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Observational Study
. 2025 Jul 8;86(1):32-45.
doi: 10.1016/j.jacc.2025.04.048.

Defibrillation Testing During Implantation of Subcutaneous Implantable Cardioverter Defibrillators

Fawzi Kerkouri  1 , Romain Eschalier  2 , Samir Fareh  3 , Christelle Marquié  4 , Mina Ait Said  5 , Walid Amara  6 , Frédéric Anselme  7 , Marc Badoz  8 , Nathalie Behar  9 , Pierre Bordachar  10 , Rim El Bouazzaoui  11 , Laure Champ Rigot  12 , Michel Chauvin  13 , Philippe Chevalier  14 , Antoine Da Costa  15 , Pascal Defaye  16 , Jean Claude Deharo  17 , Laurent Fauchier  18 , Estelle Gandjbakhch  19 , Edouard Gitenay  20 , Jean-Baptiste Gourraud  21 , Charles Guenancia  22 , Maxime de Guillebon  23 , Benoît Guy-Moyat  24 , Alexis Hermida  25 , Jérôme Hourdain  17 , Peggy Jacon  16 , Pierre Khattar  26 , Mikael Laredo  19 , Laurence Jesel  27 , Nicolas Lellouche  28 , Christophe Leclercq  9 , Vincent Mansourati  29 , Philippe Maury  30 , Pierre Mondoly  30 , Jean Luc Pasquié  31 , Michaël Peyrol  32 , Bertrand Pierre  18 , Sylvain Ploux  10 , Charlotte Potelle  4 , Nicolas Sadoul  33 , Jean Marc Sellal  33 , Emilie Varlet  34 , Rodrigue Garcia  35 , Vincent Probst  21 , Serge Boveda  36 , Eloi Marijon  37 ; HONEST Study Investigators
Collaborators, Affiliations
Observational Study

Defibrillation Testing During Implantation of Subcutaneous Implantable Cardioverter Defibrillators

Fawzi Kerkouri et al. J Am Coll Cardiol. .

Abstract

Background: Defibrillation testing (DT) remains recommended during subcutaneous implantable cardioverter defibrillator (S-ICD) implantation due to limited supporting evidence.

Objectives: The objective of this study was to evaluate the long-term impact of DT during S-ICD implantation.

Methods: The HONEST (coHOrte fraNcaise des dEfibrillateurs Sous cuTanés) study is a nationwide, ongoing observational study, including all S-ICD recipients in France (2012-2019). Five-year endpoints were centrally adjudicated, and propensity score-weighted analyses compared outcomes by DT status.

Results: Among 4,924 patients, DT was performed in 4,066 (82.6%), decreasing from 85.4% (2012-2014) to 66.9% in 2019 (P < 0.001). Nontested patients were older (51.2 vs 49.6 years; P = 0.007), had lower left ventricular ejection fraction (37.6% vs 43.3%; P < 0.001), and were more frequently implanted for primary prevention (68.0% vs 62.4%; P = 0.002) and structural heart disease (84.9% vs 76.8%; P < 0.001). DT-related complications occurred in 0.1%, including 2 deaths. Failure rate was 1.0%, with 87.8% undergoing corrective reinterventions. Independent predictors of DT failure were elevated shock impedance (≥89 Ω; OR: 4.60; 95% CI: 2.32-9.66; P < 0.001) and obesity (body mass index ≥30 kg/m2; OR: 2.17; 95% CI: 1.01-4.55; P = 0.007). After adjustment, DT omission was not associated with increased risks of overall mortality (HR: 1.17; 95% CI: 0.86-1.61; P = 0.313), cardiovascular mortality (HR: 1.04; 95% CI: 0.70-1.56; P = 0.846), sudden cardiac death (HR: 0.27; 95% CI: 0.04-1.72; P = 0.167), and appropriate (HR: 1.01; 95% CI: 0.78-1.30; P = 0.945) or inappropriate shocks (HR: 0.98; 95% CI: 0.78-1.23; P = 0.865). Combined rates of ineffective shocks or undetected ventricular arrhythmias were similar (0.05 vs 0.06 per 100 person-years).

Conclusions: Our findings suggest that DT can be safely omitted in the majority of S-ICD recipients, whereas selective DT may be considered in higher-risk subgroups. (S-ICD French Cohort Study (HONEST); NCT05302115).

Keywords: defibrillation failure; ineffective shock; shock impedance; subcutaneous implantable cardioverter defibrillator; sudden cardiac death.

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Conflict of interest statement

Funding Support and Author Disclosures The HONEST study was conducted by the French Institute of Health and Medical Research and funded by the French Federation of Cardiology and the French Society of Cardiology. Boston Scientific, the manufacturer of the studied device, had no role involvement in the study design, data collection, analysis, interpretation, or preparation of this report. Since 2020, Boston Scientific has supported the organization of the annual HONEST investigators’ meetings. Fawzi Kerkouri, Mina Ait Said, Marc Badoz, Pierre Bordachar, Laure Champ Rigot, Philippe Chevalier, Jean Claude Deharo, Laurent Fauchier, Estelle Gandjbakhch, Edouard Gitenay, Jean-Baptiste Gourraud, Benoît Guy-Moyat, Alexis Hermida, Jérôme Hourdain, Jacon Peggy, Maxime de Guillebon, Laurence Jesel, Vincent Mansourati, Philippe Maury, Jean Luc Pasquié, Michaël Peyrol, Sylvain Ploux, Charlotte Potelle, Nicolas Sadoul, Jean Marc Sellal, and Emilie Varlet declare no relevant conflicts of interest with Boston Scientific. All other authors are consultants for and/or have received fees from Boston Scientific. The first draft of the manuscript was prepared by the first, second, and last authors, who had unrestricted access to the data, in collaboration with the HONEST Scientific Committee. The manuscript underwent thorough review and was approval by all contributing authors.

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