Israel: Dual - chamber implantable cardioverter - defibrillator (ICDs) are implanted for primary prevention of sudden cardiac death in a majority of patients who do not have pacing indications despite guidelines discouraging it.
Now, a recent study published in the Journal of the American Heart Association has supported an increased risk of periprocedural complications with dual-chamber implantation. The researchers suggest that avoidance of routine implantation of atrial leads will probably improve safety outcomes.
Gilad Margolis, The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel, and colleagues noted that landmark trials did not show a benefit of dual-chamber pacing in primary prevention ICD implantation, yet it has been practised.
In a 2014 expert consensus document on the ICDs use in patients underrepresented in trials, recent European Society of Cardiology sudden cardiac death guidelines urge the placement of single-chamber ICD when the patient has no other current or anticipated indications for pacing.
Dr Margolis and colleagues conducted the study to investigate the use and safety of single-versus dual‐chamber ICD implantations in these patients.
For this purpose, the researchers identified 15,940 patients who underwent ICD implantation in the US between 2015 and 2019 from the National Inpatient Sample. About 55.6%—received a dual-chamber ICD without having any additional indications for pacing with an atrial lead. Predictors of in‐hospital complications were identified using Multivariable logistic regression.
The study led to the following findings:
In-hospital complication rates were higher for dual-chamber than for single-chamber ICD placements: 12.8% versus 10.7%, respectively.
Pneumothorax/hemothorax were the chief drivers of these higher complication rates, occurring in 4.6% and 3.4% of dual- and single-chamber patients, respectively.
Lead dislodgements were also more common: 3.6% versus 2.3%.
In multivariate analyses, the dual-chamber configuration was an independent predictor for any complications, pneumo/hemothorax, and lead dislodgement.
"The majority of patients in the US are still implanted with a dual‐chamber implantable cardioverter‐defibrillator (dICD) despite significant evidence for a dearth of clinical benefit in addition to an atrial lead to a primary prevention implantable cardioverter‐defibrillator implantation," the researchers wrote.
The researchers observed an increased risk for complications in dICD recipients compared with sICD implantation, driven by a higher incidence of lead dislodgement and pneumo/hemothorax.
"These data should be considered by professional societies in recommendations formulation, as avoidance of atrial lead implantation in patients who do not need pacing will likely contribute to a significant lowering of procedural complications," they concluded.
Reference:
Margolis G, Hamuda N, Kobo O, et al. Single‐versus dual‐chamber implantable cardioverter‐defibrillator for primary prevention of sudden cardiac death in the United States. J Am Heart Assoc. 2023;12:e029126.