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Vijayarajan V, Hsu A, Cheng YY, Shu MWS, Hyun K, Sy R, Chow V, Brieger D, Kritharides L, Ng ACC. Outcomes Following Implantable Cardioverter-Defibrillator Insertion in Patients 80 Years of Age or Older: A Statewide Population Cohort Study. Can J Cardiol 2024; 40:389-398. [PMID: 37898173 DOI: 10.1016/j.cjca.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/10/2023] [Accepted: 10/23/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Patients ≥ 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. METHODS We 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. RESULTS A 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. CONCLUSIONS ICD 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.
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Affiliation(s)
- Vijayatubini Vijayarajan
- Department of Cardiology, Concord Hospital, University of Sydney, Concord, New South Wales, Australia.
| | - Arielle Hsu
- Department of Cardiology, Concord Hospital, University of Sydney, Concord, New South Wales, Australia
| | - Yeu-Yao Cheng
- Department of Cardiology, Concord Hospital, University of Sydney, Concord, New South Wales, Australia
| | - Matthew Wei Shun Shu
- Department of Cardiology, Concord Hospital, University of Sydney, Concord, New South Wales, Australia
| | - Karice Hyun
- Department of Cardiology, Concord Hospital, University of Sydney, Concord, New South Wales, Australia
| | - Raymond Sy
- Department of Cardiology, Concord Hospital, University of Sydney, Concord, New South Wales, Australia
| | - Vincent Chow
- Department of Cardiology, Concord Hospital, University of Sydney, Concord, New South Wales, Australia
| | - David Brieger
- Department of Cardiology, Concord Hospital, University of Sydney, Concord, New South Wales, Australia
| | - Leonard Kritharides
- Department of Cardiology, Concord Hospital, University of Sydney, Concord, New South Wales, Australia
| | - Austin Chin Chwan Ng
- Department of Cardiology, Concord Hospital, University of Sydney, Concord, New South Wales, Australia
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Alvarez CK, Zweibel S, Stangle A, Panza G, May T, Marieb M. Anesthetic Considerations in the Electrophysiology Laboratory: A Comprehensive Review. J Cardiothorac Vasc Anesth 2023; 37:96-111. [PMID: 36357307 DOI: 10.1053/j.jvca.2022.10.013] [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: 06/11/2022] [Revised: 10/02/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
Catheter ablation procedures for arrhythmias or implantation and/or extraction of cardiac pacemakers can present many clinical challenges. It is imperative that there is clear communication and understanding between the anesthesiologist and electrophysiologist during the perioperative period regarding the mode of ventilation, hemodynamic considerations, and various procedural complications. This article provides a comprehensive narrative review of the anesthetic techniques and considerations for catheter ablation procedures, ventilatory modes using techniques such as high-frequency jet ventilation, and strategies such as esophageal deviation and luminal temperature monitoring to decrease the risk of esophageal injury during catheter ablation. Various hemodynamic considerations, such as the intraprocedural triaging of cardiac tamponade and fluid administration during catheter ablation, also are discussed. Finally, this review briefly highlights the early research findings on pulse-field ablation, a new and evolving ablation modality.
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Affiliation(s)
- Chikezie K Alvarez
- Hartford HealthCare Heart and Vascular Institute, Hartford, CT; University of Connecticut, Farmington, CT.
| | - Steven Zweibel
- Hartford HealthCare Heart and Vascular Institute, Hartford, CT
| | - Alexander Stangle
- Hartford HealthCare Heart and Vascular Institute, Hartford, CT; University of Connecticut, Farmington, CT
| | - Gregory Panza
- Hartford HealthCare Heart and Vascular Institute, Hartford, CT; University of Connecticut, Farmington, CT
| | - Thomas May
- Hartford HealthCare Heart and Vascular Institute, Hartford, CT
| | - Mark Marieb
- Hartford HealthCare Heart and Vascular Institute, Hartford, CT; Griffin Hospital, Derby, CT
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Darden D, Peterson PN, Xin X, Munir MB, Minges KE, Goldenberg I, Poole JE, Feld GK, Birgersdotter-Green U, Curtis JP, Hsu JC. Temporal trends and long-term outcomes among recipients of cardiac resynchronization therapy with defibrillator in the United States, 2011-2015: Insights from the National Cardiovascular Data Registry. Heart Rhythm O2 2022; 3:405-414. [PMID: 36097450 PMCID: PMC9463686 DOI: 10.1016/j.hroo.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Contemporary data on national trends and outcomes in cardiac resynchronization therapy with defibrillator (CRT-D) recipients following the 2012 updated guidelines has not been studied. Objectives This study assessed the trends in long-term outcomes among CRT-D Medicare-aged recipients implanted in 2011-2015. Methods Patients aged ≥65 years undergoing de novo CRT-D implantation in the National Cardiovascular Data Implantable Cardiac Defibrillator Registry from 2011-2015 with follow-up through 2017 using Medicare data were included and stratified by year of implant. Patient characteristics, in-hospital outcomes, and outcomes up to 2 years following implant were evaluated. Results Among 53,174 patients (aged 75.6-6.4 years, 29.7% women) implanted with CRT-D from 2011 to 2015, there was an increase in implantations based on guideline-concordant recommendations (81.0% to 84.7%, P < .001). Compared to 2011, in-hospital procedural complications decreased in 2015 (3.9% vs 2.9%; adjusted odds ratio, 0.76, 95% confidence interval, 0.66-0.88, P < .001), driven in part by decreased lead dislodgement (1.4% vs 1.0%). After multivariable adjustment, there was a lower risk of all-cause hospitalization, cardiovascular hospitalization, and mortality at 2-year follow-up in 2015 as compared to 2011, while there were no differences in heart failure hospitalizations at follow-up. Conclusion Among Medicare beneficiaries receiving CRT-D from 2011 to 2015, there was an increase in implantations based on guideline-concordant recommendations. Furthermore, there has been a reduction in in-hospital complications and long-term outcomes, including cardiovascular hospitalization, all-cause hospitalization, and mortality; however, there has been no difference in the risk of heart failure hospitalization after adjustment.
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Affiliation(s)
- Douglas Darden
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Pamela N. Peterson
- Division of Cardiology, Denver Health Medical Center, Denver, Colorado
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Xin Xin
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Muhammad Bilal Munir
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Karl E. Minges
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Ilan Goldenberg
- Division of Cardiology, University of Rochester Medical Center, Rochester, New York
- Clinical Cardiovascular Research Center, University of Rochester, Rochester, New York
| | - Jeanne E. Poole
- University of Washington School of Medicine, Seattle, Washington
| | - Gregory K. Feld
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Ulrika Birgersdotter-Green
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jonathan C. Hsu
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
- Address reprint requests and correspondence: Dr Jonathan C. Hsu, Associate Professor of Medicine, University of California San Diego, 9452 Medical Center Dr, MC7411, La Jolla, CA 92037.
