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A New Single Chamber Implantable Defibrillator with Atrial Sensing: A Practical Demonstration of Sensing and Ease of Implantation
Published on: February 28, 2012
Intercentre heterogeneity and determinants of implantable cardioverter-defibrillator technology selection in France
Fawzi Kerkouri1, Marc Badoz2, Rodrigue Garcia3
1Division of Cardiology, Georges-Pompidou European Hospital, 75015 Paris, France; Inserm U970, Paris Cardiovascular Research Centre, Université Paris Cité, 75015 Paris, France; Department of Cardiology, University Hospital of Brest, 29200 Brest, France; Laboratoire ORPHY EA 4324, Brest University, 29200 Brest, France.
Background:
With the recent introduction of the extravascular implantable cardioverter-defibrillator (EV-ICD), clinicians now have three distinct devices for sudden cardiac death prevention: the transvenous implantable cardioverter-defibrillator (TV-ICD); the subcutaneous implantable cardioverter-defibrillator (S-ICD); and the EV-ICD.
Aims:
To quantify intercentre heterogeneity in device choice, and identify patient characteristics independently associated with selecting a TV-ICD, an S-ICD or an EV-ICD.
Methods:
We conducted a cross-sectional vignette-based survey across 15 French implanting centres. Centres selected a first-line implantable cardioverter-defibrillator for 21 standardized scenarios in which all three devices were feasible (315 centre-level decisions).
Results:
Intercentre agreement on device choice was slight (κ=0.065), and the median per-vignette majority consensus was 53% (range: 40-93%), indicating substantial between-centre heterogeneity. Unsupervised clustering of centres identified three distinct selection strategies: a TV-ICD first cluster (5/15 centres; TV-ICD 51.4% of choices); an S-ICD first cluster (7/15 centres; S-ICD 68.7% of choices); and an EV-ICD forward cluster (3/15 centres; EV-ICD 81.0% of choices). In adjusted analyses, age<65years was associated with selection of both S-ICDs (odds ratio [OR]: 2.10, 95% confidence interval [95% CI]: 1.11-4.00; P=0.024) and EV-ICDs (OR: 2.27, 95% CI: 1.05-4.91; P=0.038) versus TV-ICDs. Low body mass index (17 vs. 25kg/m2) was associated with lower odds of selection of an S-ICD versus a TV-ICD (OR: 0.30, 95% CI: 0.09-0.94; P=0.039) and higher odds of selection of an EV-ICD versus an S-ICD (OR: 3.81, 95% CI: 1.27-11.44; P=0.017). Sex, heart disease and prevention setting were not independently associated with device selection.
Conclusions:
Implantable cardioverter-defibrillator selection showed a marked centre-level practice effect, and was also influenced by age and body mass index. These findings support harmonized selection pathways to reduce unwarranted variability, while preserving patient profile-oriented shared decision-making.
