Two-incision versus three-incision implantation technique of subcutaneous implantable cardioverter defibrillator: Systematic review and meta-analysis of 2076 patients

INTRODUCTION

The implantable cardioverter-defibrillator (ICD) was designed to detect and treat ventricular arrhythmias, which account for nearly half of all cardiovascular fatalities. Transvenous ICD (TV-ICD) complications were reduced by introducing subcutaneous ICD (S-ICD). S-ICD can be implanted using a three (3IT)- or two (2IT)-incision technique. This systematic review and meta-analysis was conducted to compare the 3IT to the 2IT.

METHODS

We searched medical electronic databases of Cochrane Central, Embase, PubMed, Scopus, and Web of Science (WOS) from the study's inception until March 8, 2023. We compared 2IT and 3IT techniques of S-ICDs in terms of procedural, safety, and efficacy outcomes. We used Review Manager software for the statistical analysis. We calculated the risk ratio (RR) with its 95% confidence interval (CI) for dichotomous variables; and the mean difference with its 95% CI for continuous variables. We measured the heterogeneity using the chi-squared and I-squared tests. If the data were heterogeneous, the random-effect (RE) model was applied; otherwise, the fixed-effect model (FE) was used.

RESULTS

We included three retrospective observational studies of 2076 patients, 1209 in the 2IT group and 867 in the 3IT. There was no statistically significant difference in erosion after S-ICD when 2IT compared with 3IT (RR = 0.27, 95% CI: [0.07, 1.02]; P = .05) (I2 = 0%, P = .90). There was no difference in risk of infection, lead dislocation, or inappropriate shock with either incision technique (RR = 0.78, 95% CI: [0.48, 1.29]; P = .34) (I2 = 0%, P = .71) and (RR = 0.37, 95% CI: [0.02, 8.14]; P = .53) (I2 = 66%, P = .05) respectively. Our meta-analysis showed that the efficacy of both techniques is comparable; Appropriate shock (RR = 0.94, 95% CI: [0.78, 1.12]; P = .48) (I2 = 0%, P = .81) and first shock efficacy (RR = 0.89, 95% CI: [0.44, 1.82]; P = .76) (I2 = 0%, P = .87).

CONCLUSION

2IT and 3IT of S-ICD have comparable efficacy and complication rates; however, the 3IT exposes patients to an additional incision without any additional benefits. These findings may provide clinicians with a simpler method for subcutaneous ICD implantation and likely result in improved cosmetic outcomes. Before the 2IT technique can be considered the standard of care, randomized controlled trials (RCTs) must be conducted to assess its long-term safety and efficacy.

Multicentre experience with the second-generation subcutaneous implantable cardioverter defibrillator and the intermuscular two-incision implantation technique

Introduction

The recently developed second‐generation subcutaneous implantable cardioverter defibrillator (S‐ICD) and the intermuscular two‐incision implantation technique demonstrate potential favorable features that reduce inappropriate shocks and complications. However, data concerning large patient populations are lacking. The aim of this multicentre prospective study was to evaluate the safety and outcome of second‐generation S‐ICD using the intermuscular two‐incision technique in a large population study.

Methods and Results

The study population included 101 consecutive patients (75% male; mean age, 45 ± 13 years) who received second‐generation S‐ICD (EMBLEM; Boston Scientific, Marlborough, MA) implantation using the intermuscular two‐incision technique as an alternative to the standard implantation technique. Twenty nine (29%) patients were implanted for secondary prevention. Twenty four (24%) patients had a previously implanted transvenous ICD. All patients were implanted without any procedure‐related complications. Defibrillation testing was performed in 80 (79%) patients, and ventricular tachycardia was successfully converted at less than or equal to 65 J in 98.75% (79/80) of patients without pulse generator adjustments. During a median follow‐up of 21 ± 10 months, no complications requiring surgical revision or local or systemic device‐related infections were observed. Ten patients (9.9%) received appropriate and successful shocks for ventricular arrhythmias. Three (2.9%) patients experienced inappropriate shocks due to oversensing the cardiac signal (n = 1), noncardiac signal (n = 1), and a combination of both cardiac and noncardiac signals (n = 1), with one patient requiring device explantation. No patients required device explantation due to antitachycardia pacing indications.

Conclusions

According to our multicentre study, second‐generation S‐ICD implanted with the intermuscular two‐incision technique is an available safe combination and appears to be associated with a low risk of complications, such as inappropriate shocks.

Delayed repair of distal biceps tendon ruptures is successful: a case-control study

BACKGROUND

The literature has shown an increased complication rate with a delay to surgical repair of acute distal biceps tendon ruptures; however, little has been documented regarding the outcome of delayed repairs. This case-control study compared a study cohort of delayed (>21 days) distal biceps tendon repairs with a control cohort repaired acutely (<21 days).

METHODS

Sixteen delayed repair cases were reviewed and matched with acute controls (1:3) based on repair technique, age, and workers' compensation status. The delayed cohort was reviewed and completed isometric strength testing and the Disabilities of the Arm, Shoulder and Hand questionnaire; Patient-Rated Elbow Evaluation; and American Shoulder and Elbow Surgeons elbow questionnaire.

RESULTS

The time to surgery averaged 37 ± 12 days in the delayed cohort versus 10 ± 6 days in the acute cohort. Complications occurred in 63% of patients in the delayed cohort versus 29% in the acute cohort (P = .04); however, 90% of the delayed cohort's complications consisted of transient paresthesias. Follow-up scores on the Patient-Rated Elbow Evaluation, Disabilities of the Arm, Shoulder and Hand questionnaire, and American Shoulder and Elbow Surgeons elbow questionnaire were not statistically different between cohorts (P > .37, P > .22, and P > .46, respectively).

CONCLUSIONS

Despite a high rate of initial complications, patients treated with distal biceps tendon repair after a delay (>21 days) can expect similar functional outcomes to those treated acutely.