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Doldi F, Frommeyer G, Löher A, Ellermann C, Wolfes J, Güner F, Zerbst M, Engelke H, Korthals D, Reinke F, Eckardt L, Willy K. Validation of the PRAETORIAN score in a large subcutaneous implantable cardioverter-defibrillator collective: Usefulness in clinical routine. Heart Rhythm 2024; 21:1057-1063. [PMID: 38382685 DOI: 10.1016/j.hrthm.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/20/2024] [Accepted: 02/12/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND To assess the risk of unsuccessful conversion of ventricular fibrillation during defibrillation testing (DFT) with the subcutaneous implantable cardioverter-defibrillator (S-ICD), the PRAETORIAN score has been proposed. OBJECTIVE The purpose of this study was to validate the PRAETORIAN score in a large S-ICD collective. METHODS A retrospective single-center analysis of S-ICD patients receiving intraoperative DFT was performed. DFT was performed using a stepwise protocol with 65-J standard polarity, change of polarity, increase to 80 J, and repositioning if necessary. If all DFTs failed, we switched to a transvenous ICD. RESULTS Overall, 398 patients were analyzed (268 male [67.3%]; mean age 42.4 ± 15.9 years; mean body mass index [BMI] 25.9 ± 4.8 kg/m2). Successful DFT with the first ICD shock was observed in 264 patients (66.3%). One hundred fourteen patients were defibrillated with the second (n = 104) or third (n = 10) DFT after changing shock polarity and/or shock energy. Overall, 20 patients needed at least 3 DFT (ie, 80 J and/or re-positioning). The majority (n = 88 [65.7%]) of DFT failures occurred before 2015 with the first-generation S-ICD. PRAETORIAN score was an independent predictor of DFT failure (odds ratio [OR] 1.007; 95% confidence interval [CI] 1.003-1.011 P ≤.001), while whereas BMI alone was not (P = .31). Presence of hypertrophic cardiomyopathy (HCM) (OR 2.6; 95% CI 1.3-4.4; P = .004) was predictive for at least 1 unsuccessful DFT in our multivariate regression analysis. CONCLUSION PRAETORIAN score proved to be a useful and valid predictive tool for successful DFT, whereas BMI only had a limited role. Patients with HCM were at increased risk for DFT failure or needed higher DFT energy.
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Affiliation(s)
- Florian Doldi
- Department for Cardiology II, Electrophysiology, University Hospital Münster, Münster, Germany.
| | - Gerrit Frommeyer
- Department for Cardiology II, Electrophysiology, University Hospital Münster, Münster, Germany
| | - Andreas Löher
- Department for Cardio-Thoracic Surgery, University Hospital Münster, Münster, Germany
| | - Christian Ellermann
- Department for Cardiology II, Electrophysiology, University Hospital Münster, Münster, Germany
| | - Julian Wolfes
- Department for Cardiology II, Electrophysiology, University Hospital Münster, Münster, Germany
| | - Fatih Güner
- Department for Cardiology II, Electrophysiology, University Hospital Münster, Münster, Germany
| | - Mathis Zerbst
- Department for Cardiology II, Electrophysiology, University Hospital Münster, Münster, Germany
| | - Hauke Engelke
- Department for Cardiology II, Electrophysiology, University Hospital Münster, Münster, Germany
| | - Dennis Korthals
- Department for Cardiology II, Electrophysiology, University Hospital Münster, Münster, Germany
| | - Florian Reinke
- Department for Cardiology II, Electrophysiology, University Hospital Münster, Münster, Germany
| | - Lars Eckardt
- Department for Cardiology II, Electrophysiology, University Hospital Münster, Münster, Germany
| | - Kevin Willy
- Department for Cardiology II, Electrophysiology, University Hospital Münster, Münster, Germany
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Dijkshoorn LA, Smeding L, Pepplinkhuizen S, de Veld JA, Knops RE, Olde Nordkamp LRA. Fifteen years of subcutaneous implantable cardioverter-defibrillator therapy: Where do we stand, and what will the future hold? Heart Rhythm 2024:S1547-5271(24)02741-3. [PMID: 38908460 DOI: 10.1016/j.hrthm.2024.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/14/2024] [Accepted: 06/15/2024] [Indexed: 06/24/2024]
Abstract
The subcutaneous implantable cardioverter-defibrillator (S-ICD) has emerged as a feasible alternative to the transvenous ICD in the treatment of ventricular tachyarrhythmias in patients without indications for pacing or cardiac resynchronization therapy. Since its introduction, numerous innovations have been made and clinical experience has been gained, leading to its adoption in current practice and preference in certain populations. Moreover, emerging technologies like the extravascular ICD and the combination of the S-ICD with the leadless pacemaker offer new possibilities for the future. These advancements underscore the evolving role of the S-ICD in management of ventricular tachyarrhythmia. This review outlines implantation considerations, patient selection, and troubleshooting advancements in the last 15 years and provides insights into future perspectives.