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Borne RT, Masoudi FA, Curtis JP, Zipse MM, Sandhu A, Hsu JC, Peterson PN. Use and Outcomes of Dual Chamber or Cardiac Resynchronization Therapy Defibrillators Among Older Patients Requiring Ventricular Pacing in the National Cardiovascular Data Registry Implantable Cardioverter Defibrillator Registry. JAMA Netw Open 2021; 4:e2035470. [PMID: 33496796 PMCID: PMC7838925 DOI: 10.1001/jamanetworkopen.2020.35470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Frequent right ventricular (RV) pacing can cause and exacerbate heart failure. Cardiac resynchronization therapy (CRT) has been shown to be associated with improved outcomes among patients with reduced left ventricular ejection fraction who need frequent RV pacing, but the patterns of use of CRT vs dual chamber (DC) devices and the associated outcomes among these patients in clinical practice is not known. OBJECTIVE To assess outcomes, variability in use of device type, and trends in use of device type over time among patients undergoing implantable cardioverter defibrillator (ICD) implantation who were likely to require frequent RV pacing but who did not have a class I indication for CRT. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used the National Cardiovascular Data Registry (NCDR) ICD Registry. A total of 3100 Medicare beneficiaries undergoing first-time implantation of CRT defibrillator (CRT-D) or DC-ICD from 2010 to 2016 who had a class I or II guideline ventricular bradycardia pacing indication but not a class I indication for CRT were included. Data were analyzed from August 2018 to October 2019. EXPOSURES Implantation of a CRT-D or DC-ICD. MAIN OUTCOMES AND MEASURES All-cause mortality, heart failure hospitalization, and complications were ascertained from Medicare claims data. Multivariable Cox proportional hazards models and Fine-Gray models were used to evaluate 1-year mortality and heart failure hospitalization, respectively. Multivariable logistic regression was used to evaluate 30-day and 90-day complications. All models accounted for clustering. The median odds ratio (MOR) was used to assess variability and represents the odds that a randomly selected patient receiving CRT-D at a hospital with high implant rates would receive CRT-D if they had been treated at a hospital with low CRT-D implant rates. RESULTS A total of 3100 individuals were included. The mean (SD) age was 76.3 (6.4) years, and 2500 (80.6%) were men. The 1698 patients (54.7%) receiving CRT-D were more likely than those receiving DC-ICD to have third-degree atrioventricular block (828 [48.8%] vs 432 [30.8%]; P < .001), nonischemic cardiomyopathy (508 [29.9%] vs 255 [18.2%]; P < .001), and prior heart failure hospitalizations (703 [41.4%] vs 421 [30.0%]; P < .001). Following adjustment, CRT-D was associated with lower 1-year mortality (hazard ratio [HR], 0.70; 95% CI, 0.57-0.87; P = .001) and heart failure hospitalization (subdistribution HR, 0.77; 95% CI, 0.61-0.97; P = .02) and no difference in complications compared with DC-ICD. Hospital variation in use of CRT was present (MOR, 2.00), and the use of CRT in this cohort was higher over time (654 of 1351 [48.4%] in 2010 vs 362 of 594 [60.9%] in 2016; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study of older patients in contemporary practice undergoing ICD implantation with a bradycardia pacing indication but without a class I indication for CRT, CRT-D was associated with better outcomes compared with DC devices. Variability in use of device type was observed, and the rate of CRT implantation increased over time.
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Affiliation(s)
- Ryan T. Borne
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | | | - Jeptha P. Curtis
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Matthew M. Zipse
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Amneet Sandhu
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Jonathan C. Hsu
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Diego, La Jolla
| | - Pamela N. Peterson
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
- Division of Cardiology, Denver Health Hospital, Denver, Colorado
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Kim J, Choi J, Shin MS, Park JK, An M, Kim SH, Choi N, Lee MO, Heo S. Effect of physical and psychocognitive function and perceived health status on 12-month adverse cardiac events among implantable cardioverter-defibrillator recipients. Heart Lung 2020; 49:530-536. [PMID: 32434703 DOI: 10.1016/j.hrtlng.2020.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/31/2020] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Post-implant recovery in patients with implantable cardioverter-defibrillators (ICDs) is often compromised because of reduced physical and psycho-cognitive function and poor health perception, leading to short event-free survival. OBJECTIVES To examine the effects of psychocognitive function, health perception, and ICD-related factors on 12-month cardiac events among ICD patients. METHODS Using a prospective study design, ICD patients underwent baseline assessment and were followed for 12 months to assess cardiac events. RESULTS Cardiac events occurred in 14 patients (18.9%) (N = 74: age, 58 years; primary ICDs, 45.9%). Time after ICD implant (odds ratio [OR] = 1.002; p = .028) and executive function (OR = 1.021; p = .027) were significant predictors of 12-month cardiac events, while other physical and psychological indices were not. CONCLUSIONS Reduced executive function and longer time after implant predicted the events. Healthcare professionals need to assess executive function and provide treatment and support to improve executive function.
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Affiliation(s)
- JinShil Kim
- Gachon University, College of Nursing, Incheon, South Korea
| | - Jiin Choi
- Office of Hospital Information, Seoul National University Hospital, Seoul, South Korea
| | - Mi-Seung Shin
- Division of Cardiology, Department of Internal Medicine, Gil Medical Center, Gachon University, College of Medicine, Incheon, South Korea
| | - Jin-Kyu Park
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Hanyang University Medical Center, Seoul, South Korea
| | - Minjeong An
- Chonnam National University, College of Nursing, Gwangju, South Korea
| | - Sun Hwa Kim
- Department of Nursing, Hanyang University Medical Center, Seoul, South Korea.
| | - Nayeon Choi
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Seoul, Korea
| | - Mee Ok Lee
- Gachon University Gil Medical Center, Incheon, South Korea
| | - Seongkum Heo
- Mercer University, Georgia Baptist College of Nursing, Atlanta, USA
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Steinhaus DA, Lubitz SA, Noseworthy PA, Kramer DB. Exercise Interventions in Patients With Implantable Cardioverter-Defibrillators and Cardiac Resynchronization Therapy: A SYSTEMATIC REVIEW AND META-ANALYSIS. J Cardiopulm Rehabil Prev 2019; 39:308-317. [PMID: 31397767 PMCID: PMC6715540 DOI: 10.1097/hcr.0000000000000389] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE Physical activity improves outcomes across a broad spectrum of cardiovascular disease. The safety and effectiveness of exercise-based interventions in patients with implantable cardioverter-defibrillators (ICDs) including cardiac resynchronization therapy defibrillators (CRT-Ds) remain poorly understood. METHODS We identified clinical studies using the following search terms: "implantable cardioverter-defibrillators"; "ICD"; "cardiac resynchronization therapy"; "CRT"; and any one of the following: "activity"; "exercise"; "training"; or "rehabilitation"; from January 1, 2000 to October 1, 2015. Eligible studies were evaluated for design and clinical endpoints. RESULTS A total of 16 studies were included: 8 randomized controlled trials, 5 single-arm trials, 2 observational cohort trials, and 1 randomized crossover trial. A total of 2547 patients were included (intervention groups = 1215 patients, control groups = 1332 patients). Exercise interventions varied widely in character, duration (median 84 d, range: 23-168 d), and follow-up time (median 109 d, range: 23 d to 48 mo). Exercise performance measures were the most common primary endpoints (87.5%), with most studies (81%) demonstrating significant improvement. Implantable cardioverter-defibrillator shocks were uncommon during active exercise intervention, with 6 shocks in 635 patients (0.9%). Implantable cardioverter-defibrillator shocks in follow-up were less common in patients receiving any exercise intervention (15.6% vs 23%, OR = 0.68; 95% CI, 0.48-0.80, P < .001). (Equation is included in full-text article.)O2 peak improved significantly in patients receiving exercise intervention (1.98 vs 0.36 mL/kg/min, P < .001). CONCLUSION In conclusion, exercise interventions in patients with ICDs and CRT-Ds appear safe and effective. Lack of consensus on design and endpoints remains a barrier to broader application to this important patient population.
