Sudden Unexpected Death in Patients With Implanted Cardiac Defibrillators: Results of Postmortem Interrogation in MADIT-CRT.

IF 8 1区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS JACC. Clinical electrophysiology Pub Date : 2025-01-08 DOI:10.1016/j.jacep.2024.11.015

Robert E Goldstein, Margaret L McCarthy, Ronald J Krone, Mark C Haigney, Wojciech Zareba

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Abstract

Background: Ventricular tachyarrhythmia presumably causes sudden unexpected death (SUD) in patients lacking an implantable cardioverter-defibrillator (ICD). The mechanism of SUD is less clear in patients with an ICD to remedy ventricular tachycardia (VT) or ventricular fibrillation (VF).

Objectives: This study sought to assess mechanisms of SUD in patients with an ICD.

Methods: MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy) compared ICD alone with ICD with added cardiac resynchronization therapy in 1,820 patients with ischemic or nonischemic cardiomyopathy. In the current analysis, all 35 postmortem device interrogations were reviewed among the trial's 191 decedents. SUD (<3 hours after symptom onset or found dead <3 days after last seen) occurred in 39 (20%) of 191 decedents, including 24 with and 15 without ICD interrogation.

Results: Interrogation showed 11 of 24 with SUD had fatal VT/VF: 6 had inadequate ICD performance (inappropriate shock initiating VT/VF in 2 and failure to detect low-amplitude and/or slow VF in 4), 4 had refractory or recurrent VT/VF, and 1 had refractory bradycardia following defibrillating shock. The remaining 13 interrogated SUDs had no tachyarrhythmia initiating device activation. Autopsy in 3 disclosed only scattered myocardial fibrosis. No clinical features discriminated 11 interrogated SUD patients with VT/VF from 13 without VT/VF.

Conclusions: First, spontaneous VT/VF, undetected by ICD or refractory to ICD shock, caused a minority (33%) of SUD in 24 MADIT-CRT patients. Second, no tachyarrhythmia was identified in many (54%), suggesting SUD unrelated to tachyarrhythmia - or due to VT/VF undersensing. Last, ICD-related proarrhythmia instigated SUD in 2 (17%). Postmortem device interrogation revealed important outcomes and should be encouraged for decedents with ICD, particularly when investigating cardiovascular therapies.

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背景：室性心动过速可能会导致未安装植入式心律转复除颤器（ICD）的患者发生意外猝死（SUD）。在使用 ICD 治疗室性心动过速（VT）或室颤（VF）的患者中，猝死的机制尚不明确：本研究旨在评估 ICD 患者 SUD 的机制：方法：MADIT-CRT（多中心自动除颤器植入试验-心脏再同步化疗法）对 1820 名缺血性或非缺血性心肌病患者进行了单独 ICD 与 ICD 加心脏再同步化疗法的比较。在本次分析中，对该试验的 191 名死者进行了全部 35 次尸检。SUD（结果：询问结果显示，24 名 SUD 患者中有 11 人患有致命的 VT/VF：6 人 ICD 性能不佳（2 人电击不当引发 VT/VF，4 人未能检测到低振幅和/或慢速 VF），4 人患有难治性或复发性 VT/VF，1 人在除颤电击后出现难治性心动过缓。其余 13 例接受检查的 SUD 均未出现导致设备启动的快速性心律失常。3 人的尸检仅发现散在的心肌纤维化。临床特征无法区分11例有VT/VF和13例无VT/VF的SUD患者：结论：首先，在 24 名 MADIT-CRT 患者中，ICD 未检测到或 ICD 电击难治性的自发性 VT/VF 造成了少数 SUD（33%）。其次，许多患者（54%）未发现快速性心律失常，这表明 SUD 与快速性心律失常无关，或因 VT/VF 信号不足所致。最后，与 ICD 相关的原发性心律失常导致了 2 例患者（17%）的 SUD。死后设备检查揭示了重要的结果，应鼓励对使用 ICD 的死者进行检查，尤其是在调查心血管疗法时。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

JACC. Clinical electrophysiology CARDIAC & CARDIOVASCULAR SYSTEMS-

CiteScore

10.30

自引率

5.70%

发文量

250

期刊介绍： JACC: Clinical Electrophysiology is one of a family of specialist journals launched by the renowned Journal of the American College of Cardiology (JACC). It encompasses all aspects of the epidemiology, pathogenesis, diagnosis and treatment of cardiac arrhythmias. Submissions of original research and state-of-the-art reviews from cardiology, cardiovascular surgery, neurology, outcomes research, and related fields are encouraged. Experimental and preclinical work that directly relates to diagnostic or therapeutic interventions are also encouraged. In general, case reports will not be considered for publication.