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Affiliation(s)
| | - Lonneke Smeding
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - Jolien A de Veld
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Reinoud E Knops
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
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Knops RE, El-Chami MF, Marquie C, Nordbeck P, Quast AFBE, Tilz RR, Brouwer TF, Lambiase PD, Cassidy CJ, Boersma LVA, Burke MC, Pepplinkhuizen S, de Veld JA, de Weger A, Bracke FALE, Manyam H, Probst V, Betts TR, Bijsterveld NR, Defaye P, Demming T, Elders J, Field DC, Ghani A, Golovchiner G, de Jong JSSG, Lewis N, Marijon E, Martin CA, Miller MA, Shaik NA, van der Stuijt W, Kuschyk J, Olde Nordkamp LRA, Arya A, Borger van der Burg AE, Boveda S, van Doorn DJ, Glikson M, Kaiser L, Maass AH, van Woerkens LJPM, Zaidi A, Wilde AAM, Smeding L. Predictive value of the PRAETORIAN score for defibrillation test success in patients with subcutaneous ICD: A subanalysis of the PRAETORIAN-DFT trial. Heart Rhythm 2024; 21:836-844. [PMID: 38336193 DOI: 10.1016/j.hrthm.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/24/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND The PRAETORIAN score estimates the risk of failure of subcutaneous implantable cardioverter-defibrillator (S-ICD) therapy by using generator and lead positioning on bidirectional chest radiographs. The PRospective randomized compArative trial of subcutanEous implanTable cardiOverter-defibrillatoR ImplANtation with and without DeFibrillation Testing (PRAETORIAN-DFT) investigates whether PRAETORIAN score calculation is noninferior to defibrillation testing (DFT) with regard to first shock efficacy in spontaneous events. OBJECTIVE This prespecified subanalysis assessed the predictive value of the PRAETORIAN score for defibrillation success in induced ventricular arrhythmias. METHODS This multicenter investigator-initiated trial randomized 965 patients between DFT and PRAETORIAN score calculation after de novo S-ICD implantation. Successful DFT was defined as conversion of induced ventricular arrhythmia in <5 seconds from shock delivery within 2 attempts. Bidirectional chest radiographs were obtained after implantation. The predictive value of the PRAETORIAN score for DFT success was calculated for patients in the DFT arm. RESULTS In total, 482 patients were randomized to undergo DFT. Of these patients, 457 (95%) underwent DFT according to protocol, of whom 445 (97%) had successful DFT and 12 (3%) had failed DFT. A PRAETORIAN score of ≥90 had a positive predictive value of 25% for failed DFT, and a PRAETORIAN score of <90 had a negative predictive value of 99% for successful DFT. A PRAETORIAN score of ≥90 was the strongest independent predictor for failed DFT (odds ratio 33.77; confidence interval 6.13-279.95; P < .001). CONCLUSION A PRAETORIAN score of <90 serves as a reliable indicator for DFT success in patients with S-ICD, and a PRAETORIAN score of ≥90 is a strong predictor for DFT failure.
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Affiliation(s)
- Reinoud E Knops
- Amsterdam UMC location University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences Heart Failure & Arrhythmias, Amsterdam, The Netherlands.
