Prophylactic implantable defibrillator in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia and no prior ventricular fibrillation or sustained ventricular tachycardia.
BACKGROUND
The role of implantable cardioverter-defibrillator (ICD) in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia and no prior ventricular fibrillation (VF) or sustained ventricular tachycardia is an unsolved issue.


RESULTS
We studied 106 consecutive patients (62 men and 44 women; age, 35.6±18 years) with arrhythmogenic right ventricular cardiomyopathy/dysplasia who received an ICD based on 1 or more arrhythmic risk factors such as syncope, nonsustained ventricular tachycardia, familial sudden death, and inducibility at programmed ventricular stimulation. During follow-up of 58±35 months, 25 patients (24%) had appropriate ICD interventions and 17 (16%) had shocks for life-threatening VF or ventricular flutter. At 48 months, the actual survival rate was 100% compared with the VF/ventricular flutter-free survival rate of 77% (log-rank P=0.01). Syncope significantly predicted any appropriate ICD interventions (hazard ratio, 2.94; 95% confidence interval, 1.83 to 4.67; P=0.013) and shocks for VF/ventricular flutter (hazard ratio, 3.16; 95% confidence interval, 1.39 to 5.63; P=0.005). The positive predictive value of programmed ventricular stimulation was 35% for any appropriate ICD intervention and 20% for shocks for VF/ventricular flutter, with a negative predictive value of 70% and 74%. None of the 27 asymptomatic patients with isolated familial sudden death had appropriate ICD therapy. Twenty patients (19%) had inappropriate ICD interventions, and 18 (17%) had device-related complications.


CONCLUSIONS
One fourth of patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia and no prior sustained ventricular tachycardia or VF had appropriate ICD interventions. Syncope was an important predictor of life-saving ICD intervention and is an indication for ICD. Prophylactic ICD may not be indicated in asymptomatic patients because of their low arrhythmic risk regardless of familial sudden death and programmed ventricular stimulation findings. Programmed ventricular stimulation had a low predictive accuracy for ICD therapy.
Corrado
Domenico
D
Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua Medical School, Via Giustiniani 2, Padua, Italy. domenico.corrado@unipd.it
Calkins
Hugh
H
Link
Mark S
MS
Leoni
Loira
L
Favale
Stefano
S
Bevilacqua
Michela
M
Basso
Cristina
C
Ward
Deirdre
D
Boriani
Giuseppe
G
Ricci
Renato
R
Piccini
Jonathan P
JP
Dalal
Darshan
D
Santini
Massimo
M
Buja
Gianfranco
G
Iliceto
Sabino
S
Estes
N A Mark
NA
Wichter
Thomas
T
McKenna
William J
WJ
Thiene
Gaetano
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Marcus
Frank I
FI
D000293:Adolescent; D000328:Adult; D019571:Arrhythmogenic Right Ventricular Dysplasia / Q000401:mortality / Q000503:physiopathology* / Q000628:therapy*; D017147:Defibrillators, Implantable; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007391:International Cooperation; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D015996:Survival Rate; D017180:Tachycardia, Ventricular / Q000503:physiopathology*; D016896:Treatment Outcome; D014693:Ventricular Fibrillation / Q000503:physiopathology*; D055815:Young Adult