A novel tool to evaluate the implant position and predict defibrillation success of the subcutaneous implantable cardioverter-defibrillator: The PRAETORIAN score

Quast, Anne‐Floor B.E.; Baalman, Sarah W.E.; Brouwer, Tom F.; Smeding, Lonneke; Wilde, Arthur A.M.; Burke, Martin C.; Knops, Reinoud E.

doi:10.1016/j.hrthm.2018.09.029

Cited by 115 publications

(86 citation statements)

References 18 publications

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“…Most recent reports show that, despite a Class I recommendation, VF termination testing is declining in clinical practice due to physician preference . Definite data will derive from the ongoing randomized Trial of S‐ICD implantation with and without defibrillation testing (PRAETORIAN‐DFT), which aims to prove the safety of withholding defibrillation verification when implant optimization is based on the PRAETORIAN score …”

Section: Discussionmentioning

confidence: 99%

Successful defibrillation verification in subcutaneous implantable cardioverter‐defibrillator recipients by low‐energy shocks

Biffi

Ziacchi

Angeletti

et al. 2019

Clinical Cardiology

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Background The subcutaneous implantable cardioverter‐defibrillator (S‐ICD) is an effective alternative to the transvenous one. Defibrillation efficacy depends on maximum device output and on the optimal device location at device implantation. Hypothesis We sought to investigate the defibrillation safety margin in real life clinical practice. Methods We sought to understand what is the efficacy of induced ventricular fibrillation (VF) termination at S‐ICD implantation using lower energies than the recommended 65 J. Results Sixty‐four consecutive S‐ICD recipients underwent VF termination attempts at implantation with energies ranging from 20 to 50 J. Overall, VF termination occurred in 84% of patients with ≤40 J, in 88% with 45 J, and in 100% with 60 J. Intermuscular S‐ICD placement was associated with 94% VF termination at ≤40 J. An ejection fraction <35% was associated to higher energy requirement for defibrillation; however, an intermuscular S‐ICD placement conferred 90% defibrillation efficacy at 31 ± 5 J in this patients subset. Conclusions This is a hypothesis‐generating observation that prompts a methodologically correct investigation to prove that a 60 J output S‐ICD can provide an adequate safety margin to terminate VF in clinical practice. This would enable superior device longevity and/or device downsizing for pediatric/small size patients.

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Section: Discussionmentioning

confidence: 99%

Successful defibrillation verification in subcutaneous implantable cardioverter‐defibrillator recipients by low‐energy shocks

Biffi

Ziacchi

Angeletti

et al. 2019

Clinical Cardiology

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“…The effect of the improved implant technique on the DFT has not been examined. In addition, retrospective analysis of DFTs in two large cohorts by analyzing S‐ICD implant position resulted in a higher predictive value of the newly developed PREATORIAN score compared to impedance, suggesting that optimal position of the S‐ICD may result in lower thresholds than previously reported …”

Section: Introductionmentioning

confidence: 80%

“…Device positioning is evaluated in all patients using bidirectional chest X‐rays routinely performed post‐S‐ICD implant using the PRAETORIAN score . DFT are all performed within the same procedure as the implant.…”

Section: Methodsmentioning

confidence: 99%

“…: Conversion of the induced ventricular arrhythmia failed PRAETORIAN score. 16 DFT are all performed within the same procedure as the implant. Chest X-rays are taken the day of implant or 1 day after implant.…”

Section: Implant Positionmentioning

confidence: 99%

“…In addition, retrospective analysis of DFTs in two large cohorts by analyzing S-ICD implant position resulted in a higher predictive value of the newly developed PREATORIAN score compared to impedance, suggesting that optimal position of the S-ICD may result in lower thresholds than previously reported. 16 In this study, we determine if a single 30 J conversion test is feasible in S-ICD patients and we determine the lowest energy which successfully converts the induced ventricular arrhythmia following a predetermined, step-down, DFT protocol, to explore whether the DFT in S-ICD patients is lower than previously reported.…”