| | - Mikhael F El-Chami
- Division of Cardiology Section of Electrophysiology, Emory University, Atlanta, Georgia
| | | | - Peter Nordbeck
- Department of Internal Medicine I, University and University Hospital Würzburg, Würzburg, Germany
| | - Anne-Floor B E Quast
- Amsterdam UMC location University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences Heart Failure & Arrhythmias, Amsterdam, The Netherlands
| | - Roland R Tilz
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Tom F Brouwer
- Amsterdam UMC location University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences Heart Failure & Arrhythmias, Amsterdam, The Netherlands
| | - Pier D Lambiase
- Office of the Director of Clinical Electrophysiology Research and Lead for Inherited Arrhythmia Specialist Services, University College London and Barts Heart Centre, London, United Kingdom
| | - Christopher J Cassidy
- Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Trust, Blackpool, United Kingdom
| | - Lucas V A Boersma
- Amsterdam UMC location University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences Heart Failure & Arrhythmias, Amsterdam, The Netherlands; Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Shari Pepplinkhuizen
- Amsterdam UMC location University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences Heart Failure & Arrhythmias, Amsterdam, The Netherlands
| | - Jolien A de Veld
- Amsterdam UMC location University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences Heart Failure & Arrhythmias, Amsterdam, The Netherlands
| | - Anouk de Weger
- Amsterdam UMC location University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences Heart Failure & Arrhythmias, Amsterdam, The Netherlands
| | - Frank A L E Bracke
- Department of Electrophysiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Harish Manyam
- Department of Cardiology Erlanger Health System, University of Tennessee, Chattanooga, Tennessee
| | - Vincent Probst
- Service de Cardiologie, L'institut du thorax, CHU Nantes, Nantes, France
| | - Timothy R Betts
- Oxford Biomedical Research Centre, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Nick R Bijsterveld
- Amsterdam UMC location University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences Heart Failure & Arrhythmias, Amsterdam, The Netherlands; Department of Cardiology, Flevoziekenhuis, Almere, The Netherlands
| | - Pascal Defaye
- Service de Cardiologie, Centre hospitalier universitaire, Grenoble, France
| | - Thomas Demming
- Department of Internal Medicine III, Cardiology, Angiology, and Critical Care, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jan Elders
- Department of Cardiology, Canisius Wilhelminahospital, Nijmegen, The Netherlands
| | - Duncan C Field
- Cardiology, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon, United Kingdom
| | - Abdul Ghani
- Department of Cardiology, Isala Heart Centre, Zwolle, The Netherlands
| | | | | | - Nigel Lewis
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Eloi Marijon
- Division of Cardiology, European Georges Pompidou Hospital, Paris, France
| | - Claire A Martin
- Department of Cardiology, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Marc A Miller
- Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | - Naushad A Shaik
- Department of Cardiac Electrophysiology, Advent Health Orlando, Orlando, Florida
| | - Willeke van der Stuijt
- Amsterdam UMC location University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences Heart Failure & Arrhythmias, Amsterdam, The Netherlands
| | - Jürgen Kuschyk
- First Department of Medicine, University Medical Center Mannheim, Mannheim, Germany; First Department of Medicine-Cardiology, University Medical Center Mannheim, and the German Center for Cardiovascular Research Partner Site Heidelberg-Mannheim, Mannheim, Germany
| | - Louise R A Olde Nordkamp
- Amsterdam UMC location University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences Heart Failure & Arrhythmias, Amsterdam, The Netherlands
| | - Anita Arya
- New Cross Hospital, Heart and Lung Centre, Division of Electrophysiology and Devices, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | | | - Serge Boveda
- Heart Rhythm Department, Clinique Pasteur, Toulouse, France
| | - Dirk J van Doorn
- Department of Cardiology, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Lukas Kaiser
- Department of Cardiology and Critical Care Medicine, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Alexander H Maass
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Amir Zaidi
- Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Arthur A M Wilde
- Amsterdam UMC location University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences Heart Failure & Arrhythmias, Amsterdam, The Netherlands
| | - Lonneke Smeding
- Amsterdam UMC location University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences Heart Failure & Arrhythmias, Amsterdam, The Netherlands
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van der Stuijt W, Pepplinkhuizen S, de Veld JA, Quast ABE, van Halm VP, Bijsterveld NR, Olde Nordkamp LRA, Wilde AAM, Smeding L, Knops RE. Defibrillation threshold in elective subcutaneous implantable defibrillator generator replacements: Time to reduce the size of the pulse generator? Int J Cardiol 2024; 398:131639. [PMID: 38065323 DOI: 10.1016/j.ijcard.2023.131639] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/11/2023] [Accepted: 12/03/2023] [Indexed: 01/23/2024]
