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Periprocedural Risk With ICD Placement in Older Heart Failure Patients
Study Questions:
What are the utilization rates, patient characteristics, and outcomes of implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy defibrillator (CRT-D) placements among patients with advanced heart failure (HF)?
Methods:
This was a post hoc analysis of 81,492 Medicare patients in the National Cardiovascular Data Registry (NCDR) ICD Registry. Inclusion criteria were patients who had received an HF diagnosis, had a left ventricular ejection fraction of ≤35%, and New York Heart Association (NYHA) class IV symptoms, inotrope use within the last 60 days, left ventricular assist device (LVAD) in situ, or orthotopic heart transplant listing. The comparator group included patients with NYHA class II and no HF hospitalization within the last 12 months, no LVAD, no orthotopic heart transplant listing, and no current or recent inotrope use. All patients underwent first-time ICD or CRT-D for primary prevention between 2010 and 2014.
Results:
Patients with advanced HF numbered 3,343 and there were 19,424 in the comparator group. The all-cause mortality rate at 30 days was 3.1% in the advanced HF group versus 0.5% in the comparator group (p < 0.001). In the advanced HF population, the in-hospital periprocedural complication rate was 3.74% versus 1.10% in the comparator group (p < 0.001). Most adverse events in this group were in-hospital fatality (1.82%) and resuscitated cardiac arrest (1.05%). Patients with NYHA class IV, ischemic heart disease, or diabetes had a higher risk of death.
Conclusions:
Patients with advanced HF experienced periprocedural complication rates associated with in-hospital death and cardiac arrest relative to patients with nonadvanced HF.
Perspective:
This analysis of the elderly patients in the NCDR ICD Registry shows that patients with advanced HF comprise only about 4% of the patients who undergo first-time ICD implantation. This small group has a high risk of death (22% at 1 year) and a low median survival rate (3.5 years). For comparison, trials with nonadvanced HF patients had an annual mortality rate of 5-8.5%. The authors identified NYHA class IV symptoms, ischemic heart disease, and diabetes as the main risk factors associated with all-cause mortality. Periprocedural complications occurred in 1 in 25 patients with advanced HF and were primarily in-hospital death and cardiac arrest. The sickest patients with HF are indeed at high risk of death and complications.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support
Keywords: Arrhythmias, Cardiac, Cardiac Resynchronization Therapy, ICD Registry, Defibrillators, Implantable, Geriatrics, Heart Arrest, Heart Failure, Heart Transplantation, Heart-Assist Devices, Hospital Mortality, Myocardial Ischemia, Primary Prevention, Risk Factors, Stroke Volume, Ventricular Function, Left
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