Effect of posture on position of subcutaneous implantable cardioverter-defibrillator

Background: The PRAETORIAN score was developed as an alternative for defibrillation testing after subcutaneous implantable cardioverter-defibrillator implantation to assess 3 aspects of implant position on a bidirectional chest radiograph. The score is validated on a standard standing chest radiograph with arms elevated in the lateral view.

Objective: We aimed to evaluate the effect of different anatomic positions on the PRAETORIAN score.

Methods: Thirty patients with a subcutaneous implantable cardioverter-defibrillator underwent standard posterior-anterior and lateral chest radiography, including additional lateral views in 2 positions: standing with arms down and supine with arms alongside the body. PRAETORIAN score and weighted κ coefficient were calculated for each position.

Results: In 8 of 30 patients, the PRAETORIAN score was ≥90 in standard position. The agreement in PRAETORIAN score was substantial (κ = 0.677) for the position with the arms down and fair (κ = 0.399) for the supine position. With the arms down, the PRAETORIAN score decreased in 10 patients (33%), 4 of whom changed to a lower risk category. In supine position, the PRAETORIAN score decreased in 16 patients (53%), 7 of whom changed to a lower risk category, 1 from high to low risk.

Conclusion: A supine or arms-down position during chest radiography can result in lower PRAETORIAN scores and underestimation of associated risk on defibrillation testing failure. This emphasizes the importance of correct anatomic positioning (arms up) during chest radiography when the PRAETORIAN score is used.