Abstract
INTRODUCTION The first step-down defibrillation studies in the subcutaneous implantable cardioverter-defibrillator (S-ICD) described a defibrillation threshold (DFT) of 32.5 ± 17.0 J and 36.6 ± 19.8 J. Therefore, the default shock output of the S-ICD was set at 80 J. In de novo implants, the DFT is lower in optimally positioned S-ICDs. However, a retrospective analysis raised concerns about a high DFT in S-ICD replacements, possibly related to fibrosis. OBJECTIVE We aimed to find the DFT in patients undergoing S-ICD generator replacement. METHODS This prospective study enrolled patients who underwent S-ICD generator replacement with subsequent defibrillation testing. A pre-specified defibrillation testing protocol was used to determine the DFT, defined as the lowest shock output that effectively terminated the induced ventricular arrhythmia. RESULTS A total of 45 patients were enrolled, 6.0 ± 2.1 years after initial implant. Mean DFT during replacement in the total cohort was 27.4 ± 14.3 J. In patients with a body mass index (BMI) 18.5-25 kg/m2 (N = 22, BMI 22.5 ± 1.6), median DFT was 20 J (IQR 17.5-30). In 18/22 patients, the DFT was ≤30 J and 5/22 patients were successfully defibrillated at 10 J. One patient with hypertrophic cardiomyopathy had a DFT of 65 J. In patients with a BMI >25 kg/m2 (N = 23, BMI 29.5 ± 4.2), median DFT was 30 J (IQR 20-40). In 15/23 patients, the DFT was ≤30 J and 4/23 patients had a successful defibrillation test at 10 J. CONCLUSIONS This study eases concerns about a high DFT after S-ICD generator replacement. The majority of patients had a DFT ≤30 J, regardless of BMI, suggesting that the shock output of the S-ICD could be safely reduced.
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Affiliation(s)
- W van der Stuijt
- Amsterdam UMC Location University of Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands.
| | - S Pepplinkhuizen
- Amsterdam UMC Location University of Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands
| | - J A de Veld
- Amsterdam UMC Location University of Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands
| | - A B E Quast
- Amsterdam UMC Location University of Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands
| | - V P van Halm
- Amsterdam UMC, Location VUmc, Department of Cardiology, Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
| | - N R Bijsterveld
- Amsterdam UMC Location University of Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands
| | - L R A Olde Nordkamp
- Amsterdam UMC Location University of Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands
| | - A A M Wilde
- Amsterdam UMC Location University of Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands
| | - L Smeding
- Amsterdam UMC Location University of Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands
| | - R E Knops
- Amsterdam UMC Location University of Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands
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Yap SC, Oosterwerff EFJ, Boersma LVA, van der Stuijt W, Lenssen A, Hahn SJ, Knops RE. Acute human defibrillation performance of a subcutaneous implantable cardioverter-defibrillator with an additional coil electrode. Heart Rhythm 2023; 20:1649-1656. [PMID: 37579867 DOI: 10.1016/j.hrthm.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND The subcutaneous implantable cardioverter-defibrillator (S-ICD) delivers 80 J shocks from an 8 cm left-parasternal coil to a 59 cm3 left lateral pulse generator (PG). A system that defibrillates with lower energy could significantly reduce PG size. Computer modeling and animal studies suggested that a second shock coil either parallel to the left-parasternal coil or transverse from the xiphoid to the PG pocket would significantly reduce the defibrillation threshold. OBJECTIVE The purpose of this study was to acutely assess the defibrillation efficacy of parallel and transverse configurations in patients receiving an S-ICD. METHODS Testing was performed in patients receiving a conventional S-ICD system. Success at 65 J was required before investigational testing. A second electrode was temporarily inserted from the xiphoid incision connected to the PG with an investigational Y-adapter. Phase 1 (n = 11) tested the parallel configuration. Phase 2 (n = 21) tested both parallel and transverse configurations in random order. RESULTS This study enrolled 35 patients (28 males (80%); mean age 51 ± 17 years; left ventricular ejection fraction 40% ± 15%; body mass index 26 ± 4 kg/m2; prior myocardial infarction 46%; congestive heart failure 49%; cardiomyopathy 63%). Compared to the conventional S-ICD system, mean shock impedance decreased for both parallel (69 ± 15 Ω vs 86 ± 20 Ω; n = 33; P < .001) and transverse (56 ± 14 Ω vs 81 ± 21 Ω; n = 20; P < .001) configurations. Shock success rates at 20, 30, and 40 J were 55%, 79%, 97%, and 25%, 70%, 90% for parallel and transverse configurations, respectively. Defibrillation threshold testing was well tolerated with no serious adverse events. CONCLUSION Adding a second shock coil, particularly in the parallel configuration, significantly reduced the impedance and had a high likelihood of defibrillation success at energies ≤40 J. This may enable the development of a smaller S-ICD.
