Trends in hospitalization and factors associated with in‐hospital death among pediatric admissions with implantable cardioverter defibrillators

Abstract Background Although randomized clinical trials have shown that implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients, patients on dialysis are excluded from these trials. Thus, data on mortality risk after ICD implantation in these patients are sparse. Purpose To examine all-cause mortality in patients receiving an ICD according to dialysis status and to identify factors associated with all-cause mortality in patients on dialysis. Methods Using Danish nationwide registries from 2000–2017, all patients ≥18 years old undergoing first-time ICD implantation were included. Patients on dialysis were identified prior to ICD implantation and followed for up to five years. The cumulative incidence of all-cause mortality according to dialysis status was assessed. Factors associated with all-cause mortality after ICD implantation in dialysis patients were examined using multivariable Cox proportional hazard regression. Results A total of 14,681 ICD patients were identified, of which 218 (1.5%) were on dialysis prior to ICD implantation. Compared with ICD patients not on dialysis, those on dialysis were younger (median age 64 years [IQR: 58–70] vs. 66 years [IQR: 57–72], p=0.02), more likely to receive an ICD for secondary prophylaxis (69.7% vs 53.7%), and had more comorbidities including ischaemic heart disease (60.6% vs. 46.3%), diabetes (28.4% vs. 20.4%), and peripheral vascular disease (10.1% vs. 5.6%) (p for all <0.05). The median time to death among ICD patients on dialysis and not on dialysis were 1.3 years (IQR: 0.4–2.8 years] and 2.2 years [IQR: 1.0–3.5 years], respectively. One-year mortality among ICD patients on dialysis (13.0%) was significantly higher compared with ICD patients not on dialysis (4.7%), p<0.001 (Figure). Five-year mortality was significantly higher in ICD patients on dialysis than those not on dialysis (42.2% vs 23.6%), p<0.001 (Figure). Factors associated with increased risk of all-cause mortality among ICD patients on dialysis were age ≥65 years at time of implantation (reference: age <65 years) (HR 1.90 [95% CI: 1.13–3.19]), primary prophylactic ICD (HR 1.81 [95% CI 1.08–3.05]), and diabetes (HR 1.87 [95% CI 1.14–3.07]). Sex, ischaemic heart disease, heart failure, stroke, chronic obstructive pulmonary disease, and malignancy were not associated with the risk of mortality (p>0.05 for all). Cardiovascular causes of death were common both in patients with- and without dialysis, 69.6% and 60.0%, respectively. Conclusion Five-year mortality in ICD patients on dialysis was 42% and twice as high compared with ICD patients not on dialysis. Age ≥65 years, primary prophylactic indication, and diabetes were factors associated with increased mortality. Careful evaluation of the potential benefit from an ICD implantation in dialysis patients is important considering the overall high mortality rates. Funding Acknowledgement Type of funding source: None

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Trends in hospitalization and factors associated with in-hospital death among pediatric admissions with implantable cardioverter defibrillators

10.22541/au.163483122.27029224/v1 ◽

2021 ◽

Author(s):

Amna Qasim ◽

Tam Dan Pham ◽

Jeffrey Kim ◽

Santiago Valdes ◽

Taylor Howard ◽

...

Keyword(s):

Heart Failure ◽

Hospital Mortality ◽

Multivariable Analysis ◽

Diagnostic Category ◽

Patient Characteristics ◽

Hospital Death ◽

Implantable Cardioverter Defibrillators ◽

Factors Associated ◽

Admission Rates ◽

Hospital Deaths

Background: As pediatric implantable cardioverter defibrillator (ICD) utilization increases, hospital admission rates will increase. Data regarding hospitalizations among pediatric patients with ICDs is lacking. In addition, hospital mortality rates are unknown. This study aimed to evaluate 1) trends in hospitalization rates of admissions over 20 years, 2) hospital mortality, and 3) factors associated with hospital mortality among pediatric admissions with ICDs. Methods: The Kids’ Inpatient Database (2000-2016) was used to identify all hospitalizations with an existing ICD 20 years of age. ICD9/10 codes were used to stratify admissions by underlying diagnostic category as: 1) congenital heart disease (CHD), 2) primary arrhythmia, 3) primary cardiomyopathy, or 4) other. Trends were analyzed using linear regression. Hospital and patient characteristics among hospital deaths were compared to those surviving to discharge using mixed multivariable logistic regression, accounting for hospital clustering. Results: Of 42,570,716 hospitalizations, 4165 were admitted <21 years with an ICD. ICD admissions increased four-fold (p = 0.002) between 2000-2016. Hospital death occurred in 54 (1.3%). In multivariable analysis, cardiomyopathy (OR 3.5, 95%CI 1.1–11.2, p=0.04) and CHD (OR 4.8, 95%CI 1.5–15.6, p=0.01) were significantly associated with mortality. In further exploratory multivariable analysis incorporating a coexisting diagnosis of heart failure, only the presence of heart failure remained associated with mortality (OR 8.6, 95%CI 3.7-20.0, p<0.0001). Conclusions: Pediatric ICD hospitalization are increasing over time and hospital mortality is low (1.3%). Hospital mortality is associated with cardiomyopathy or CHD; however, the underlying driver for in-hospital death may be heart failure.

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