When Is It Safe Not to Reimplant an Implantable Cardioverter Defibrillator at the Time of Battery Depletion?

Abstract

The implantable cardioverter defibrillator (ICD) is a life-saving therapy in various patient populations. Although data on the outcomes of initial ICD implants are abundant, data on ICD replacements, especially in patients with improved left ventricular (LV) function, are scarce. Therefore, it is not known when it is safe to not replace an ICD that has reached the end of battery life. This article reviews data on patients with primary prevention ICDs who have improvement in left ventricular ejection fraction during follow-up and provides some guidance, based on the available evidence, related to circumstances when replacement of an ICD may be forgone.

Incidence of appropriate anti-tachycardia therapies after elective generator replacement in patient with heart failure initially implanted with a defibrillator for primary prevention: Results of a meta-analysis

“…The results of our study support the algorithm recently proposed by Al-Khatib et al [31] to help the decision making at the time of battery depletion for both single/dual-chamber ICD and for CRT-D devices. The proposed algorithm emphasizes the need to consider LVEF, previous arrhythmias and patients engagement in order to drive the decision.…”

Factors and outcomes associated with improved left ventricular systolic function in patients with cardiomyopathy

“…Left ventricular ejection fraction improvement in patients with a primary prevention ICD presents a dilemma to clinicians and patients when deciding to replace the ICD generator at the end of battery life [ 15 , 19 – 22 ]. Naksuk et al [ 23 ] demonstrated that patients who had an LVEF improvement to > 35% and an increase in > 10% from baseline LVEF had a similar survival benefit before and after ICD replacement when compared with patients who had no improvement in LVEF.…”

Risk of ventricular arrhythmias following implantable cardioverter‐defibrillator generator change in patients with recovered ejection fraction: Implications for shared decision‐making

“…[2][3][4] However, no guidelines exist regarding patients with primary prevention ICD implants who recover to LVEF > 35% and who have never required therapy from their ICD, at the time of generator battery depletion. 5 Since up to 45% of patients have LVEF > 35% at time of generator depletion and 65% of all ICD patients do not receive a shock before generator battery depletion, this represents a substantial patient population unaccounted for in terms of management guidelines. [5][6][7] At present, ICDs are often replaced upon battery depletion, even when the LVEF has recovered.…”

“…The utility of implantable cardioverter‐defibrillators (ICDs) for primary prevention of SCA has been demonstrated in several clinical trials, and current guidelines indicate ICD implantation for most patients with left ventricular ejection fraction (LVEF) ≤ 35% 2–4 . However, no guidelines exist regarding patients with primary prevention ICD implants who recover to LVEF > 35% and who have never required therapy from their ICD, at the time of generator battery depletion 5 . Since up to 45% of patients have LVEF > 35% at time of generator depletion and 65% of all ICD patients do not receive a shock before generator battery depletion, this represents a substantial patient population unaccounted for in terms of management guidelines 5–7 .…”

“…5 Since up to 45% of patients have LVEF > 35% at time of generator depletion and 65% of all ICD patients do not receive a shock before generator battery depletion, this represents a substantial patient population unaccounted for in terms of management guidelines. [5][6][7] At present, ICDs are often replaced upon battery depletion, even when the LVEF has recovered. However, this practice is questionable; in fact, it is a frequent topic of "pro versus con" debates at meetings of international organized cardiology societies.…”