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Affiliation(s)
- Sing-Chien Yap
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus Medisch Centrum, Rotterdam, The Netherlands.
| | | | - Lucas V A Boersma
- Department of Cardiology, St Antonious Ziekenhuis, Nieuwegein, The Netherlands; Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Willeke van der Stuijt
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | | | - Reinoud E Knops
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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de Veld JA, Pepplinkhuizen S, van der Stuijt W, Quast AFBE, Olde Nordkamp LRA, Kooiman KM, Wilde AAM, Smeding L, Knops RE. Successful defibrillation testing in patients undergoing elective subcutaneous implantable cardioverter-defibrillator generator replacement. Europace 2023; 25:euad184. [PMID: 37379530 PMCID: PMC10325005 DOI: 10.1093/europace/euad184] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023] Open
Abstract
AIMS After implantation of a subcutaneous implantable cardioverter-defibrillator (S-ICD), a defibrillation test (DFT) is performed to ensure that the device can effectively detect and terminate the induced ventricular arrhythmia. Data on DFT efficacy at generator replacement are scarce with a limited number of patients and conflicting results. This study evaluates conversion efficacy during DFT at elective S-ICD generator replacement in a large cohort from our tertiary centre. METHODS AND RESULTS Retrospective data of patients who underwent an S-ICD generator replacement for battery depletion with subsequent DFT between February 2015 and June 2022 were collected. Defibrillation test data were collected from both implant and replacement procedures. PRAETORIAN scores at implant were calculated. Defibrillation test was defined unsuccessful when two conversions at 65 J failed. A total of 121 patients were included. The defibrillation test was successful in 95% after the first and 98% after two consecutive tests. This was comparable with success rates at implant, despite a significant rise in shock impedance (73 ± 23 vs. 83 ± 24 Ω, P < 0.001). Both patients with an unsuccessful DFT at 65 J successfully converted with 80 J. CONCLUSION This study shows a high DFT conversion rate at elective S-ICD generator replacement, which is comparable to conversion rates at implant, despite a rise in shock impedance. Evaluating device position before generator replacement may be recommended to optimize defibrillation success at generator replacement.
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Affiliation(s)
- Jolien A de Veld
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Location AMC, Room C0-333, Meibergdreef 9, PO Box 22700, Amsterdam 1105AZ, The Netherlands
| | - Shari Pepplinkhuizen
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Location AMC, Room C0-333, Meibergdreef 9, PO Box 22700, Amsterdam 1105AZ, The Netherlands
| | - Willeke van der Stuijt
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Location AMC, Room C0-333, Meibergdreef 9, PO Box 22700, Amsterdam 1105AZ, The Netherlands
| | - Anne-Floor B E Quast
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Location AMC, Room C0-333, Meibergdreef 9, PO Box 22700, Amsterdam 1105AZ, The Netherlands
| | - Louise R A Olde Nordkamp
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Location AMC, Room C0-333, Meibergdreef 9, PO Box 22700, Amsterdam 1105AZ, The Netherlands
| | - Kirsten M Kooiman
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Location AMC, Room C0-333, Meibergdreef 9, PO Box 22700, Amsterdam 1105AZ, The Netherlands
| | - Arthur A M Wilde
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Location AMC, Room C0-333, Meibergdreef 9, PO Box 22700, Amsterdam 1105AZ, The Netherlands
| | - Lonneke Smeding
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Location AMC, Room C0-333, Meibergdreef 9, PO Box 22700, Amsterdam 1105AZ, The Netherlands
| | - Reinoud E Knops
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Location AMC, Room C0-333, Meibergdreef 9, PO Box 22700, Amsterdam 1105AZ, The Netherlands
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Budrejko S, Kempa M, Krupa W, Królak T, Fabiszak T, Raczak G. Real-Life Inter-Rater Variability of the PRAETORIAN Score Values. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:9700. [PMID: 35955057 PMCID: PMC9368382 DOI: 10.3390/ijerph19159700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/01/2022] [Accepted: 08/05/2022] [Indexed: 06/15/2023]
Abstract
(1) Background: The PRAETORIAN score is a tool developed for postoperative evaluation of the position of subcutaneous implantable cardioverter-defibrillator systems. The aim of our study was to evaluate the real-life inter-rater variability of the PRAETORIAN score, based on chest radiographs of S-ICD patients reviewed by independent clinical raters. (2) Methods: Postoperative chest X-rays of patients that underwent S-ICD implantation were evaluated by five clinical raters who gave values of the PRAETORIAN score. Ratings were then compared in a fully crossed manner to determine the inter-rater variability of the attributed scores. (3) Results: In total, 87 patients were included in the study. In the case of the most important final risk category of the PRAETORIAN score, the mean Light's kappa was 0.804, the Fleiss' kappa was 0.249, and the intraclass correlation was 0.38. The final risk category was identically determined by all five raters in 75.86% of patients, by four raters in 14.94%, and by three raters in 9.20% of patients. (4) Conclusions: The overall inter-rater variability of the PRAETORIAN score in a group of electrophysiologists experienced in S-ICD implantation, yet previously naive to the PRAETORIAN score, and self-trained in its utilization, was only modest in our study. Appropriate use of the score might require training of clinical raters.
