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Mortality Reduction in Nonischemic Cardiomyopathy ICD Patients
Study Questions:
Is left ventricular scar (LVS) in patients with nonischemic cardiomyopathy (NICM) a predictor of improved survival after implantation of an implantable cardioverter-defibrillator (ICD)?
Methods:
The subjects of this study were 452 patients (mean age 53.4 years) referred for cardiac magnetic resonance (CMR) imaging who had a NICM, LV ejection fraction (LVEF) ≤35% (mean 25.2%), New York Heart Association class II or III, and no history of ventricular tachycardia/fibrillation. LVS was assessed by late gadolinium enhancement imaging. ICD implantation for primary prevention of sudden death was at the discretion of the referring physicians. The primary outcome of the study was all-cause mortality.
Results:
An ICD was implanted in 246 patients. LVS was present in 59% of patients. The median duration of follow-up was 37.9 months. There was not a significant difference in mortality at 3 years between the ICD group (11%) and the patients without an ICD (19%). After propensity matching, ICDs were not associated with a survival advantage and LVS was associated with a 71% higher risk of mortality. Among the patients without LVS, ICD implantation did not significantly affect mortality. Among the patients with LVS, ICD implantation was independently associated with a 55% reduction in the risk of death.
Conclusions:
The presence of LVS identifies patients with NICM who derive a survival benefit from implantation of an ICD for primary prevention of sudden cardiac death.
Perspective:
Prior studies have demonstrated that LVS identified by CMR imaging is associated with malignant ventricular arrhythmias and appropriate ICD therapies. The results of this study are consistent with these prior studies and suggest that screening for LVS can improve cost-effectiveness by identifying low-risk NICM patients who would not benefit from an ICD, at least during 3 years of follow-up.
Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Magnetic Resonance Imaging
Keywords: Arrhythmias, Cardiac, Cardiomyopathies, Cicatrix, Cost-Benefit Analysis, Death, Sudden, Cardiac, Defibrillators, Implantable, Diagnostic Imaging, Gadolinium, Heart Failure, Magnetic Resonance Imaging, Primary Prevention, Secondary Prevention, Stroke Volume
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