Comparison of transvenous vs subcutaneous defibrillator therapy in patients with cardiac arrhythmia syndromes and genetic cardiomyopathies
Introduction
Implantable cardioverter defibrillators (ICDs) are widely used in primary and secondary prevention of sudden cardiac death [1]. Conventional transvenous ICDs (TV-ICDs) rely on leads placed over venous vessels and anchored in the endocardium of the heart. Apart from short-term complications such as pneumothorax or cardiac tamponade, long-term complications may play a far more critical role. Over time, these leads become encapsulated with fibrous tissue, complicating replacement or removal. There is good evidence that transvenous ICD leads lose their long-term functionality in up to 20% and that mechanical lead fractures precipitate inappropriate shocks or even impede delivery of appropriate therapy for ventricular tachyarrhythmias [2,3]. In addition, lead-associated complications significantly increase morbidity and mortality of patients [4,5]. Patients with inherited cardiac arrhythmia syndromes and patients with genetic cardiomyopathies are usually at young age when defibrillator therapy is indicated and mostly have a normal life-expectancy. Together with their often active life-style, this imposes a predicament for ICD therapy.
The subcutaneous ICD (S-ICD) was developed to ameliorate long-term complications related to conventional endocardial leads, such as lead fracture or lead infection [6]. Its advantages are offset by its inability of pacing in terms of anti-tachycardia therapy (ATP) or for anti-bradycardia pacing. Despite the perception that the S-ICD is similarly useful as the TV-ICD, a considerable disparity in the usage of the S-ICD remains and decisions for a specific defibrillator type are often made based on experience and anticipation [7]. Randomized trials that compare the TV-ICD with the S-ICD are lacking and the approval of the S-ICD was based on prospective trials in the absence of control groups [6]. Few case-control and retrospective studies have compared the two in terms of efficacy and complications with limited follow-up data [[8], [9], [10]]. Moreover, data regarding outcomes of patients with arrhythmogenic cardiomyopathies and S-ICD are very limited, with only two systematic analyses addressing this topic [11,12].
The current study aimed to assess the long-term outcome of S-ICD patients compared to TV-ICD patients in a selected cohort of patients with either cardiac arrhythmia syndromes or genetic cardiomyopathies. We hypothesized that S-ICD therapy in these patients will display lower rates of lead-related complications and therefore less adverse events during long-term follow-up compared to the TV-ICD.
Section snippets
Patient selection
Patients with cardiac arrhythmia syndromes or genetic cardiomyopathies implanted with an ICD from 2010 until 2018 at the Hannover Medical School and the University Medical Centre Mannheim were included in the study. Cardiac arrhythmia syndromes were defined as either Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia (CPVT) or idiopathic ventricular fibrillation with onset <45 years of age. Patients with genetic cardiomyopathies had
Patient population
A total of 183 consecutive patients with either cardiac arrhythmia syndromes or genetic cardiomyopathies were implanted at two large German tertiary care centers and were included in this analysis. A cumulative follow-up of 782 patient years was available. Only 3 (2%) patients were lost to follow-up after a median uneventful follow-up of 18 months.
Baseline characteristics are provided in Table 1. The mean age at implantation was 40 ± 15 years, 78 patients (43%) were female. Secondary prevention
Main findings
We report the outcome of a large cohort of patients at high risk for ventricular tachyarrhythmias who were implanted with a transvenous ICD vs subcutaneous ICD for primary or secondary prevention. In this multicenter study we compared the outcome of 86 patients implanted with a TV-ICD to 97 patients who received an S-ICD. The total cohort comprised patients diagnosed with either cardiac arrhythmia syndromes or genetic cardiomyopathies. The main findings of the present study are: 1) appropriate
Conclusion
In comparison with the TV-ICD, the present data favor the use of the S-ICD for patients with inherited arrhythmia syndromes and genetic cardiomyopathies who do not need anti-bradycardia pacing.
Funding
None.
Declaration of competing interest
None declared.
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2021, Annals of Medicine and SurgeryCitation Excerpt :However, complications, including lead malfunction and infection, were more common with the transvenous ICD [11,12], whereas inappropriate shocks were more common with the subcutaneous ICD. The risk of inappropriate shock can be mitigated by selecting the appropriate vector in case of subcutaneous ICDs [13–15]. Recently, there has been another study done which favor the use of the subcutaneous ICD for patients with inherited arrhythmia syndromes and genetic cardiomyopathies who do not need anti-bradycardia pacing [15].
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JK and JML contributed equally