Anaesthesia strategies for subcutaneous implantable cardioverter-defibrillator implantation: results from the HONEST national registry
L Donisi, F Kerkouri, M Badoz, W Aoudjeghout, V Probst, C Marquie, P Defaye, S Boveda, E Marijon, R GuarciaAbstract
Background
Subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation can be performed under general anesthesia (GA), defined as controlled unconsciousness with airway management, or under non-general anesthesia (non-GA), which includes monitored anesthesia care (MAC) or Non-Anesthesia Personnel Administered Sedation and Analgesia (NASA). While non-GA strategies may reduce procedural burden, their impact on clinical outcomes remains uncertain.
Purpose
To evaluate the association between anesthesia strategy and peri-procedural as well as long-term clinical outcomes in a large nationwide cohort of S-ICD recipients.
Methods
The HONEST (coHOrte fraNçaise des dEfibrillateurs Sous cuTanés) registry prospectively included all S-ICD implantations performed in France between 2012 and 2019 across 150 accredited centers. Anesthesia modality was categorized as GA or non-GA (MAC or NASA). Baseline, procedural, and follow-up data were extracted from electronic records and remote monitoring. Outcomes included overall and local complications, complications requiring reintervention, appropriate and inappropriate shocks, and mortality. Multivariable Cox proportional-hazards and inverse probability weighting (IPW) models adjusted for baseline and procedural variables including indication, generation of device, and year of implantation.
Results
Among 4 924 patients (mean age 50 ± 15 years; 23 % women), 3 883 (78.9 %) underwent GA and 1 041 (21.1 %) non-GA. Non-GA use increased from 2.5 % in 2012 to 26.9 % in 2019 (p < 0.001). Patients implanted under non-GA were slightly older, more often treated for primary prevention, and less frequently underwent defibrillation testing (61.8 % vs 88.2 %; p < 0.001). After a mean follow-up of 4.2 ± 2.1 years, there were no significant differences between GA and non-GA in overall complications (aHR 0.91, 95 % CI 0.72–1.52; p = 0.29), reinterventions (aHR 0.88; p = 0.21), inappropriate shocks (aHR 0.94; p = 0.65), or all-cause mortality (aHR 1.05; p = 0.71). Local and lead-related complications were rare (< 1 % per year) and unaffected by anesthesia type. Within the non-GA group, outcomes were similar between MAC and NASA (overall complications HR 1.26, 95 % CI 0.92–1.73; p = 0.15).
Conclusion
In this nationwide real-world cohort, anesthesia modality did not influence early or long-term clinical outcomes following S-ICD implantation. Non-general anesthesia proved safe and effective, supporting its broader adoption as a standard option for S-ICD implantation in contemporary clinical practice.Graphical AbstractForest Plots NGA vs. GA