Out of Hospital Sudden Death in a Rural Population: Low Rates of ICD Underutilization Among Decedents.

BACKGROUND: Implantable cardioverter defibrillators (ICDs) reduce mortality in patients at risk for life-threatening arrhythmias. Implantation of ICDs in rural or economically disadvantaged populations is suspected to be low. This study examined Out of Hospital Premature Natural Death (OHPND) and electronic medical record (EMR) data to identify rates of non-implantation of ICDs among decedents in eastern North Carolina. METHODS: OHPND cases in 2016 were identified using mortality data and matched with EMRs. Those meeting criteria for ICD implantation based on chart review were adjudicated by two electrophysiologists to determine whether they qualified for implantation. Comorbidity burden was established using Charlson's Comorbidity Index (CCI). RESULTS: Out of 1316 OHPND cases, 967 (73.4%) had EMR records. Chart review identified 70 (7.2%) potential ICD candidates with a LVEF ≤35 of which 5 (7.1%) did not meet criteria because LVEF subsequently improved. Of the remaining 65 patients, 32 (49.2%) already received an ICD, and 33 patients (50.7%) met criteria but had not received one. Reasons for non-implantation included: limited life expectancy secondary to comorbidities, principally chronic kidney disease (CKD) (N = 11, 17%), physician non-adherence to guidelines (N = 9, 14%), loss to follow-up (N = 7, 11%), patient refusal (N = 5, 8%), and death before commencing medical therapy (N = 1, 2%). Among our cohort of 967 individuals who died unexpectedly, nine (0.9%) patients may have avoided death with an ICD. CONCLUSION: This study using decedent data shows low rates of ICD-underutilization in a rural population and emphasizes the role of advanced comorbidities such as CKD in ICD-underutilization.

A patient with single coronary artery, bicuspid aortic valve and sinus of Valsalva aneurysm.

BACKGROUND: We report a rare case of a patient who presented with chest pain and was found to have a constellation of rare cardiac anomalies. CASE PRESENTATION: A 67-year-old patient with no past medical history presented with chest pain. He had mild troponin elevation, but no ischemic changes on ECG. He underwent a CT coronary angiogram for further evaluation. He was found to have a type 0 bicuspid aortic valve, large left sinus of Valsalva aneurysm and type R-III single coronary artery. These findings were confirmed with transesophageal echocardiogram and coronary angiogram. He underwent a successful repair of his aortic root aneurysm with a synthetic patch. CONCLUSIONS: The combination of type R-III single coronary artery, bicuspid aortic valve, and left sinus of Valsalva aneurysm congenital anomalies in one individual is extremely rare and marks our case unique. Given the size of his Sinus of Valsalva aneurysm, the patient underwent surgical repair of his aneurysm and was asymptomatic when seen in follow-up.