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Affiliation(s)
- Daniel A. Steinhaus
- Saint Luke’s Mid America Heart Institute, Kansas City, MO
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Steven A. Lubitz
- Cardiac Arrhythmia Service, Department of Medicine, Massachusetts General Hospital, Harvard Medical School
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De Vincentis G, Frantellizzi V, Fedele F, Farcomeni A, Scarparo P, Salvi N, Fegatelli DA, Mancone M, Verschure DO, Verberne HJ. Role of cardiac 123I-mIBG imaging in predicting arrhythmic events in stable chronic heart failure patients with an ICD. J Nucl Cardiol 2019; 26:1188-1196. [PMID: 29594915 PMCID: PMC6660500 DOI: 10.1007/s12350-018-1258-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/27/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Despite therapeutic improvement, the prognosis of chronic heart failure (CHF) remains unfavorable partly due to arrhythmia and sudden cardiac death (SCD). This prospective study evaluated myocardial 123I-meta-iodobenzylguanidine (123I-mIBG) scintigraphy as a predictor of arrhythmic events (AE) in CHF patients. METHODS 170 CHF patients referred for implantable cardioverter-defibrillator (ICD) implantation for both primary and secondary prevention were enrolled. All patients underwent planar and SPECT imaging. Early and late heart-to-mediastinum (H/M) ratio, 123I-mIBG washout (WO), early and late summed SPECT scores were calculated The primary endpoint was an AE: sustained ventricular tachycardia, resuscitated cardiac arrest, appropriate ICD therapy or SCD. The secondary endpoint was appropriate ICD therapy. RESULTS During a median follow-up of 23.3 months, 69 patients experienced an AE. Early summed score (ESS) was the only independent predictor of AE [HR 1.023 (1.003-1.043)]. Focussing on only patients with an ICD for primary prevention, ESS was the only independent predictor of AE [HR 1.028 (1.007-1.050)]. 123I-mIBG-derived parameters failed to be independent predictors of appropriate ICD therapy. However there was a "bell-shaped" relation between 123I-mIBG scintigraphy-derived parameters and AE and appropriate ICD therapy, i.e., those with intermediate 123I-mIBG abnormalities tended to be at higher risk of events. CONCLUSION Although SPECT 123I-mIBG scintigraphy was associated with AE in CHF patients with ICD implantation for primary and secondary prevention, no association was found between 123I-mIBG scintigraphy-derived parameters and appropriate ICD therapy.
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Affiliation(s)
- Giuseppe De Vincentis
- Department of Radiological Sciences, Oncology and Anatomo-Pathology, Sapienza - University of Rome, Rome, Italy
| | - Viviana Frantellizzi
- Department of Radiological Sciences, Oncology and Anatomo-Pathology, Sapienza - University of Rome, Rome, Italy
- Angio-Cardio-Thoracic Pathophysiology and Imaging, Sapienza - University of Rome, Rome, Italy
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza - University of Rome, Rome, Italy
| | - Alessio Farcomeni
- Department of Public Health and Infectious Diseases, Sapienza - University of Rome, Rome, Italy
| | - Paola Scarparo
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza - University of Rome, Rome, Italy
| | - Nicolò Salvi
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza - University of Rome, Rome, Italy
| | - Danilo Alunni Fegatelli
- Department of Public Health and Infectious Diseases, Sapienza - University of Rome, Rome, Italy
| | - Massimo Mancone
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza - University of Rome, Rome, Italy
| | - Derk O. Verschure
- Department of Cardiology, Zaans Medical Center, Zaandam, The Netherlands
- Department of Radiology and Nuclear Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Hein J. Verberne
- Department of Radiology and Nuclear Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Marzec LN, Peterson PN, Bao H, Curtis JP, Masoudi FA, Varosy PD, Bradley SM. Use of Cardiac Resynchronization Therapy Among Eligible Patients Receiving an Implantable Cardioverter Defibrillator: Insights From the National Cardiovascular Data Registry Implantable Cardioverter Defibrillator Registry. JAMA Cardiol 2019; 2:561-565. [PMID: 28122073 DOI: 10.1001/jamacardio.2016.5388] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Cardiac resynchronization therapy (CRT) reduces the risk for mortality and heart failure-related events in select patients. Little is known about the use of CRT in combination with an implantable cardioverter defibrillator (ICD) in patients who are eligible for this therapy in clinical practice. Objective To (1) identify patient, clinician, and hospital characteristics associated with CRT defibrillator (CRT-D) use and (2) determine the extent of hospital-level variation in the use of CRT-D among guideline-eligible patients undergoing ICD placement. Design, Setting, and Participants Multicenter retrospective cohort from 1428 hospitals participating in the National Cardiovascular Data Registry ICD Registry between April 1, 2010, and June 30, 2014. Adult patients meeting class I or IIa guideline recommendations for CRT at the time of device implantation were included in this study. Main Outcomes and Measures Implantation of an ICD with or without CRT. Results A total of 63 506 eligible patients (88.6%) received CRT-D at the time of device implantation. The mean (SD) ages of those in the ICD and CRT-D groups were 67.9 (12.2) years and 68.4 (11.5) years, respectively. In hierarchical multivariable models, black race was independently associated with lower use of CRT-D (odds ratio [OR], 0.77; 95% CI, 0.71-0.83) as was nonprivate insurance (OR, 0.90; 95% CI, 0.85-0.95 for Medicare and OR, 0.73; 95% CI, 0.65-0.82 for Medicaid). Clinician factors associated with greater CRT-D use included clinician implantation volume (OR, 1.01 per 10 additional devices implanted; 95% CI, 1.01-1.01) and electrophysiology training (OR, 3.13 as compared with surgery-boarded clinicians; 95% CI, 2.50-3.85). At the hospital level, the overall median risk-standardized rate of CRT-D use was 79.9% (range, 26.7%-100%; median OR, 2.08; 95% CI, 1.99-2.18). Conclusions and Relevance In a national cohort of patients eligible for CRT-D at the time of device implantation, nearly 90% received a CRT-D device. However, use of CRT-D differed by race and implanting operator characteristics. After accounting for these factors, the use of CRT-D continued to vary widely by hospital. Addressing disparities and variation in CRT-D use among guideline-eligible patients may improve patient outcomes.