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Affiliation(s)
- Szymon Budrejko
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, 80-214 Gdansk, Poland
| | - Maciej Kempa
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, 80-214 Gdansk, Poland
| | - Wojciech Krupa
- Department of Cardiology and Internal Diseases, Collegium Medicum, Nicolaus Copernicus University, 87-100 Bydgoszcz, Poland
| | - Tomasz Królak
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, 80-214 Gdansk, Poland
| | - Tomasz Fabiszak
- Department of Cardiology and Internal Diseases, Collegium Medicum, Nicolaus Copernicus University, 87-100 Bydgoszcz, Poland
| | - Grzegorz Raczak
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, 80-214 Gdansk, Poland
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Biffi M, Bongiorni MG, D'Onofrio A, Manzo M, Pieragnoli P, Palmisano P, Ottaviano L, Perego GB, Pangallo A, Lavalle C, Bonfantino V, Nigro G, Landolina ME, Katsouras G, Diemberger I, Viani S, Bianchi V, Lovecchio M, Valsecchi S, Ziacchi M. Is 40 Joules Enough to Successfully Defibrillate With Subcutaneous Implantable Cardioverter-Defibrillators? JACC Clin Electrophysiol 2021; 7:767-776. [PMID: 33516714 DOI: 10.1016/j.jacep.2020.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVES This study evaluated the efficacy of conversion test performed at 40 J (defibrillation margin ≥40 J), and factors potentially associated with test failure were identified. BACKGROUND Current subcutaneous implantable cardioverter-defibrillator (S-ICD) devices deliver a maximum of 80 J. Functional defibrillation testing is recommended at S-ICD implantation, and it is usually conducted by delivering a shock energy of 65 J to ensure a safety defibrillation margin ≥15 J. Although high rates of successful conversion were reported at 65 J, limited data exist on the defibrillation margin extent. METHODS Ventricular fibrillation was induced and conversion test was performed by delivering a 40-J shock in 308 patients. Success was defined as termination of ventricular fibrillation by the first shock delivered in standard polarity. The S-ICD system positioning was evaluated with the PRAETORIAN score using bidirectional chest X-rays. RESULTS The generator was positioned in an intermuscular pocket in 301 patients (98%) and the lead was implanted by means of a 2-incision technique. The PRAETORIAN score was <90 (low risk of conversion failure) in 293 (95%) patients. Overall, ventricular fibrillation termination occurred in 259 (84%) patients with 40 J. Male gender (odds ratio [OR]: 3.79; 95% confidence interval [CI]: 1.09 to 13.14; p = 0.036), body mass index (OR: 1.09; 95% CI: 1.01 to 1.19; p = 0.036), dilated cardiomyopathy with reduced ejection fraction (OR: 0.42; 95% CI: 0.20 to 0.87; p = 0.019), and PRAETORIAN score >50 (OR: 2.93; 95% CI: 1.26 to 6.83; p = 0.013) were independently associated with conversion failure. CONCLUSIONS The authors showed a high rate of defibrillation success with 40-J shocks in S-ICD systems implanted by means of modern surgical techniques. The variables associated with shock failure were male gender, higher body mass index, and suboptimal device position according to the PRAETORIAN score.
