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ICDs in nonischemic cardiomyopathy
1. When to consider an ICD in the
non-ischemic cardiomyopathy
patient without arrhythmia?
Sergio L. Pinski, MD, FHRS
Cleveland Clinic Florida
Weston, FL, USA
2. SCD-HeFT and subsequent meta-analysis
Bardy et al. N Engl J Med 2005;352:2251
Desai et al. JAMA 2004;292:2874
3. Declining risk of sudden death in NICM
Kober et al. N Engl J Med 2017;377:41
8. Refining the indication-Risk stratification
• Select patients with higher risk of sudden cardiac death but lower risk
of death due to heart failure and competing comorbidities
9. Elming et al. Circulation 2017;136:1772
Older age limits the benefits of ICD
10. Saba et al. Heart Rhythm 2019;16:1065
CRT-P vs CRT-D in elderly pts with NICM
11. Kristensen et al. JACC Heart Fail 2019:(in press)
Risk models in DANISH
12. Goldberger et al. JACC 2014;63:1879
Electrical parameters are mediocre in identifying NICM
pts ar risk for sudden death
16. Becker et al. JACC Cardiovasc Imag 2018;11:1274
Meta-analysis of LGE as predictor of ventricular
arrhythmias or LV remodeling in DCM
17. Ongoing randomized trial
• Cardiac Magnetic Resonance GUIDEd Management of Mild-
moderate Left Ventricular Systolic Dysfunction (CMR-
GUIDE)
• ~ 400 pts with ischemic or nonischemic cardiomyopathy, LVEF 36 to
50%, + LGE
• Randomized to ICD vs ILR
• End-point is composite of SCD or hemodynamically significant
ventricular arrhythmia
• 2023
18. Di Marco et al. J Am Coll Cardiol HF 2017;5:28
Meta-analysis of LGE as predictor of SD or
ventricular arrhythmias in DCM
26. Cleland et al. JACC 2017:70:1028
Reclassification of Risk of Sudden Death
27. My approach to ICD in nonischemic cardiomyopathy
Familial DCM with SCD or mutation with high
risk of sudden death (LMNA, SCN5A, RBM20,
FLCN)
Significant LGE in CRM?
Treatable condition?
Low risk of competing mortality?
(younger age, no severe HF (or transplant
listed), no comorbidities)
Detailed clinical and family history, deep phenotyping (CMR +), genotyping
(ie, MOGE(S) classification, JACC 2014;64:304)
ICD
ICD
No ICD, treat
and reevalaute
ICD
28. Prabhu et al. J Am Coll Cardiol 2017;70:1949
Prabhu et al. J Am Coll Cardiol EP 2018;4:999
AF ablation and LV fibrosis: The CAMERA-
MRI Study
29. Leyva et al. J Am Coll Cardiol 2012;60:1659
Patients with NICM and no fibrosis have excellent
long-term prognosis with CRT-P alone
30. Saini et al. JACC Clin Electrophysiol 2016;2:307
CRT responders have lower risk of ventricular arrhythmia
31. Interesting Clinical Dilemma
• Younger patient with heart block and mild LV dysfunction requiring
more or less urgent pacemaker (LMNA, SCN5A, sarcoidosis)
• Family history?
• Extracardiac features? Chest CT for sarcoidosis
• Same day in hospital CMR generally not available
• Turn around time for genetic test, biopsy too long
• ? EP study.
• DF-1 ICD lead for RV pacing with pacemaker- Not MRI compatible
32. Conclusions
• Current guidelines, based on LVEF, are not specific or sensitive to identify
pts who benefit from ICD
• “Nonischemic” cardiomyopathy should not be longer used. Appropriate
disease characterization identifies pts with diffent risks, natural history
and response to treatment
• Absence of LGE in CMR identifies pts with much lower risk of sudden
death, at any given LVEF
• Older age decreases the benefit of ICDs
• RCTs to expand indications are likely. However, large RCTs to restrict
indications are not forthcoming. We will have to use clinical judgement.