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Affiliation(s)
| | - Pamela N Peterson
- University of Colorado School of Medicine, Aurora2Denver Health Medical Center, Denver, Colorado
| | - Haikun Bao
- Yale University School of Medicine, New Haven, Connecticut
| | | | | | - Paul D Varosy
- University of Colorado School of Medicine, Aurora4Veterans Affairs Eastern Colorado Health Care System, Denver
| | - Steven M Bradley
- University of Colorado School of Medicine, Aurora4Veterans Affairs Eastern Colorado Health Care System, Denver
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Hajduk AM, Gurwitz JH, Tabada G, Masoudi FA, Magid DJ, Greenlee RT, Sung SH, Cassidy-Bushrow AE, Liu TI, Reynolds K, Smith DH, Fiocchi F, Goldberg R, Gill TM, Gupta N, Peterson PN, Schuger C, Vidaillet H, Hammill SC, Allore H, Go AS. Influence of Multimorbidity on Burden and Appropriateness of Implantable Cardioverter-Defibrillator Therapies. J Am Geriatr Soc 2019; 67:1370-1378. [PMID: 30892695 DOI: 10.1111/jgs.15839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 01/25/2019] [Accepted: 01/26/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To determine whether burden of multiple chronic conditions (MCCs) influences the risk of receiving inappropriate vs appropriate device therapies. DESIGN Retrospective cohort study. SETTING Seven US healthcare delivery systems. PARTICIPANTS Adults with left ventricular systolic dysfunction receiving an implantable cardioverter-defibrillator (ICD) for primary prevention. MEASUREMENTS Data on 24 comorbid conditions were captured from electronic health records and categorized into quartiles of comorbidity burden (0-3, 4-5, 6-7 and 8-16). Incidence of ICD therapies (shock and antitachycardia pacing [ATP] therapies), including appropriateness, was collected for 3 years after implantation. Outcomes included time to first ICD therapy, total ICD therapy burden, and risk of inappropriate vs appropriate ICD therapy. RESULTS Among 2235 patients (mean age = 69 ± 11 years, 75% men), the median number of comorbidities was 6 (interquartile range = 4-8), with 98% having at least two comorbidities. During a mean 2.2 years of follow-up, 18.3% of patients experienced at least one appropriate therapy and 9.9% experienced at least one inappropriate therapy. Higher comorbidity burden was associated with an increased risk of first inappropriate therapy (adjusted hazard ratio [HR] = 1.94 [95% confidence interval {CI} = 1.14-3.31] for 4-5 comorbidities; HR = 2.25 [95% CI = 1.25-4.05] for 6-7 comorbidities; and HR = 2.91 [95% CI = 1.54-5.50] for 8-16 comorbidities). Participants with 8-16 comorbidities had a higher total burden of ICD therapy (adjusted relative risk [RR] = 2.12 [95% CI = 1.43-3.16]), a higher burden of inappropriate therapy (RR = 3.39 [95% CI = 1.67-6.86]), and a higher risk of receiving inappropriate vs appropriate therapy (RR = 1.74 [95% CI = 1.07-2.82]). Comorbidity burden was not significantly associated with receipt of appropriate ICD therapies. Patterns were similar when separately examining shock or ATP therapies. CONCLUSIONS In primary prevention ICD recipients, MCC burden was independently associated with an increased risk of inappropriate but not appropriate device therapies. Comorbidity burden should be considered when engaging patients in shared decision making about ICD implantation.
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Affiliation(s)
- Alexandra M Hajduk
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jerry H Gurwitz
- Meyers Primary Care Institute, a Joint Endeavor of University of Massachusetts Medical School, Fallon Health, and Reliant Medical Group, Worcester, Massachusetts
| | - Grace Tabada
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Frederick A Masoudi
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David J Magid
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Robert T Greenlee
- Center for Clinical Epidemiology & Population Health, Marshfield Clinic Research Foundation, Marshfield, Wisconsin
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Taylor I Liu
- Department of Cardiac Electrophysiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - David H Smith
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Frances Fiocchi
- National Cardiovascular Data Registry, American College of Cardiology Foundation, Washington, DC
| | - Robert Goldberg
- Meyers Primary Care Institute, a Joint Endeavor of University of Massachusetts Medical School, Fallon Health, and Reliant Medical Group, Worcester, Massachusetts
| | - Thomas M Gill
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Nigel Gupta
- Department of Cardiac Electrophysiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Pamela N Peterson
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Claudio Schuger
- Heart and Vascular Institute, Henry Ford Health System, Detroit, Michigan
| | - Humberto Vidaillet
- Marshfield Clinical Research Foundation, Marshfield Clinic, Marshfield, Wisconsin
| | | | - Heather Allore
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California.,Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, California.,Departments of Medicine, Health Research and Policy, Stanford University School of Medicine, Palo Alto, California
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10
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Afzal MR, Horner S, Matre NB, Blake P, Dunham K, Pinkhas D, Okabe T, Tyler J, Houmsse M, Kalbfleisch SJ, Weiss R, Hummel JD, Daoud EG, Augostini RS. Comprehensive strategy to reduce the incidence of lead dislodgement for cardiac implantable electronic devices. Pacing Clin Electrophysiol 2018; 42:58-62. [PMID: 30414285 DOI: 10.1111/pace.13544] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/23/2018] [Accepted: 09/24/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lead dislodgement (LD) is a well-recognized complication during implantation of cardiac implantable electronic devices (CIEDs). An intraprocedural protocol, referred to as reduction of LD protocol, was developed to reduce the risk of LD. METHODS The protocol involved (1) inserting a straight stylet down the right atrial lead and applying forward pressure while monitoring for fluoroscopic stability, (2) visualizing all leads during deep inspiration to determine if there is adequate lead redundancy, and (3) having the patient take a deep breath and cough while pacing just at capture threshold to assess for loss of capture in each lead. Any intraprocedural change in the parameters fulfilling the predefined criteria for inadequate lead implantation prompted lead repositioning. Data regarding demographic factors, clinical characteristics, and incidence of LD in the first 30 days after implant was obtained from intramural CIED database. The preintervention (control) group spanned 27 months and consisted of a total of 4,294 leads while the postintervention (intervention) group spanned 17 months and consisted of 2,361 leads implanted. RESULTS There was no significant difference in the demographic factors and clinical characteristics in the two groups. Protocol compliance was > 90%. There were 44 occurrences of LD (1.02%) before and 10 (0.4%) after implementation of the protocol. The protocol significantly reduced the incidence of LD during the 30 days after implant (P = 0.014). No clinical characteristic predicted the risk of LD. CONCLUSION Intraprocedural maneuvers performed to assess the adequacy of lead implantation results in reduced risk of LD.
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Affiliation(s)
- Muhammad R Afzal
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
| | - Sarah Horner
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
| | - Nancy B Matre
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
| | - Patricia Blake
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
| | - Kari Dunham
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
| | - Daniel Pinkhas
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
| | - Toshimasa Okabe
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
| | - Jaret Tyler
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
| | - Mahmoud Houmsse
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
| | - Steven J Kalbfleisch
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
| | - Raul Weiss
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
| | - John D Hummel
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
| | - Emile G Daoud
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
| | - Ralph S Augostini
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
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11
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Patel N, Viles-Gonzalez J, Agnihotri K, Arora S, Patel NJ, Aneja E, Shah M, Badheka AO, Pothineni NV, Kancharla K, Mulpuru S, Noseworthy PA, Kusumoto F, Cha YM, Deshmukh AJ. Frequency of in-hospital adverse outcomes and cost utilization associated with cardiac resynchronization therapy defibrillator implantation in the United States. J Cardiovasc Electrophysiol 2018; 29:1425-1435. [PMID: 30016005 DOI: 10.1111/jce.13701] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND The utilization of cardiac resynchronization therapy defibrillator (CRT-D) has increased significantly, since its initial approval for use in selected patients with heart failure. Limited data exist as for current trends in implant-related in-hospital complications and cost utilization. The aim of our study was to examine in-hospital complication rates associated with CRT-D and their trends over the last decade. METHODS AND RESULTS Using the Nationwide Inpatient Sample, we estimated 378 248 CRT-D procedures from 2003 to 2012. We investigated common complications, including mechanical, cardiovascular, pericardial complications (hemopericardium, cardiac tamponade, or pericardiocentesis), pneumothorax, stroke, vascular complications (consisting of hemorrhage/hematoma, incidents requiring surgical repair, and accidental arterial puncture), and in-hospital deaths described with CRT-D, defining them by the validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code. Mechanical complications (5.9%) were the commonest, followed by cardiovascular (3.6%), respiratory failure (2.4%), and pneumothorax (1.5%). Age (≥65 years), female gender (OR, 95% CI; P value) (1.08, 1.03-1.13; 0.001), and the Charlson score ≥3 (1.52, 1.45-1.60; <0.001) were significantly associated with increased mortality/complications. CONCLUSIONS The overall complication rate in patients undergoing CRT-D has been increasing in the last decade. Age (≥65), female sex, and the Charlson score ≥3 were associated with higher complications. In patients who underwent CRT-D implantation, postoperative complications were associated with significant increases in cost.
