Implantable Cardioverter-Defibrillators (ICDs) may be reused after explantation

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Key study points:

1. There were no  infectious complications after the implantation of the used and resterilized implantable cardioverter defibrillators (ICD).
2. Only 2 out of the 106 reimplanted ICDs were replaced because of ventricular lead dislodgment and due to multiple inappropriate shocks.

Primer: Implantable Cardioverter-Defibrillators (ICDs) have been a mainstay therapy to treat ventricular arrhythmias, heart failure (ejection fraction < 35%), and sudden cardiac death. These devices sense electrical activity in the heart, and when appropriate, deliver an electrical burst into the cardiac muscle to try to re-establish normal automaticity. In lower income nations, the rate of implantation of ICDs is much lower than higher income nations because of the high cost of the device. Although many ICDs have a battery life of 6 to 10 years, many of these devices are either replaced or no longer needed after 4 years in the United States. The purpose of this article was to explore whether it was possible to reuse viable ICDs in patients who could not regularly afford them.

Background reading: 

1. Tan TC, Sindone AP, Denniss AR. Cardiac electronic implantable devices in the treatment of heart failure. Heart, Lung and Circulation 2012;21:338-351.

This [observational] study: The authors collected and implanted a total of 106 ICDs. These ICDs were obtained from patients around the United States from regional funeral homes, from patients who were receiving newer ICDs or were explanted due to infection. Explanted ICDs needed to have a battery voltage of at least 3.0 volts or more than 3 years of battery life. Recipients in India who received these devices needed to have a class I indication for ICD placement.

81 patients received 106 ICDs since 2002. After the implantation, there was no indication of any infection of the resterilized devices. Only 2 out of the 106 units were replaced due to malfunction; one was due to a dislodged lead and the other was due to multiple inappropriate shocks. The ICDs needed to be replaced within a mean time of 1287.4 days (range: 125 to 2108 days). As a result, 22 patients received a second device and 3 received a third device. 9 out of 81 patients were lost to follow up due to death. 60.4% of 106 ICDs provided proper treatment in 54.3% of patients.

In sum: The study examined whether explanted ICD devices could be sterilized and reused in a low-income population. The authors demonstrated that reused ICDs were not associated with any infectious complications after surgery and that these devices were able to deliver appropriate treatment. This study illustrates that many explanted ICDs that are functional can be reused in a population who cannot afford the device. The authors note that this strategy could be used within the United States –devices retrieved from upgrades, infections or death could be given to the uninsured. However, certain legislations would need to be put in place in order to protect liable parties.

There are several limitations to this study. Only 2 physicians performed all of the implantations and this was at only one center in India. Therefore, this data may not be very generalizable to larger populations. Furthermore, only a small number of devices and small population were used in this study. To see whether this may be a feasible option, further research would need to include more patients and more devices. Last, the authors did not calculate whether the implantation of the ICDs were cost-effective. However, the strengths of this study were that it showed that even after extensive handling and time between explantation and implantation, these devices still delivered proper treatment. Future research needs to expand the population and number of devices to see whether this strategy is feasible.

 Click to read the study in Annals of Internal Medicine

 By [JC] and [MP]

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