Subcutaneous ICDs Increasing in Dialysis Patients With Low Complication Rates, NCDR Study Shows

Use of subcutaneous ICDs in dialysis patients has been steadily increasing, with overall low complication rates compared with transvenous ICDs, according to a study published Nov. 6 in the Clinical Journal of the American Society of Nephrology.

Patrick H. Pun, MD, et al., used data from ACC’s ICD Registry to examine overall trends in subcutaneous ICD adoption among eligible dialysis patients between September 2012 – when subcutaneous ICDs first became available – and March 2018, and compare in-hospital outcomes among dialysis patients receiving subcutaneous ICDs vs. transvenous ICDs. For the comparative analysis, the researchers limited the cohort to only dialysis patients who met criteria for a subcutaneous ICD and were hospitalized for an elective first-time ICD implantation. The primary outcome was the composite of any in-hospital adverse events.

During the study period, there were 23,135 ICD implantations among dialysis patients. Of these patients, 3,195 (14%) received subcutaneous devices. Subcutaneous devices accounted for about 5% of all ICD implantations at the beginning of the study, compared with 20% of all ICD implantation procedures in 2018.

For the comparative analysis, there were 1,539 patients who received subcutaneous ICDs and 1,788 who received transvenous ICDs. Among these patients, use of subcutaneous devices increased from 10% of all implants in 2012 to 69% of all implants in 2018. Before propensity scoring, subcutaneous ICD recipients were younger, more likely to be Black, and less likely to be from southern states. The composite of any in-hospital adverse event was not statistically different between those receiving subcutaneous ICDs (2.39 events per 100 implantations) vs. transvenous ICDs (1.48 events per 100 implantations). However, patients receiving subcutaneous devices were more likely to experience in-hospital cardiac arrest vs. those receiving transvenous ICDs.

According to the researchers, the study shows an overall low complication rate in dialysis patients who receive subcutaneous ICDs. While the low complication rate supports use of subcutaneous devices in eligible dialysis patients, they note that "potential benefits of lower long-term infection risk and reduction in central venous stenosis, compared with transvenous ICD, have not been proven." Moving forward, longer-term studies are needed to determine the risk-benefit and cost-effectiveness of subcutaneous ICDs in this population, they conclude.

Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, SCD/Ventricular Arrhythmias

Keywords: Nephrology, Cost-Benefit Analysis, Renal Dialysis, Cohort Studies, Longitudinal Studies, Risk Assessment, Registries, Heart Arrest, Infections, National Cardiovascular Data Registries, ICD Registry

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