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Affiliation(s)
- Nilay Patel
- Internal Medicine Department, Saint Peter s University Hospital, New Brunswick, New Jersey
| | - Juan Viles-Gonzalez
- Cardiovascular Disease, Tulane University School of Medicine, New Orleans, Louisiana
| | - Kanishk Agnihotri
- Internal Medicine Department, Saint Peter s University Hospital, New Brunswick, New Jersey
| | - Shilpkumar Arora
- Internal Medicine Department, Mount Sinai St Luke's Roosevelt Hospital, New York, New York
| | - Nileshkumar J Patel
- Cardiovascular Department, University of Miami Miller School of Medicine, Miami, Florida
| | - Ekta Aneja
- Internal Medicine Department, Saint Barnabas Medical Center, Bronx, New York
| | - Mahek Shah
- Cardiovascular Department, Lehigh Valley Healthcare Network, Allentown, Pennsylvania
| | - Apurva O Badheka
- Cardiovascular Department, The Everett Clinic, Everett, Washington
| | - Naga Venkata Pothineni
- Cardiovascular Department, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Krishna Kancharla
- Clinical Cardiac Electrophysiology Program, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Siva Mulpuru
- Clinical Cardiac Electrophysiology Program, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Peter A Noseworthy
- Clinical Cardiac Electrophysiology Program, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Fred Kusumoto
- Clinical Cardiac Electrophysiology Program, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Yong Mei Cha
- Clinical Cardiac Electrophysiology Program, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Abhishek J Deshmukh
- Clinical Cardiac Electrophysiology Program, Mayo Clinic College of Medicine, Rochester, Minnesota
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12
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Hosseini SM, Moazzami K, Rozen G, Vaid J, Saleh A, Heist KE, Vangel M, Ruskin JN. Utilization and in-hospital complications of cardiac resynchronization therapy: trends in the United States from 2003 to 2013. Eur Heart J 2018; 38:2122-2128. [PMID: 28329322 DOI: 10.1093/eurheartj/ehx100] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 02/13/2017] [Indexed: 01/08/2023] Open
Abstract
Aims Cardiac resynchronization therapy (CRT) device implantation has been shown to reduce morbidity and mortality in selected patients with heart failure. We sought to investigate the utilization and in-hospital complications of cardiac resynchronization therapy defibrillator (CRT-D) and pacemaker (CRT-P) implantations in the United States from 2003 to 2013. Methods and results Patients receiving CRT-D or CRT-P were identified in the National Inpatient Sample database (NIS), using the International Classification of Diseases-Ninth Revision-Clinical Modification procedure codes. Annual implantation rates, patient demographics, co-morbidities, in-hospital complications, and length of stay were analysed. From 2003 to 2013, an estimated total of 439 010 (95% CI: 406 723-471 296) inpatient CRT implantations were performed in the U.S. The median age of patients was 72 and 71% were male. Overall, 6.1% had at least one complication. During the study period, comorbidity index and overall complication rate increased (P = 0.002 and P = 0.01, respectively). Mortality and length of stay showed no significant trend. Predictors of complications included: age 65 and older, female sex (OR: 1.19; 95% CI: 1.12-1.27), Deyo-Charlson Comorbidity Index, and elective admission (OR: 0.61; 95% CI: 0.57-0.66). Conclusion From 2003 to 2013, the severity of comorbid conditions increased and a rising trend was observed in the rate of periprocedural complications among patients undergoing CRT in the United States. In-hospital mortality and length of stay showed no uniform trend.
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Affiliation(s)
- Seyed Mohammadreza Hosseini
- Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.,Department of Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Kasra Moazzami
- Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.,Department of Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Guy Rozen
- Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.,Department of Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Jeena Vaid
- Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.,Department of Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Ahmed Saleh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.,Department of Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Kevin E Heist
- Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.,Department of Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Mark Vangel
- Department of Biostatistics, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Jeremy N Ruskin
- Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.,Department of Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
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13
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Thirty-day readmissions after cardiac implantable electronic devices in the United States: Insights from the Nationwide Readmissions Database. Heart Rhythm 2018; 15:708-715. [DOI: 10.1016/j.hrthm.2018.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Indexed: 11/21/2022]
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14
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Ajam T, Kalra V, Shen C, Li X, Gautam S, Kambur T, Barmeda M, Yancey KW, Ajam S, Garlie J, Miller JM, Jain R. Natural History of Implantable Cardioverter-Defibrillator Implanted at or after the Age of 70 years in a Veteran Population: A Single Center Study. J Atr Fibrillation 2017; 9:1496. [PMID: 29250256 DOI: 10.4022/jafib.1496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 11/19/2016] [Accepted: 12/10/2016] [Indexed: 11/12/2022]
Abstract
Background The median age of patients in major Implantable Cardioverter-defibrillator (ICD)trials (MUSTT, MADIT-I, MADIT-II, and SCD-HeFT) was 63-67 years; with only 11% ≥70 years. There is little follow-up data on patients over 70 years of age who received an ICD for primary/secondary prevention of sudden cardiac death, particularly for veterans. Objective The aim of this study was to study the natural history of ICD implantation for veterans over 70 years of age. Methods We retrospectively reviewed single center ICD data in 216 patients with a mean age at implantation 76 ± 4 years. The ICD indication was primary prevention in 161 patients and secondary prevention in 55 patients. The ICD indication was unavailable in 4 patients. Results Mean duration of follow up was 1686 ± 1244 days during which 114 (52%) patients died. Of these, 31% died without receiving any appropriate ICD therapy. Overall, 60/216 (28%) received appropriate therapy and 28/216 (13%) received inappropriate therapy. Patients who had ICD implantation for secondary prophylaxis had statistically more (p= 0.02) appropriate therapies compared to patients who had ICD implantation for primary prevention. Indication for implantation and hypertension predicted appropriate therapy, while age at the time of implantation and presence of atrial fibrillation predicted inappropriate therapies. Overall, 7.7% had device related complications. Conclusions Although 28% septuagenarians in this study received appropriate ICD therapy, they had high rates of mortality, inappropriate therapy, and device complications. ICD implantation in the elderly merits individualized consideration, with higher benefit for secondary prevention.
