ESC Congress 2017 In Review – Focus on Arrhythmias - 17

ESC Congress 2017

In Review

Arrhythmias

Device Implantation in CKD
Chronic kidney disease (CKD) is associated with
increased CV mortality, especially from SCD, said
Mohammed Shurrab, MD, MSc, University of Toronto,
Toronto, Canada. The rate of SCD also increases with
increased stage of CKD, he added, and SCD accounts for
up to 60% of cardiac deaths in dialysis patients. Even
mild to moderate renal impairment is a risk factor for
CV disease and mortality. However, the efficacy of ICD
therapy and CRT in patients with CKD remains controversial despite active use.
Dr Shurrab also reported findings from a meta-analysis of 11 retrospective studies, including 21,136 patients,
to investigate the effects of ICD-CRT on survival in CKD
patients [Shurrab M et al. Eur Heart J. 2017].
Compared with no ICD, use of ICDs was associated with
a decrease in all-cause mortality in CKD patients (OR, 0.66;
95% CI, 0.45 to 0.98; P = .04), with a similar protective
effect among dialysis-only patients (OR, 0.49; 95% CI,
0.38 to 0.64; P < .001).
CRT use was associated with better survival in CKD
patients than ICD use (all-cause mortality OR, 0.73; 95%
CI, 0.57 to 0.92; P = .01), but all-cause hospitalisation was
similar between the groups (P = .57).
A randomised controlled trial is needed to better
define the role of ICD therapy and CRT in CKD patients,
concluded Dr Shurrab.
Future Perspectives in Preventing SCD
Dr Kutyifa shared data suggesting that, because of recent
medical advances, many clinicians are now changing
their practice and no longer systematically implant ICDs
for primary prevention in patients with nonischaemic
cardiomyopathy [Haguaa KH et al. Europace. 2017].
She stressed the need to therefore re-evaluate the
use of ICD therapy for patients with ischaemic and
nonischaemic cardiac disease, and discussed new studies that are in the pipeline to help accomplish this.
For example, RESET SCD is a European Heart Rhythm
Association initiative in patients with ischaemic cardiomyopathy. This trial will involve 110 electrophysiology
centres in 12 countries, and is estimated to last for 5
years. It will include approximately 2,550 ischaemic cardiomyopathy patients who will receive state of the art
treatment with and without ICD implantation; the primary endpoint is all-cause mortality.

Less invasive subcutaneous ICD (S-ICD) technology is
now also available, said Dr Kutyifa, and might become
more widely used. Emphasising the importance of optimal lead and device selection, she noted that transvenous ICD leads are associated with failures and a 3%
to 5% infection risk. However, the S-ICD lead is a novel
technology that leaves the heart untouched, and minimises the risk of bloodstream infections. Whether this
new technology becomes the primary choice for ICD
implantation in the coming decade remains to be seen.
However, the PRAETORIAN clinical trial comparing use
of the S-ICD with the transvenous ICD with respect to
major ICD-related adverse events has recently ended
and results will be reported in 1 year [Olde Nordkamp LR
et al. Am Heart J. 2012].
Although anti-tachycardia pacing (ATP) has been
shown to be effective in secondary prevention, its role
in treating VT and VF in primary prevention also needs
to be re-evaluated, Dr Kutyifa indicated. In this setting,
the APPRAISE ATP trial [NCT02923726] is currently
recruiting participants, and will investigate ATP in primary prevention patients indicated for ICD therapy and
programmed according to current guidance of higher
rate cut-offs and therapy delays.
Dr Kutyifa also stressed that the declining incidence
of SCD in recent decades does not apply to patients
with diabetes and these individuals remain at a high
risk for CV death and SCD. After a myocardial infarction
(MI), even diabetic patients with relatively preserved
left ventricular ejection fraction (LVEF) are at high risk
for SCD, and therefore might benefit from the S-ICD. A
new trial, MADIT S-CID [NCT02787785], is designed to
evaluate whether an S-ICD in patients aged ≥ 65 years
with a previous MI, diabetes mellitus, and a relatively
preserved LVEF of 36% to 50% will offer a life-saving
benefit over conventional medical therapy. The primary
endpoint is the reduction in all-cause mortality. The
trial will enrol approximately 1,800 patients from the
United States, Europe, and Israel, and will involve an
interdisciplinary team approach at each site.
Findings from studies such as these will provide
important information to help investigators reassess
use of ICD therapy for patients with ischaemic and nonischaemic cardiac disease, concluded Dr Kutyifa.

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