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ICDs in Brugada Syndrome Patients
Study Questions:
What are the long-term outcomes after implantable cardioverter-defibrillator (ICD) placement in Brugada syndrome patients?
Methods:
In this registry, there were 370 patients with Brugada syndrome. The follow-up was 43 ± 14 years, and 74% were male. A total of 104 patients (28.1%) were treated with ICDs. The authors analyzed the long-term incidence of shocks and complications in patients who underwent ICD implantation.
Results:
An ICD was implanted for secondary prevention in 10 patients (10%), and for primary prevention in 94 patients (90%). After a mean follow-up of 9 years, 21 patients (20%) experienced a total of 81 appropriate shocks (incidence rate 2.2% person-year). The rate of appropriate shock was higher in secondary prevention patients (p < 0.01). However, 4 of the 45 asymptomatic patients (8.9%) experienced appropriate ICD therapy, all with a spontaneous type 1 electrocardiogram (ECG) and inducible ventricular arrhythmias. In the multivariable analysis, type 1 ECG with syncope (hazard ratio [HR], 4.96; 95% confidence interval [CI], 1.87-13.14; p < 0.01) and secondary prevention indication (HR, 6.85; 95% CI, 2.29-20.50; p < 0.01) were significant predictors of appropriate therapy. Nine patients (8.7%) suffered 37 inappropriate shocks (incidence rate 0.9% person-year). Twenty-one patients (20%) had other ICD-related complications (incidence rate 1.4% person-year). Three patients (2.9%) died (one electrical storm and two noncardiovascular deaths).
Conclusions:
ICD therapy is an effective therapy in high-risk patients with Brugada syndrome, but it is associated with a significant risk of device-related complications.
Perspective:
Rate of appropriate therapy in Brugada syndrome varies widely across reports, and the indications for ICD implantation for primary prevention in Brugada syndrome remain debatable due to lack of a satisfying risk stratification scheme. Appropriate ICD therapies in this study were significantly associated with the presence of aborted sudden death and syncope with the presence of type 1 ECG pattern. However, appropriate shocks also occurred in 9% of asymptomatic patients in which ventricular arrhythmias were induced on electrophysiology study. The risk of ICD-related adverse events was high at 23%. In addition to improved risk stratification for sudden death, emphasis should be placed on programming to reduce inappropriate shocks.
Keywords: Arrhythmias, Cardiac, Brugada Syndrome, Cardiac Electrophysiology, Death, Sudden, Defibrillators, Implantable, Electrocardiography, Primary Prevention, Secondary Prevention, Syncope
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