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Affiliation(s)
- Mauro Biffi
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy.
| | - Maria Grazia Bongiorni
- Second Cardiology Division, Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Antonio D'Onofrio
- "Unità Operativa di Elettrofisiologia, Studio e Terapia delle Aritmie," Monaldi Hospital, Naples, Italy
| | - Michele Manzo
- Ospedali Riuniti San Giovanni di Dio e Ruggi D'Aragona, Salerno, Italy
| | | | | | | | | | | | - Carlo Lavalle
- Policlinico Umberto I -"Sapienza" University of Rome, Italy
| | | | | | | | | | - Igor Diemberger
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | - Stefano Viani
- Second Cardiology Division, Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Valter Bianchi
- "Unità Operativa di Elettrofisiologia, Studio e Terapia delle Aritmie," Monaldi Hospital, Naples, Italy
| | | | | | - Matteo Ziacchi
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
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9
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Ricciardi D, Ziacchi M, Gasperetti A, Schiavone M, Picarelli F, Diemberger I, Bontempi L, Di Belardino N, Bisignani G, De Bonis S, Mitacchione G, Calabrese V, Lavalle C, Piro A, Pignalberi C, Santini L, Grigioni F, Tondo C, Biffi M, Forleo GB. Clinical impact of defibrillation testing in a real‐world S‐ICD population: Data from the ELISIR registry. J Cardiovasc Electrophysiol 2020; 32:468-476. [DOI: 10.1111/jce.14833] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/29/2020] [Accepted: 11/19/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Danilo Ricciardi
- Department of Cardiology Policlinico Universitario Campus Bio‐Medico Roma Italy
| | - Matteo Ziacchi
- Unit of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine‐DIMES University of Bologna Bologna Italy
| | | | | | - Francesco Picarelli
- Department of Cardiology Policlinico Universitario Campus Bio‐Medico Roma Italy
- Department of Cardiology Ospedali Riuniti Anzio‐Nettuno Anzio Italy
| | - Igor Diemberger
- Unit of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine‐DIMES University of Bologna Bologna Italy
| | - Luca Bontempi
- Department of Cardiology Spedali Civili Brescia Brescia Italy
| | | | - Giovanni Bisignani
- Department of Cardiology Ospedale “Ferrari”, Castrovillari Cosenza Italy
| | - Silvia De Bonis
- Department of Cardiology Ospedale “Ferrari”, Castrovillari Cosenza Italy
| | | | - Vito Calabrese
- Department of Cardiology Policlinico Universitario Campus Bio‐Medico Roma Italy
| | - Carlo Lavalle
- Department of Cardiovascular/Respiratory Diseases, Nephrology, Anesthesiology, and Geriatric Sciences Policlinico Umberto I Sapienza University of Rome Rome Italy
| | - Agostino Piro
- Department of Cardiovascular/Respiratory Diseases, Nephrology, Anesthesiology, and Geriatric Sciences Policlinico Umberto I Sapienza University of Rome Rome Italy
| | | | - Luca Santini
- Division of Cardiology Ospedale G.B. Grassi Ostia Italy
| | - Francesco Grigioni
- Department of Cardiology Policlinico Universitario Campus Bio‐Medico Roma Italy
| | - Claudio Tondo
- Heart Rhythm Center Centro Cardiologico Monzino, IRCCS Milan Italy
- Department of Clinical Sciences and Community Health University of Milan Milan Italy
| | - Mauro Biffi
- Unit of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine‐DIMES University of Bologna Bologna Italy
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10
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von Alvensleben JC, Dechert B, Bradley DJ, Fish FA, Moore JP, Pilcher TA, Escudero C, Ceresnak SR, Kwok SY, Balaji S, Aziz PF, Papagiannis J, Cortez D, Garnreiter J, Kean A, Schäfer M, Collins KK. Subcutaneous Implantable Cardioverter-Defibrillators in Pediatrics and Congenital Heart Disease. JACC Clin Electrophysiol 2020; 6:1752-1761. [DOI: 10.1016/j.jacep.2020.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/06/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
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11
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Francia P, Biffi M, Adduci C, Ottaviano L, Migliore F, De Bonis S, Dello Russo A, De Filippo P, Viani S, Bongiorni MG, Caravati F, Lavalle C, Landolina ME, Pisanò E, Giorgi D, Lovecchio M, Valsecchi S, Diemberger I. Implantation technique and optimal subcutaneous defibrillator chest position: a PRAETORIAN score-based study. Europace 2020; 22:1822-1829. [DOI: 10.1093/europace/euaa231] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/16/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
The traditional technique for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation involves three incisions and a subcutaneous pocket. Recently, a two-incision and intermuscular (IM) technique has been adopted. The PRAETORIAN score is a chest radiograph-based tool that predicts S-ICD conversion testing. We assessed whether the S-ICD implantation technique affects optimal position of the defibrillation system according to the PRAETORIAN score.