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Affiliation(s)
- Tarek Ajam
- Division of Cardiology, Department of Medicine, Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN.,Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN
| | - Vikas Kalra
- Division of Cardiology, Department of Medicine, Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN.,Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN
| | - Changyu Shen
- Department of Biostatistics, School of Medicine and Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN
| | - Xiaochen Li
- Department of Biostatistics, School of Medicine and Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN
| | - Sandeep Gautam
- Division of Cardiovascular Medicine, University of Missouri, Columbia, MO
| | - Thomas Kambur
- Division of Cardiology, Department of Medicine, Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN.,Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN
| | - Mamta Barmeda
- Indiana University School of Allied Health Sciences, Indianapolis, IN
| | - Kyle W Yancey
- Division of Cardiovascular and Thoracic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Samer Ajam
- Division of Cardiology, Department of Medicine, Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN.,Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN
| | - Jason Garlie
- Division of Cardiology, Department of Medicine, Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN.,Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN
| | - John M Miller
- Division of Cardiology, Department of Medicine, Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN.,Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN
| | - Rahul Jain
- Division of Cardiology, Department of Medicine, Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN.,Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN
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15
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Schleifer JW, Shen WK. Implantable Cardioverter-Defibrillator Implantation, Continuation, and Deactivation in Elderly Patients. CURRENT GERIATRICS REPORTS 2017. [DOI: 10.1007/s13670-017-0226-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Hawkins NM, Grubisic M, Andrade JG, Huang F, Ding L, Gao M, Bashir J. Long-term complications, reoperations and survival following cardioverter-defibrillator implant. Heart 2017; 104:237-243. [PMID: 28747313 DOI: 10.1136/heartjnl-2017-311638] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/26/2017] [Accepted: 06/28/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Implantable cardioverter-defibrillators (ICDs) reduce risk of death in select populations, but are also associated with harms. We aimed to characterise long-term complications and reoperation rate. METHODS We assessed the rate, cumulative incidence and predictors of long-term reoperation and survival using a prospective, multicentre registry serving British Columbia in Canada, a universal single payer healthcare system with 4.5 million residents. 3410 patients (mean 63.3 years, 81.7% male) with new primary (n=1854) or secondary prevention (n=1556) ICD implant from 2003 to 2012 were followed for a median of 34 months (single chamber n=1069, dual chamber n=1905, biventricular n=436). Independent predictors of adverse outcomes were defined using Cox regression models. RESULTS The overall reoperation rate was 12.0% per patient-year, and less for single vs dual vs biventricular ICDs (9.1% vs 12.5% vs 17.8% per patient-year, respectively). The Kaplan-Meier complication estimates (excluding generator end of life) at 1, 3 and 5 years were respectively: single chamber 10.2%, 16.2% and 21.6%; dual 11.7%, 19.1% and 27.4% and biventricular 15.9%, 22.2% and 24.7%. Cardiac resynchronisation therapy had the highest rate of early lead complications, but lower long-term need for upgrade. Device complexity, age and atrial fibrillation were key determinants of complications. Overall mortality at 1, 3 and 5 years was 5.4%, 17.4% and 32.7%, respectively. In younger patients, observed 5-year survival approached the expected survival in the general population (relative survival ratio=0.96 (0.90-0.98)). With increasing age, observed survival steadily declined relative to expected. CONCLUSIONS In a prospective registry capturing all procedures, complication and reoperation rates following de novo ICD implantation were high. Shared decision making must carefully consider these factors.
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Affiliation(s)
| | - Maja Grubisic
- BC Centre for Improved Cardiovascular Health, Vancouver, Canada
| | - Jason G Andrade
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Flora Huang
- University of British Columbia, Vancouver, Canada
| | - Lillian Ding
- Cardiac Services of British Columbia, Vancouver, Canada
| | - Min Gao
- BC Centre for Improved Cardiovascular Health, Vancouver, Canada
| | - Jamil Bashir
- Division of Cardiovascular Surgery, University of British Columbia, Vancouver, Canada
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17
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Betz JK, Katz DF, Peterson PN, Borne RT, Al-Khatib SM, Wang Y, Hansen CM, McManus DD, Mathew JS, Masoudi FA. Outcomes Among Older Patients Receiving Implantable Cardioverter-Defibrillators for Secondary Prevention: From the NCDR ICD Registry. J Am Coll Cardiol 2017; 69:265-274. [PMID: 28104069 DOI: 10.1016/j.jacc.2016.10.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 10/18/2016] [Accepted: 10/18/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Clinical trials of implantable cardioverter-defibrillators (ICDs) for secondary prevention of sudden cardiac death were conducted nearly 2 decades ago and enrolled few older patients. OBJECTIVES This study assessed morbidity and mortality of older patients receiving ICDs for secondary prevention in contemporary clinical practice. METHODS We identified 12,420 Medicare beneficiaries from the National Cardiovascular Data Registry ICD Registry undergoing first-time secondary prevention ICD implantation between 2006 and 2009 in 956 U.S. hospitals. Risks of death, hospitalization, and admission to a skilled nursing facility (SNF) were assessed over 2 years in age strata (65 to 69, 70 to 74, 75 to 79, and ≥80 years of age) using Medicare claims. The adjusted association between age and outcomes was evaluated using multivariable models. RESULTS The mean age was 75 years at the time of implantation; 25.3% were <70 years of age and 25.7% were ≥80 years of age. Overall, the risk of death at 2 years was 21.8%, ranging from 14.7% among those <70 years of age to 28.9% among those ≥80 years of age (adjusted risk ratio [aRR]: 2.01; 95% confidence interval [CI]: 1.85 to 2.33; p for trend <0.001). The cumulative incidence of hospitalizations was 65.4%, ranging from 60.5% in those <70 years of age to 71.5% in those ≥80 years of age (aRR: 1.27; 95% CI: 1.19 to 1.36; p for trend <0.001). The cumulative incidence of admission to a SNF ranged from 13.1% among those <70 years of age to 31.9% among those ≥80 years of age (aRR: 2.67; 95% CI: 2.37 to 3.01; p for trend <0.001); SNF admission risk was highest in the first 30 days. CONCLUSIONS Almost 4 in 5 older patients receiving a secondary prevention ICD survives at least 2 years. High hospitalization and SNF admission rates, particularly among the oldest patients, identify substantial care needs after device implantation.
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Affiliation(s)
- Jarrod K Betz
- Department of Medicine, University of Colorado, Denver, Colorado
| | - David F Katz
- Division of Cardiology, University of Colorado, Denver, Colorado; Colorado Cardiovascular Outcomes Research Group, Denver, Colorado
| | - Pamela N Peterson
- Division of Cardiology, University of Colorado, Denver, Colorado; Colorado Cardiovascular Outcomes Research Group, Denver, Colorado; Denver Health Medical Center, Denver, Colorado
| | - Ryan T Borne
- Division of Cardiology, University of Colorado, Denver, Colorado; Colorado Cardiovascular Outcomes Research Group, Denver, Colorado
| | | | - Yongfei Wang
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | | | - David D McManus
- Division of Cardiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jehu S Mathew
- Division of Cardiology, University of Colorado, Denver, Colorado; Colorado Cardiovascular Outcomes Research Group, Denver, Colorado
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado, Denver, Colorado; Colorado Cardiovascular Outcomes Research Group, Denver, Colorado.
