A new window on subcutaneous ICD system performance: Z-lead impedance change over time in devices with and without extracellular matrix envelope use

Background

Device impedance for subcutaneous ICDs (S-ICDs) may rise over time reflecting changes in tissue electrical conduction due to fibrosis from the natural foreign body response, increasing the risk of defibrillation failure. A biologic envelope optimized for S-ICDs may mitigate fibrosis and encourages angiogenesis around the device possibly decreasing impedance rise over time. The S-ICD system performs routine low-voltage Z-lead (LVZ) impedance testing (impedance between shocking coil and can) that may provide insight into the impedance changes on device functionality and efficacy over time.

Purpose

Explore early and late impedance changes over time in S-ICDs implanted with and without envelopes using periodic LVZ measurements.

Methods

30 patients received S-ICDs (15 with envelope) between 1/2017 and 3/2021, after excluding those with device complications, uncontrolled comorbidities, or recent cardiac surgery. Impedance data was recorded at initial implantation. LVZ impedance data was extracted from the wireless remote monitoring system, trended over 0–4 years post implant, and analyzed blinded to patient information.

Results

24 patients (12 envelope) had evaluable implant and chronic data sets. Baseline clinical characteristics were similar between groups. Impedance in general was higher in the envelope group at initial implantation (LVZ mean 89 Ω vs 74 Ω) and throughout the first year. Comparing envelope to no envelope, the initial average shock impedance was 87.3±30.50 vs 66.7±10.40, followed by an average low-V impedance drop of 29 Ω vs 17 Ω during the first month, with a recovery to 109 Ω vs 91 Ω at 30 months post implant. After 30 months, impedance trends demonstrated a modest linear increase up to 48 months in the no envelope group in comparison with a modest decrease in the envelope group (sample sizes too small to determine significance) (Figure 1).

Conclusion

The results demonstrate periodic LVZ testing in the S-ICD monitoring system can reliably trend changes in system impedance over time. Impedance measurements within the first 6–7 months (and most markedly within the first 3 months) appear to be transiently lower than the values seen after this timepoint suggesting that early impedance measurements may not predict steady-state impedance. Further studies are needed to explore the impact of envelope use and the S-ICD impedance changes beyond 30 months.

Funding Acknowledgement

Type of funding sources: None.

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