Aim The wearable cardioverter‐defibrillator (WCD) is used for temporary protection from sudden cardiac death (SCD) in patients with newly diagnosed heart failure with reduced ejection fraction before considering an implantable cardioverter‐defibrillator (ICD). However, the prognostic significance of the WCD remains controversial due to conflicting evidence. The aim of the present study was to evaluate prognosis of patients receiving life‐saving WCD shocks. Methods and results All patients receiving a WCD at Hannover Medical School for heart failure with reduced ejection fraction between 2012 and 2017 were included. Data were acquired at baseline, at 3 months and at last available follow‐up (FU). Three hundred and fifty‐three patients were included (69% male; age 56 ± 15 years; left ventricular ejection fraction 25 ± 8%). FU after the WCD was 2.8 ± 1.5 years with a maximum of 6.8 years. Daily WCD wear time was 22 ± 4 h. Fourteen patients (4%) received appropriate WCD shocks. Two patients (0.6%) died during the WCD period. Thirty patients (9%) died during extended FU. Mean estimated survival after the WCD was similar between patients with and without WCD shocks. Patients without an ICD recommendation after WCD prescription did not experience SCD during FU. Conclusions Patients with WCD shocks showed a favourable survival. Patients without an ICD recommendation after WCD prescription had no SCD during FU. These findings support the practice of careful risk stratification before considering an ICD and the use of the WCD for temporary protection from SCD.
In patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF), three months of optimal therapy are recommended before considering a primary preventive implantable cardioverter-defibrillator (ICD). It is unclear which patients benefit from a prolonged waiting period under protection of the wearable cardioverter-defibrillator (WCD) to avoid unnecessary ICD implantations. This study included all patients receiving a WCD for newly diagnosed HFrEF (n = 353) at our center between 2012 and 2017. Median follow-up was 2.7 years. From baseline until three months, LVEF improved in patients with all peripartum cardiomyopathy (PPCM), myocarditis, dilated cardiomyopathy (DCM), or ischemic cardiomyopathy (ICM). Beyond this time, LVEF improved in PPCM and DCM only (10 ± 8% and 10 ± 12%, respectively), whereas patients with ICM showed no further improvement. The patients with newly diagnosed HFrEF were compared to 29 patients with a distinct WCD indication, which is an explantation of an infected ICD. This latter group had a higher incidence of WCD shocks and poorer overall survival. All-cause mortality should be considered when deciding on WCD prescription. In patients with newly diagnosed HFrEF, the potential for delayed LVEF recovery should be considered when timing ICD implantation, especially in patients with PPCM and DCM.
Funding Acknowledgements Type of funding sources: None. Introduction The wearable cardioverter-defibrillator (WCD) is a tool for temporary protection from sudden cardiac death (SCD). It is used in patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF) as well as in patients with a preexisting ICD indication who need explantation of the device. There is no data on long-term prognosis after the WCD in this latter group of patients. Methods All patients receiving the WCD at a Medical School between 2012 and 2017 were analyzed. Patients with newly diagnosed HFrEF from the PROLONG-II study were compared to patients receiving the WCD after an ICD explantation. Follow-up (FU) data were analyzed after 3 months and at last available FU including WCD data, clinical status, medication, echocardiography and ECG. Results 353 patients (69% male) with newly diagnosed HFrEF from the PROLONG-II study were compared to 29 patients (86% male) having received a WCD after explantation of an ICD (45% with secondary preventive indication). Mean baseline LVEF was 25±8% and 34±13% respectively (p<0.001). Follow-up was 2.8±1.5 and 3.2±1.8 years. WCD shocks occurred in 14 (4%) of the patients with newly diagnosed HFrEF and in 3 (10%) patients after ICD explantation (2 with a secondary preventive indication). During long-term FU, patients with an explanted ICD had a poorer prognosis compared to patients with newly diagnosed HFrEF (p=0.02), and appropriate WCD shocks were associated with even higher mortality in patients after ICD explantation (p=0.045). Conclusion Patients after ICD explantation have an increased risk of ventricular arrhythmias and WCD shocks, but also show an increased risk of all-cause mortality despite wearing the WCD compared to patients with newly diagnosed HFrEF.
Funding Acknowledgements Type of funding sources: None. Introduction Patients with a first diagnosis of heart failure with reduced ejection (HFrEF) have potential for improvement under appropriate therapy. We and others have previously suggested to extend the time of therapy optimization beyond 3 months before considering implantation of a primary preventive implantable cardioverter-defibrillator (ICD), in order to avoid unnecessary ICD implantations. This sub-analysis of the PROLONG-II study sought to investigate which patients show recovery of left ventricular ejection fraction (LVEF) beyond 3 months under optimized therapy. Methods Patients with newly diagnosed HFrEF with either ischemic cardiomyopathy (ICM), dilated cardiomyopathy (DCM), peripartum cardiomyopathy (PPCM) or myocarditis at our center between 2012 and 2017 were included. All patients received a wearable cardioverter defibrillator (WCD) for temporary protection from sudden cardiac death. Follow-up (FU) data were analyzed after 3 months and at last available FU, and included WCD data, clinical status, medication, echocardiography and ECG. Results 353 patients (69% male) with newly diagnosed HFrEF (LVEF 25±8%) were followed for 2.8±1.5 years: 126 patients with ICM (35%), 169 patients with DCM (48%), 27 patients with PPCM (7%), 24 patients with myocarditis (7%) and 7 patients with other diagnoses (2%). LVEF improvement within the first 3 months was observed in all subgroups but was more pronounced in patients with DCM (9±9%) compared to ICM (5±8%) and in PPCM (20±10%) and myocarditis (15±9%) compared to both DCM and ICM. In patients with DCM and PPCM, LVEF continued to improve significantly beyond 3 months (another 10% each). Conclusion Potential for delayed LVEF improvement in newly diagnosed HFrEF under optimized therapy depends on etiology. Patients with PPCM and DCM seem to be particularly eligible for an extended period of therapy optimization and risk stratification before considering an ICD.
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