Methods and results
We analysed consecutive patients undergoing S-ICD implantation. The χ2 test and regression analysis were used to determine the association between the PRAETORIAN score and implantation technique. Two hundred and thirteen patients were enrolled. The S-ICD generator was positioned in an IM pocket in 174 patients (81.7%) and the two-incision approach was adopted in 199 (93.4%). According to the PRAETORIAN score, the risk of conversion failure was classified as low in 198 patients (93.0%), intermediate in 13 (6.1%), and high in 2 (0.9%). Patients undergoing the two-incision and IM technique were more likely to have a low (<90) PRAETORIAN score than those undergoing the three-incision and subcutaneous technique (two-incision: 94.0% vs. three-incision: 78.6%; P = 0.004 and IM: 96.0% vs. subcutaneous: 79.5%; P = 0.001). Intermuscular plus two-incision technique was associated with a low-risk PRAETORIAN score (hazard ratio 3.76; 95% confidence interval 1.01–14.02; P = 0.04). Shock impedance was lower in PRAETORIAN low-risk patients than in intermediate-/high-risk categories (66 vs. 96 Ohm; P = 0.001). The PRAETORIAN score did not predict shock failure at 65 J.
Conclusion
In this cohort of S-ICD recipients, combining the two-incision technique and IM generator implantation yielded the lowest PRAETORIAN score values, indicating optimal defibrillation system position.
Clinical trial registration
http://clinicaltrials.gov/ Identifier: NCT02275637.
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Affiliation(s)
- Pietro Francia
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University of Rome, St. Andrea Hospital, Via di Grottarossa, 1035, 00189 Rome, Italy
| | - Mauro Biffi
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Carmen Adduci
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University of Rome, St. Andrea Hospital, Via di Grottarossa, 1035, 00189 Rome, Italy
| | | | - Federico Migliore
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | | | | | | | - Stefano Viani
- Second Cardiology Division, Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Maria Grazia Bongiorni
- Second Cardiology Division, Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Fabrizio Caravati
- Division of Cardiology, ‘Circolo e Fondazione Macchi’ Hospital, Varese, Italy
| | - Carlo Lavalle
- Policlinico Umberto I—‘Sapienza’ University of Rome, Rome, Italy
| | | | | | - Davide Giorgi
- Division of Cardiology, ‘San Luca’ Hospital, Lucca, Italy
| | | | | | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
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Defibrillation testing during implantation of the subcutaneous implantable cardioverter-defibrillator: a necessary standard or becoming redundant? Neth Heart J 2020; 28:122-127. [PMID: 32780342 PMCID: PMC7419406 DOI: 10.1007/s12471-020-01448-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Since the publication of the SIMPLE and NORDIC trials, defibrillation testing (DFT) is rarely performed during routine implantation of transvenous implantable cardioverter-defibrillators (ICD). However, the results of these trials cannot be extrapolated to the later introduced subcutaneous ICD (S-ICD) and a class I recommendation to perform DFT during the implantation of these devices remains in the current guidelines. Due to the high conversion success rate of DFT on one hand, and the risk of complications on the other, a significant number of physicians omit DFT in S‑ICD recipients. Several retrospective analyses have assessed the safety of the omission of DFT and report contradicting results and recommendations. It is known that implant position, as well as device factors and patient characteristics, influence defibrillation success. A better comprehension of these factors and their relationship could lead to more reliable and safer alternatives to DFT. An ongoing randomised clinical trial, which is expected to end in 2023, is the first study to implement a method that assesses implant position to identify patients who are likely to fail their DFT.
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Afzal MR, Okabe T, Hsu K, Cook S, Koppert T, Weiss R. How to minimize peri-procedural complications during subcutaneous defibrillator implant? Expert Rev Cardiovasc Ther 2020; 18:427-434. [DOI: 10.1080/14779072.2020.1784006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Muhammad R. Afzal
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Toshimasa Okabe
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kevin Hsu
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Schuyler Cook
- Department of Internal Medicine, Adena Regional Medical Center, Chillicothe, OH, USA
| | - Tanner Koppert
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Raul Weiss
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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