Why the study?
The PRAETORIAN score predicts S-ICD defibrillation success, but its correlation with clinical characteristics and implantation variables required evaluation.
Do clinical characteristics and implantation variables correlate with the PRAETORIAN score in patients undergoing S-ICD implantation?
Do clinical characteristics and implantation variables correlate with the PRAETORIAN score in patients undergoing S-ICD implantation?
In contemporary S-ICD practice using intermuscular positioning, the PRAETORIAN score evaluation may be simplified or unnecessary for non-obese patients, as BMI and shock impedance reliably predict a favorable score.
Association between PRAETORIAN score and implantation factors is hypothesis-generating; prospective studies needed before clinical adoption.
AIMS: The subcutaneous implantable cardioverter defibrillator (S-ICD) is an alternative to traditional ICDs. The PRAETORIAN score, based on chest radiographs, has been validated to predict the probability of successful S-ICD defibrillation testing by assessing factors like fat thickness between the coil and sternum and generator placement. This study evaluated the correlation between the PRAETORIAN score and clinical characteristics, as well as implantation variables. METHODS AND RESULTS: We retrospectively analysed data from 1253 patients who had undergone implantation of an S-ICD across 33 centres. The intermuscular positioning of the pulse generator was adopted in all patients. Post-implantation posterior-anterior and lateral chest radiographs were analysed to calculate the PRAETORIAN score. A total of 95.7% of patients had a PRAETORIAN score < 90, indicative of a low risk of conversion failure. Body mass index (BMI) was the only independent predictor of a score ≥ 90, and all patients with BMI < 25 kg/m2 (normal weight or underweight) had a score < 90. The intermuscular positioning technique resulted in optimal posterior placement of the device in all patients and significant sub-generator fat in only 3% of cases. A shock impedance value > 88 Ohm enabled to detect a PRAETORIAN score ≥ 90 with 98% (95% CI 97-99%) negative predictive value. CONCLUSION: In contemporary practice, the PRAETORIAN score can be simplified. By adopting an intermuscular approach, two of the three steps of the score-evaluating the adequate posterior positioning of the generator and measuring the sub-generator fat-become superfluous, and impedance may serve as a reliable surrogate of sub-coil fat thickness. Furthermore, our data suggest that for non-obese patients, a favourable PRAETORIAN score is assured, making the score evaluation potentially unnecessary. CLINICAL TRIAL REGISTRATION: URL: http://clinicaltrials.gov/ Identifier: NCT02275637.
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Ziacchi et al. (2025) studied this question.
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