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18
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Abstract
Treatment with an implantable cardioverter-defibrillator (ICD) represents a prognostic but not symptomatic therapy. It should therefore be restricted to patients where an improvement of prognosis is possible and reasonable. ICD implantation should only be performed in patients with a life expectancy of at least 1 year at reasonable quality of life. The decision in which patient improvement of prognosis is no longer a desirable target is problematic, both medically and ethically. It is not entirely clear in which elderly patient an ICD therapy can convey prognostic benefit despite comorbidity and competitive life-threatening diseases, as it is unclear how old age should be defined. In primary prophylaxis of sudden cardiac death, data on a prognostic benefit of the ICD in elderly patients are less clear than in secondary prophylaxis since short-term mortality due to other causes is higher in the elderly. However, elderly ICD patients have a similar rate of appropriate ICD therapy as younger patients. Complications at ICD implantation or long-term lead failure do not occur more frequently in elderly patients and therefore do not represent a reason to withhold ICD implantation in elderly patients or to set an age limit above which ICD implantation should no longer be performed. The ICD indication in elderly patients should be individualized depending on remaining life expectancy, comorbidity, "biological age" and patient preferences which play a particularly important role in elderly patients. Aspects of a potential improvement in quality of life by the ICD which may also serve as a system for antibradycardiac or resynchronization treatment should be included into considerations. Deactivation of at least shock therapy should be discussed in elderly patients fitted with an ICD if the subject is brought up by the patient or if clinical deterioration suggests the need to talk about a "do not resuscitate" order. This talk should be performed before death is imminent and before an electrical storm in terminal illness leads to multiple shocks by the active device.
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Affiliation(s)
- Carsten W Israel
- Klinik für Innere Medizin - Kardiologie, Diabetologie & Nephrologie, Evangelisches Krankenhaus Bielefeld, Burgsteig 13, 33617, Bielefeld, Deutschland.
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19
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Yoshinaga K. Predicting cardiac events using ventricular dyssynchrony in patients who received implantable cardioverter defibrillators: Are more treatment options required? J Nucl Cardiol 2017; 24:130-133. [PMID: 26601672 DOI: 10.1007/s12350-015-0326-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/03/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Keiichiro Yoshinaga
- Molecular Imaging Research Center, National Institute of Radiological Sciences, 4-9-1 Anagawa, Inage-Ku, Chiba, 263-8555, Japan.
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20
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Sharma PS, Ellenbogen KA. Inside or Outside of the Heart: Where Do We Go From Here? J Am Coll Cardiol 2016; 68:2056-2058. [PMID: 27810044 DOI: 10.1016/j.jacc.2016.05.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 05/03/2016] [Indexed: 11/16/2022]
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Katz DF, Peterson P, Borne RT, Betz J, Al-Khatib SM, Varosy PD, Wang Y, Hsu JC, Hoffmayer KS, Kipp RT, Hansen CM, Turakhia MP, Masoudi FA. Survival After Secondary Prevention Implantable Cardioverter-Defibrillator Placement: An Analysis From the NCDR ICD Registry. JACC Clin Electrophysiol 2016; 3:20-28. [PMID: 29759690 DOI: 10.1016/j.jacep.2016.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 05/16/2016] [Accepted: 06/02/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study sought to define the characteristics and risks of death of patients receiving a physician-designated secondary prevention implantable cardioverter-defibrillator (ICD) in contemporary clinical practice. BACKGROUND Data on utilization and outcomes of ICDs for the secondary prevention of sudden cardiac death (SCD) are limited. METHODS Patients enrolled in the National Cardiovascular Data Registry's (NCDR) ICD Registry from 2006 to 2009 with a physician-designated secondary prevention indication for ICD implantation were identified and linked to the Social Security Death Master File. Those patients with a history either of tachycardic arrest or sustained ventricular tachycardia (SCD/VT) or of syncope without SCD/VT were included. Kaplan-Meier survival analysis was used to assess mortality. Cox proportional hazards survival modeling was used to assess the risk of death in these groups, adjusting for patient characteristics. RESULTS In the study cohort of 46,685 patients (mean age 66 ± 14 years, 73.5% male, 85% white), 78% had SCD/VT and 22% had syncope. Overall mortality was 10.4% at 1 year and 16.4% at 2 years. Compared with patients having SCD/VT, the adjusted hazard of death at 1 year was lower in the patients having syncope (hazard ratio: 0.89; 95% confidence interval: 0.83 to 0.96) but was not significantly different by 2 years (hazard ratio: 0.96; 95% confidence interval: 0.90 to 1.01). CONCLUSIONS Nearly 9 of 10 patients receiving a secondary prevention ICD in clinical practice are alive 1 year after implantation. The risk of death varies by indication and is highest among patients who survive SCD or sustained VT in the first year after device implantation.
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Affiliation(s)
- David F Katz
- Division of Cardiology, University of Colorado, Denver, Colorado; Colorado Cardiovascular Outcomes Research Group, Denver, Colorado.
| | - Pamela Peterson
- Division of Cardiology, University of Colorado, Denver, Colorado; Colorado Cardiovascular Outcomes Research Group, Denver, Colorado; Denver Health Medical Center, Denver, Colorado
| | - Ryan T Borne
- Division of Cardiology, University of Colorado, Denver, Colorado; Colorado Cardiovascular Outcomes Research Group, Denver, Colorado
| | - Jarrod Betz
- Department of Medicine, University of Colorado, Denver, Colorado
| | | | - Paul D Varosy
- Division of Cardiology, University of Colorado, Denver, Colorado; Colorado Cardiovascular Outcomes Research Group, Denver, Colorado; Eastern Colorado VA Healthcare System, Denver, Colorado
| | - Yongfei Wang
- Yale University and Center of Outcomes Research and Evaluation, New Haven, Connecticut
| | - Jonathan C Hsu
- Division of Cardiology, University of California San Diego, San Diego, California
| | - Kurt S Hoffmayer
- Division of Cardiology, University of Wisconsin, Madison, Wisconsin
| | - Ryan T Kipp
- Division of Cardiology, University of Wisconsin, Madison, Wisconsin
| | | | - Mintu P Turakhia
- VA Palo Alto Health Care System, Palo Alto, California; Division of Cardiology, Stanford University, Palo Alto, California
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado, Denver, Colorado; Colorado Cardiovascular Outcomes Research Group, Denver, Colorado
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22
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Kramer DB, Reynolds MR, Normand SL, Parzynski CS, Spertus JA, Mor V, Mitchell SL. Hospice Use Following Implantable Cardioverter-Defibrillator Implantation in Older Patients: Results From the National Cardiovascular Data Registry. Circulation 2016; 133:2030-7. [PMID: 27016104 PMCID: PMC4872640 DOI: 10.1161/circulationaha.115.020677] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/23/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Older recipients of implantable cardioverter-defibrillators (ICDs) are at increased risk for short-term mortality in comparison with younger patients. Although hospice use is common among decedents aged >65, its use among older ICD recipients is unknown. METHODS AND RESULTS Medicare patients aged >65 matched to data in the National Cardiovascular Data Registry - ICD Registry from January 1, 2006 to March 31, 2010 were eligible for analysis (N=194 969). The proportion of ICD recipients enrolled in hospice, cumulative incidence of hospice admission, and factors associated with time to hospice enrollment were evaluated. Five years after device implantation, 50.9% of patients were either deceased or in hospice. Among decedents, 36.8% received hospice services. The cumulative incidence of hospice enrollment, accounting for the competing risk of death, was 4.7% (95% confidence interval [CI], 4.6%-4.8%) within 1 year and 21.3% (95% CI, 20.7%-21.8%) at 5 years. Factors most strongly associated with shorter time to hospice enrollment were older age (adjusted hazard ratio, 1.77; 95% CI, 1.73-1.81), class IV heart failure (versus class I; adjusted hazard ratio, 1.79; 95% CI, 1.66-1.94); ejection fraction <20 (adjusted hazard ratio, 1.57; 95% CI, 1.48-1.67), and greater hospice use among decedents in the patients' health referral region. CONCLUSIONS More than one-third of older patients dying with ICDs receive hospice care. Five years after implantation, half of older ICD recipients are either dead or in hospice. Hospice providers should be prepared for ICD patients, whose clinical trajectories and broader palliative care needs require greater focus.
