD replacement. Evaluation of the patient's profile may assist in predicting vulnerability and should prompt individualized options, especially for high-risk patients.