Long-Term Outcomes of Subcutaneous Versus Transvenous Implantable Cardioverter Defibrillator Use Among Patients on Maintenance Dialysis

Background: Despite an elevated risk of sudden cardiac death among dialysis patients, implantable cardioverter defibrillators (ICDs) have not been shown to improve mortality and are associated with high complication rates. Subcutaneous (S-)ICDs may reduce the risk of complications for eligible dialysis patients, but safety and benefits vs transvenous (TV-ICDs are unknown.

Objective: To compare long-term outcomes between dialysis patients receiving S-ICD vs TV-ICDs.

Methods: We performed a retrospective analysis of ICD implants among Fee-For-Service Medicare beneficiary dialysis patients in the National Cardiovascular Data Registry ICD Registry. Outcomes were ascertained from Medicare claims data. We compared survival outcomes, hospital admissions, and ICD-associated and dialysis vascular access-associated complications, between eligible S-ICD and single-chamber TV-ICD recipients using stabilized inverse probability of treatment weighting.

Results: We identified 529 dialysis patients receiving S-ICDs and 842 receiving single-chamber TV-ICDs who met the inclusion criteria. S-ICD recipients were younger, more often Black, and had a higher burden of cardiac disease and prior dialysis access interventions. After propensity weighting, there was no difference in the risk of death (hazard ratio [HR], 1.12, 95% confidence interval [CI], 0.96-1.30), hospital admission (HR, 1.01; 95% CI, 0.88-1.16), bacteremia or sepsis (HR, 1.01; 95% CI, 0.80-1.26), device reoperation (HR, 1.06; 95% CI, 0.59-1.89), and subsequent dialysis access interventions (HR, 1.12; 95% CI, 0.86-1.46).

Conclusion: In this representative longitudinal cohort study of dialysis patients, compared with TV-ICD, S-ICD was not associated with decreased risks of death, hospitalization, device complications, or dialysis access interventions.