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confidence: 99%

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Minimal defibrillation thresholds and the correlation with implant position in subcutaneous implantable‐defibrillator patients

Quast

Baalman

Stuijt

et al. 2019

Cardiovasc electrophysiol

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Background Since the introduction of the subcutaneous implantable‐defibrillator (S‐ICD) knowledge of factors elevating the defibrillation threshold (DFT), have increased. Optimal device positioning most likely results in a decrease in DFT. The PRAETORIAN score is a tool to systematically evaluate S‐ICD implant position and predict conversion success by estimating the DFT on a chest X‐ray. The objective of this study is to determine DFT in de novo S‐ICD patients. Methods De novo S‐ICD patients were enrolled with DFT testing using a single 30 J shock or a prespecified step‐down protocol. Chest X‐rays were obtained and implant position was evaluated using the PRAETORIAN score. Results Fifteen patients, age 47 (±18) years and body mass index (BMI) 25(±3) kg/m2, underwent conversion testing with a single 30 J shock. Fourteen patients (93%) converted successfully. Implant position was optimal in all patients, PRAETORIAN score of 30 (100%). Twelve patients were available for analysis in the step‐down DFT cohort, age 46 years (±15), left ventricular ejection fraction 50% (±15%) and a median BMI of 25.7 kg/m2 (range 23.8‐29.1 kg/m2). No complications occurred during DFT testing. Mean DFT was 29 J (±12 J). Time to shock was 11 seconds (±2 seconds) for a 20 J shock compared with 17 seconds in case of a 70 J shock output. Nearly all patients were implanted with optimal device positioning with the lowest possible PRAETORIAN score of 30 (92%). Conclusion DFT in S‐ICD patients with optimal device positioning is lower than previously reported. Conversion testing using a low shock output reduced time to therapy by 6 seconds on average.

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Serratus anterior plane block and postoperative pain control in obese patients undergoing S‐ICD implantation: A case series and literature analysis

Coletta,

Schettino,

Tomasello

et al. 2024

Clinical Case Reports

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Key Clinical MessageWe report five case series of obese patients with severe left ventricular ejection fraction impairment undergoing Serratus Anterior Plane Block during S‐ICD Implantation. This anesthesia approach has a reduced impact on the patient's hemodynamics and adequately manages postprocedural pain.AbstractSubcutaneous implantable cardioverter‐defibrillator (S‐ICD) procedures are frequently performed under analgosedation or general anesthesia, leading to prolonged postoperative hospital stays and increased costs. This anesthetic technique may also have a greater hemodynamic impact, particularly in obese and cardiac patients. However, an alternative anesthetic technique can be employed: ultrasound‐guided serratus anterior plane block (US‐SAPB). We analyzed the anesthetic clinical course in 5 patients, 3 males and 2 females, who were obese (BMI ≥ 30) and underwent S‐ICD implantation for primary prevention using a two‐incision intermuscular technique and ultrasound‐guided serratus anterior plane block. All patients had a left ventricular ejection fraction less than or equal to 35%. It significantly facilitated pain control during the procedure and, especially, in the postoperative phase. However, the data available in the literature are mostly derived from case reports and small comparative studies. Therefore, further studies with a larger sample size and direct comparison with general anesthesia or deep sedation are needed.

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A novel tool to evaluate the implant position and predict defibrillation success of the subcutaneous implantable cardioverter-defibrillator: The PRAETORIAN score

Cited by 115 publications

References 18 publications

Successful defibrillation verification in subcutaneous implantable cardioverter‐defibrillator recipients by low‐energy shocks

Successful defibrillation verification in subcutaneous implantable cardioverter‐defibrillator recipients by low‐energy shocks

Minimal defibrillation thresholds and the correlation with implant position in subcutaneous implantable‐defibrillator patients

Serratus anterior plane block and postoperative pain control in obese patients undergoing S‐ICD implantation: A case series and literature analysis

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