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Affiliation(s)
- Daniel B Kramer
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.).
| | - Matthew R Reynolds
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - Sharon-Lise Normand
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - Craig S Parzynski
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - John A Spertus
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - Vincent Mor
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - Susan L Mitchell
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
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23
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Cano Ó, Andrés A, Alonso P, Osca J, Sancho-Tello MJ, Olagüe J, Martínez-Dolz L. Incidence and predictors of clinically relevant cardiac perforation associated with systematic implantation of active-fixation pacing and defibrillation leads: a single-centre experience with over 3800 implanted leads. Europace 2016; 19:96-102. [PMID: 26847075 DOI: 10.1093/europace/euv410] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 11/10/2015] [Indexed: 11/14/2022] Open
Abstract
AIMS Active-fixation leads have been associated with higher incidence of cardiac perforation. Large series specifically evaluating this complication are lacking. We sought to evaluate the incidence and predictors of clinically relevant cardiac perforation in a consecutive series of patients implanted with active-fixation pacing and defibrillation leads. METHODS AND RESULTS We conducted a retrospective observational study including all consecutive patients implanted with an active-fixation pacing/defibrillation lead at our institution from July 2008 to July 2015. The incidence of clinically relevant cardiac perforation and cardiac tamponade was evaluated. Univariate and multivariate analyses were used to identify predictors of cardiac perforation. Acute and long-term management of these patients was also investigated. A total of 3822 active-fixation pacing (n = 3035) and defibrillation (n = 787) leads were implanted in 2200 patients. Seventeen patients (0.8%) had clinically relevant cardiac perforation (13 acute and 4 subacute perforations), and 13 (0.5%) had cardiac tamponade resolved with pericardiocentesis. None of the patients with cardiac perforation required surgical treatment. In multivariate analysis, an age >80 years (OR 3.84, 95% CI 1.14-12.87, P = 0.029), female sex (OR 3.14, 95% CI 1.07-9.22, P = 0.037), and an apical position of the right ventricular lead (OR 3.37, 95% CI 1.17-9.67, P = 0.024) were independent predictors of cardiac perforation. CONCLUSIONS Implantation of active-fixation leads is associated with a low incidence of clinically relevant cardiac perforation. Older and female patients have a higher risk of perforation as well as those patients receiving the ventricular lead in an apical position.
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Affiliation(s)
- Óscar Cano
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ana Andrés
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Instituto Investigación Sanitaria La Fe, Valencia, Spain
| | - Pau Alonso
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Instituto Investigación Sanitaria La Fe, Valencia, Spain
| | - Joaquín Osca
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - María-José Sancho-Tello
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - José Olagüe
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Luis Martínez-Dolz
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Procedural Success of Left Ventricular Lead Placement for Cardiac Resynchronization Therapy: A Meta-Analysis. JACC Clin Electrophysiol 2015; 2:69-77. [PMID: 29766856 DOI: 10.1016/j.jacep.2015.08.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 07/20/2015] [Accepted: 08/13/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The goal of this study was to assess the contemporary and historical success rates of transvenous left ventricular (LV) lead placement for cardiac resynchronization therapy (CRT), their change over time, and the reasons for failure. BACKGROUND In selected patients, CRT improves morbidity and mortality, but the placement of the LV lead can be technically challenging. METHODS A literature search was used to identify all studies reporting success rates of LV lead placement for CRT via the coronary sinus (CS) route. A total of 164 studies were identified, and a meta-analysis was performed. RESULTS The studies included 29,503 patients: 74% (95% confidence interval [CI]: 72% to 76%) were male; their mean age was 66 years (95% CI: 65 to 67); their mean New York Heart Association functional class was 2.8 (95% CI: 2.7 to 2.9); the mean LV ejection fraction was 26% (95% CI: 25% to 28%); and the mean QRS duration was 155 ms (95% CI: 150 to 160). The overall rate of failure of implantation of an LV lead was 3.6% (95% CI: 3.1 to 4.3). The rate of failure in studies commencing before 2005 was 5.4% (95% CI: 4.4% to 6.5%), and from 2005 onward it was 2.4% (95% CI: 1.9% to 3.1%; p < 0.001). Causes of failure (reported for 39% of failures) also changed over time. Failure to cannulate and navigate the CS decreased from 53% to 30% (p = 0.01), and the absence of any suitable, acceptable vein increased from 39% to 64% (p = 0.007). The proportion of leads in a lateral or posterolateral final position (reported for 26% of leads) increased from 66% to 82% (p = 0.004). CONCLUSIONS The reported rate of failure to place an LV lead via the CS has decreased steadily over time. A greater proportion of failures in recent studies are due to coronary venous anatomy that is unsuitable for this technique.
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25
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Kramer DB, Matlock DD, Buxton AE, Goldstein NE, Goodwin C, Green AR, Kirkpatrick JN, Knoepke C, Lampert R, Mueller PS, Reynolds MR, Spertus JA, Stevenson LW, Mitchell SL. Implantable Cardioverter-Defibrillator Use in Older Adults: Proceedings of a Hartford Change AGEnts Symposium. Circ Cardiovasc Qual Outcomes 2015; 8:437-46. [PMID: 26038525 DOI: 10.1161/circoutcomes.114.001660] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniel B Kramer
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.).
| | - Daniel D Matlock
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Alfred E Buxton
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Nathan E Goldstein
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Carol Goodwin
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Ariel R Green
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - James N Kirkpatrick
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Christopher Knoepke
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Rachel Lampert
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Paul S Mueller
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Matthew R Reynolds
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - John A Spertus
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Lynne W Stevenson
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Susan L Mitchell
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
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Buckley U, Shivkumar K. Implantable cardioverter defibrillators: even better than we thought? Eur Heart J 2015; 36:1646-8. [PMID: 25943537 DOI: 10.1093/eurheartj/ehv158] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Una Buckley
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine, Los Angeles, CA, USA
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Raphael CE, Finegold JA, Barron AJ, Whinnett ZI, Mayet J, Linde C, Cleland JG, Levy WC, Francis DP. The effect of duration of follow-up and presence of competing risk on lifespan-gain from implantable cardioverter defibrillator therapy: who benefits the most? Eur Heart J 2015; 36:1676-88. [DOI: 10.1093/eurheartj/ehv102] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 03/16/2015] [Indexed: 11/14/2022] Open
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