Interventional cardiology

Evidence supports use of subcutaneous ICD in older patients


Outcomes are comparable in older patients receiving a subcutaneous implantable cardioverter-defibrillator (S-ICD) or a transvenous ICD (TV-ICD), according to an international study.

More than 16,000 patients were identified from a cardiovascular data registry, were ≥65 years (mean 72 years), and underwent ICD implantation between 2012 and 2017.

The study, published in the Journal of the American College of Cardiology, found no significant difference between the groups in the primary outcome of all-cause mortality (HR 1.02) over a median follow-up of 2.3 years.

Similarly, secondary outcomes of all-cause readmission (HR 1.072), device reoperation (HR 0.976), device removal caused by infection (HR 0.614), device reoperation without infection (HR 0.975), and cardiovascular readmission (HR 1.087) were not statistically different between the groups.

“These findings support the use of the S-ICD as an option for the prevention of sudden cardiac death in appropriately selected older patients,” said the study authors, including Dr Dr Isuru Ranasinghe, Senior Staff Specialist Cardiologist at the Prince Charles Hospital, Brisbane.

“The S-ICD obviates the need for intravascular or intracardiac leads, which limits certain ICD complications such as short-term cardiac perforation and long-term intravascular device infection and lead dislodgement.”

The study showed that the S-ICD patients were more often Black (18.1% vs 12.4%), younger (71.0 vs 72.7 years), dialysis dependent (22.9% vs 2.1%), and less likely to have atrial fibrillation or flutter (26.9% vs 33.4%).

The authors said S-ICD use in younger patients may be related to avoiding intravascular leads in patients with a longer life expectancy and low risk of developing a pacing indication.

The researchers noted their results were consistent with the PRAETORIAN study in which patients had a median age of 63 years.

“These results support the use of the S-ICD for the prevention of sudden cardiac death in older patients.”

An Editorial Comment in the Journal said all contemporary S-ICD trials now support the concept that age should not be a limiting factor for their use.

“These important results support and extend previous studies suggesting that the age bias in S-ICD use is not warranted with contemporary ICD devices and programming.”

“So, hopefully we can treat older patients with a new trick of avoiding TV leads while still protecting from SCD in the absence of pacing indications.”

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