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    • br The indications for ICD placement for the secondary

    2019-05-04


    The indications for ICD placement for the secondary prevention of sudden cardiac death Some patients with underlying d-biotin disease and/or LV dysfunction die from tachyarrhythmias even after ICD placement [18]. However, no arrhythmic deaths occurred during the implantation or during the follow-up period in this young, otherwise healthy population of Brugada syndrome patients [17]. Appropriate shocks were more frequent in symptomatic than in asymptomatic patients (12% vs. 4%; p<0.05) [17]. These data are relevant to and in agreement with other reports on sudden cardiac death risk stratification [4,12,16]. Therefore, there is a world-wide consensus for ICD placement in symptomatic patients. However, there is a 2.5-fold greater frequency of inappropriate (20%) than appropriate shocks (8%), with an overall complication rate of 28% [17] .We should be well aware of all the complications related to ICD placement in order to explain them to candidates undergoing placement of the device for secondary prevention of sudden cardiac death.
    Complications of ICDs Complications occurred in 28% of the patients, including inappropriate shocks in 20% of the cases [17]. Early complications (the first months) included pneumothorax, pericardial effusions, re-intervention for a lead displacement, venous thrombosis, and hematomas. Late complications (more than 1 month after the implantation) consisted of lead failures requiring an extraction and re-implantation, pocket and/or lead infections, pericardial effusions, pocket revisions for deeper implantations of a superficial lead, device failures, and d-biotin severe psychological difficulties (Table 2). Complications also included inappropriate shocks (4±3 shocks/patient) occurring in 20% of the patients during a period of 21±20 months after the ICD implantation. The reasons for the inappropriate shocks were lead dysfunction, T-wave oversensing, sinus tachycardia, and supraventricular arrhythmias. Patients with shocks due to T-wave oversensing were more likely to have low R-wave amplitude at the implantation. Factors predictive of inappropriate shocks were a history of supraventricular tachycardia (p<0.02), T-wave oversensing (p<0.001), and a low R-wave amplitude (p<0.007). Further, patients with inappropriate shocks tended to be younger [17]. Among the complications of ICDs for primary prevention, [19] inappropriate shocks were noted in 47 asymptomatic Brugada syndrome patients; eight patients with sinus tachycardia; six patients with new-onset atrial arrhythmias; and 5 patients with noise oversensing during a median follow-up period of 47.5 months. In a multivariable Cox-regression analysis, new-onset atrial fibrillation and age less than 50 years were independent predictors of a significantly short inappropriate-shock-free survival (p=0.04 and p=0.036, respectively). In the young and otherwise healthy population of Brugada syndrome patients, the inappropriate shock rate is high [17,19]. However, recent advances in electrophysiological technology have led to the development of an algorithm and/or signal processing tools for successfully reducing the incidence of inappropriate and unnecessary shocks [20,21].
    The indications for ICD placement for the primary prevention of sudden cardiac death
    Guidelines in patients with Brugada syndrome Some investigators [11,12,15,24] have reported that there are no independent predictors in patients without a history of an aborted sudden cardiac death, i.e., there are no predictors other than aborted sudden cardiac death or documented VF. A multivariable analysis [33] identified a history of syncope and inducibility of sustained ventricular arrhythmias during an EP study [49] as predictors of future sudden death or VF. Accordingly, some approaches [3] favored the use of the combination of the clinical characteristics, history of syncope, and findings of EP study for the risk stratification in this patient population [50]. High-risk patients, who present with syncope and/or have inducible ventricular arrhythmia during an EP study, are recommended a prophylactic implantation of an ICD for the prevention of sudden death [50]. In Japan, a large-scale multicenter trial [11] revealed that family history may be an independent predictive factor in asymptomatic Brugada syndrome. Therefore, the Japan Guidelines 2007 recommends that a combination of the clinical characteristics (syncope), findings of EP study, and a family history be used in this patient population [51]. Further, a class III indication, “patients have no history of VF, family history of sudden cardiac death, or no VF induced by EPS, if patients have a Brugada-type ECG (saddle-back-type ST elevation),” was deleted since the Guideline 2011 (Table 5), [52] because no one would expect a patient with a saddle-back-type ECG to die suddenly [11].