DeWitt Elizabeth S, Triedman John K, Cecchin Frank, Mah Doug Y, Abrams Dominic J, Walsh Edward P, Gauvreau Kimberlee, Alexander Mark E
From the Department of Cardiology (E.S.D., K.G., J.K.T., F.C., D.Y.M., D.J.A., E.P.W., M.E.A.) and Arrhythmia Service (J.K.T., F.C., D.Y.M., D.J.A., E.P.W., M.E.A.), Boston Children's Hospital, MA; and Department of Pediatrics, Harvard Medical School, Boston, MA (E.S.D., K.G., J.K.T., F.C., D.Y.M., D.J.A., E.P.W., M.E.A.).
Circ Arrhythm Electrophysiol. 2014 Dec;7(6):1057-63. doi: 10.1161/CIRCEP.114.001569. Epub 2014 Sep 27.
Implantable cardioverter defibrillators (ICDs) used to prevent sudden cardiac arrest in children not only provide appropriate therapy in 25% of patients but also result in a significant incidence of inappropriate shocks and other device complications. ICDs placed for secondary prevention have higher rates of appropriate therapy than those placed for primary prevention. Pediatric patients with primary prevention ICDs were studied to determine time-dependent incidence of appropriate use and adverse events.
A total of 140 patients aged <21 years (median age, 15 years) at first ICD implantation at Boston Children's Hospital (2000-2009) in whom devices were placed for primary prevention were retrospectively identified. Demographics and times to first appropriate shock; adverse events (including inappropriate shock, lead failure, reintervention, and complication); generator replacement and follow-up were noted. During mean follow-up of 4 years, appropriate shock occurred in 19% patients and first adverse event (excluding death/transplant) occurred in 36%. Risk of death or transplant was ≈1% per year and was not related to receiving appropriate therapy. Conditional survival analysis showed rates of appropriate therapy and adverse events decrease soon after implantation, but adverse events are more frequent than appropriate therapy throughout follow-up.
Primary prevention ICDs were associated with appropriate therapy in 19% and adverse event in 36% in this cohort. The incidence of both first appropriate therapy and device-related adverse events decreased during longer periods of follow-up after implantation. This suggests that indications for continued device therapy in pediatric primary prevention ICD patients might be reconsidered after a period of nonuse.
用于预防儿童心脏性猝死的植入式心脏复律除颤器（ICD）不仅能为25%的患者提供恰当治疗，还会导致相当比例的不恰当电击及其他器械相关并发症。用于二级预防的ICD比用于一级预防的ICD有更高的恰当治疗率。对植入一级预防ICD的儿科患者进行研究，以确定恰当使用和不良事件的时间依赖性发生率。
回顾性确定了波士顿儿童医院（2000 - 2009年）首次植入ICD时年龄＜21岁（中位年龄15岁）且植入ICD用于一级预防的140例患者。记录人口统计学资料、首次恰当电击的时间；不良事件（包括不恰当电击、导线故障、再次干预和并发症）；发生器更换情况及随访情况。在平均4年的随访期间，19%的患者发生了恰当电击，36%的患者发生了首次不良事件（不包括死亡/移植）。死亡或移植风险约为每年1%，且与接受恰当治疗无关。条件生存分析显示，植入后不久恰当治疗率和不良事件发生率均下降，但在整个随访期间不良事件比恰当治疗更频繁。
在该队列中，一级预防ICD与19%的恰当治疗和36%的不良事件相关。首次恰当治疗和器械相关不良事件的发生率在植入后的长期随访期间均下降。这表明，对于儿科一级预防ICD患者，在一段时间未使用后，可能需要重新考虑继续进行器械治疗的指征。
