Why the study?
CIED removal and interrogation are recommended at autopsy for suspected sudden cardiac death, but data on the role of nonselective post-mortem CIED analysis are lacking.
What is the utility of systematic routine cardiovascular implantable electronic device (CIED) removal and analysis at autopsy?
Observational (n=84)
No
What is the utility of systematic routine cardiovascular implantable electronic device (CIED) removal and analysis at autopsy?
Absolute Event Rate: 62.8% vs 19.5%
p-value: p=< 0.001
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Very often when someone dies, especially if it's an unwitnessed death, we can hypothesize what the probable cause of death is, but unless we do an autopsy and look at all the possible clues available we really 'don't know what we don't know,' as the old saying goes.”
“compelling collective evidence”
Routine post-mortem CIED analysis provides clinically useful information for determining the timing, mechanism, and cause of death, particularly in sudden death cases, and can identify potentially fatal device failures.
BACKGROUND: Cardiovascular implantable electronic device (CIED) removal and interrogation are recommended at autopsy in suspected cases of sudden cardiac death, but data on the role of nonselective post-mortem CIED (pacemaker or defibrillator) analysis in this setting are lacking. OBJECTIVES: This study undertook an institutional registry analysis to determine the utility of systematic routine CIED removal, interrogation, and analysis at autopsy. METHODS: From May 19, 2009, to May 18, 2015, autopsy subjects with a CIED at a Johns Hopkins University medical institution (Baltimore, Maryland) underwent CIED removal and interrogation by an electrophysiologist for clinical alerts. The CIED was then submitted for technical analysis by the manufacturer. The CIED interrogation, the manufacturer's technical analysis, and the final autopsy report were all cataloged in the Johns Hopkins Post-mortem CIED Registry. RESULTS: A total of 2,025 autopsies were performed; 84 subjects had CIEDs removed and analyzed. These devices included 37 pacemakers and 47 defibrillators. Overall, 43 subjects had died suddenly, and 41 had not died suddenly. Significant clinical alerts (sustained tachyarrhythmias or an elevated fluid index value) were seen in 62.8% cases of sudden deaths. In the nonsudden death cohort, 19.5% displayed a significant clinical alert. Significant association of CIED alerts were noted when comparing sudden deaths versus nonsudden deaths (p < 0.001), defibrillators versus pacemakers (p < 0.005), and cardiac versus noncardiac causes of death (p < 0.001). Manufacturer analyses revealed a case of premature pacemaker battery depletion, as well as a hard reset in a defibrillator as a result of cold exposure. CONCLUSIONS: Post-mortem CIED analysis was clinically useful in assisting with determination of the timing, mechanism, and cause of death in the majority of sudden deaths and in almost 20% of nonsudden deaths. The authors advocate CIED removal with analysis as an important diagnostic tool in all autopsies and to assist manufacturers in identifying potentially fatal device failures.
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Sinha et al. (2016) conducted an observational in Deceased subjects with a cardiovascular implantable electronic device (n=84). Post-mortem CIED analysis vs. Nonsudden death cases was evaluated on Significant clinical alerts (sustained tachyarrhythmias or an elevated fluid index value) (p=< 0.001).
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