Key result
Omitting defibrillation testing during S-ICD implantation is not associated with increased overall mortality.
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Why the study?
Defibrillation testing remains recommended during S-ICD implantation due to limited supporting evidence, prompting evaluation of its long-term impact.
Does defibrillation testing during S-ICD implantation improve long-term outcomes or reduce mortality and shock failure in S-ICD recipients?
Observational (n=4,924)
Yes
Does defibrillation testing during S-ICD implantation improve long-term outcomes or reduce mortality and shock failure in S-ICD recipients?
Answers are grounded in this paper and cite their sources.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Defibrillation testing can be safely omitted after S-ICD implantation when guided by the PRAETORIAN score. [This strategy] simplifies the procedure, potentially increasing S-ICD adoption.”
“This has potential medicolegal implications, and so these guidelines absolutely need to be updated.”
Defibrillation testing during S-ICD implantation can be safely omitted in the majority of patients without increasing the risk of mortality or ineffective shocks.
BACKGROUND Defibrillation testing (DT) remains recommended during subcutaneous implantable cardioverter defibrillator (S-ICD) implantation due to limited supporting evidence. OBJECTIVES The objective of this study was to evaluate the long-term impact of DT during S-ICD implantation. METHODS The HONEST (coHOrte fraNcaise des dEfibrillateurs Sous cuTanés) study is a nationwide, ongoing observational study, including all S-ICD recipients in France (2012-2019). Five-year endpoints were centrally adjudicated, and propensity score-weighted analyses compared outcomes by DT status. RESULTS Among 4,924 patients, DT was performed in 4,066 (82.6%), decreasing from 85.4% (2012-2014) to 66.9% in 2019 (P < 0.001). Nontested patients were older (51.2 vs 49.6 years; P = 0.007), had lower left ventricular ejection fraction (37.6% vs 43.3%; P < 0.001), and were more frequently implanted for primary prevention (68.0% vs 62.4%; P = 0.002) and structural heart disease (84.9% vs 76.8%; P < 0.001). DT-related complications occurred in 0.1%, including 2 deaths. Failure rate was 1.0%, with 87.8% undergoing corrective reinterventions. Independent predictors of DT failure were elevated shock impedance (≥89 Ω; OR: 4.60; 95% CI: 2.32-9.66; P < 0.001) and obesity (body mass index ≥30 kg/m2; OR: 2.17; 95% CI: 1.01-4.55; P = 0.007). After adjustment, DT omission was not associated with increased risks of overall mortality (HR: 1.17; 95% CI: 0.86-1.61; P = 0.313), cardiovascular mortality (HR: 1.04; 95% CI: 0.70-1.56; P = 0.846), sudden cardiac death (HR: 0.27; 95% CI: 0.04-1.72; P = 0.167), and appropriate (HR: 1.01; 95% CI: 0.78-1.30; P = 0.945) or inappropriate shocks (HR: 0.98; 95% CI: 0.78-1.23; P = 0.865). Combined rates of ineffective shocks or undetected ventricular arrhythmias were similar (0.05 vs 0.06 per 100 person-years). CONCLUSIONS Our findings suggest that DT can be safely omitted in the majority of S-ICD recipients, whereas selective DT may be considered in higher-risk subgroups. (S-ICD French Cohort Study (HONEST); NCT05302115).
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Kerkouri et al. (2025) conducted an observational in Subcutaneous implantable cardioverter defibrillator (S-ICD) recipients (n=4,924). Defibrillation testing omission vs. Defibrillation testing performed was evaluated on Overall mortality (HR 1.17, 95% CI 0.86-1.61, p=0.313). Omission of defibrillation testing during S-ICD implantation was not associated with an increased risk of overall mortality (HR 1.17; 95% CI 0.86-1.61; P=0.313) compared to performing the test.
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