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ICD Replacement Decision with LVEF Recovery — EECC MCQ

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HardCardiac DevicesICD Replacement Decision with LVEF RecoveryEECC

A 70-year-old man with an ICD has reached elective replacement indicator (ERI) for battery depletion. His LVEF has recovered from 25% to 48% on optimal GDMT over 5 years. He has never received any ICD therapies (no shocks or ATP). Should the ICD be replaced?

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Correct answer: B — This is a shared decision — LVEF recovery above 35% reduces SCD risk but does not eliminate it; factors including aetiology, presence of scar on CMR, arrhythmia history, and patient preferences should guide the decision

ICD generator replacement at ERI when LVEF has recovered presents a clinical dilemma. The 2022 ESC VA/SCD Guidelines acknowledge that LVEF recovery above 35% reduces but does not eliminate SCD risk, particularly in: (1) ischaemic cardiomyopathy (arrhythmogenic scar persists despite LVEF improvement); (2) patients with ongoing risk markers (NSVT, extensive LGE on CMR, genetic arrhythmogenic variants). The decision should be shared between the patient and the multidisciplinary team, weighing: aetiology, presence of myocardial scar, arrhythmia burden, device complication history, patient age/comorbidities, and patient preferences. Some studies (DANISH long-term follow-up) suggest waning ICD benefit over time.

Reference: ESC (2022): Guidelines on VA and SCD Prevention