Defibrillator exchange in the elderly

Abstract

Background: Implantable cardioverter-defibrillator (ICD) therapy in elderly patients is controversial because survival benefits might be attenuated by nonarrhythmic causes of death.

Objective: The purpose of this study was to investigate the outcome of septuagenarians and octogenarians after ICD generator exchange (GE).

Methods: A total of 506 patients undergoing elective GE were analyzed to determine the incidence of ICD shocks and/or survival after GE. Patients were divided into a septuagenarian group (age 70-79 years) and an octogenarian group (age ≥80 years). The primary endpoint was death from any cause. Secondary endpoints were survival after appropriate ICD shock and death without experiencing ICD shocks after GE ("prior death").

Results: The association of the ICD with all-cause mortality and arrhythmic death was determined for septuagenarians and octogenarians. Comparing both groups, similar left ventricular ejection fraction (35.6% ± 11.2% vs 32.4% ± 8.9%) and baseline prevalence of New York Heart Association functional class III or IV heart failure (17.1% vs 14.7%) were found. During the entire follow-up period of the study, 42.5% of patients in the septuagenarian group died compared to 79% in the octogenarian group (P <.01). Prior death was significantly more frequent in both age groups than were appropriate ICD shocks. Predictors of mortality were common in both groups and included advanced heart failure, peripheral arterial disease, and renal failure.

Conclusion: In clinical practice, decision-making for ICD GE among the elderly should be considered carefully for individual patients.

Keywords: Generator exchange; Implantable cardioverter-defibrillator; Octogenarians; Quality of life; Septuagenarians.

Graphical abstract

Figure 1

A: Unadjusted survival of the septuagenarian group (blue line) and the octogenarian group (orange line). There is an unadjusted 37% difference in survival between the 2 age groups. B: Unadjusted survival of the septuagenarian group (blue line) and the octogenarian group (orange line) after the first implantable cardioverter-defibrillator (ICD) shock after generator exchange. There is a 20% decrease in survival in the first 6 months after an appropriate ICD shock. C: Cumulative incidence of first appropriate ICD therapy and prior death after ICD exchange in the septuagenarian group. D: Cumulative incidence of first appropriate ICD therapy and prior death after ICD exchange in the octogenarian group.

Figure 2

Modes of antiarrhythmic death separated by age group. Terminal heart failure (HF) was the leading mode of death in both age groups. The prevalence of neurological disorders increased in the octogenarian group. CKD = chronic kidney disease; COPD = chronic obstructive pulmonary disease; ICB = intracranial bleeding; MI = myocardial infarction.

Figure 3

A: Implantable cardioverter-defibrillator (ICD) use after previous therapies during earlier generator lifetimes. The number of patients in the septuagenarian group with secondary prevention indication or previous ICD shocks who received an ICD shock during follow-up compared to the octogenarian group. B: Assessment for relevance of prior ICD criteria. Most patients still met the previous criteria from the first ICD implantation at the time of ICD generator exchange. Nevertheless, patients who did not meet the previous criteria experienced appropriate ICD shocks during follow-up.

Figure 4

Patient views on generator exchange (GE). Most patients preferred implantable cardioverter-defibrillator GE after being asked the hypothetical question whether GE exchange should take place in case of battery depletion. The number of patients with no clear opinion increased in the octogenarian group.