Perioperative and postoperative pain in patients undergoing subcutaneous implantable cardioverter-defibrillator placement

FUNDING ACKNOWLEDGEMENTS: Type of funding sources: None. BACKGROUND: The recent Avoiding Transvenous Leads in Appropriate Subjects (ATLAS) Trial demonstrated that the subcutaneous implantable cardioverter–defibrillator (S-ICD) reduces lead-related complications without significantly compromising the effectiveness of ICD shocks, but with more early postoperative pain. PURPOSE: To assess the perioperative and postoperative pain during S-ICD implantation in current clinical practice and evaluate the influence of implantation techniques. METHODS: We analyzed 255 consecutive patients (84% male, 52±16 years, body mass index 26±4 Kg/m², ejection fraction 42±16%) who had undergone S-ICD implantation from 2017 to 2022. The primary endpoint was pain during S-ICD placement. The secondary outcome measure included static and dynamic pain intensity 6 hours after the end of the procedure. Patients were asked to rate pain intensity on a 10-point visual analogue scale from 0 (no pain) to 10 (worst imaginable pain). RESULTS: The mean procedure duration was 62±22 minutes. The serratus anterior plane block (SAPB) was performed in 161 (63%) patients for anesthesia/analgesia, and 161 (63%) patients underwent the defibrillation testing. Implantation success was reported in all patients with no operative complications. In the overall group, the pain intensity was 2 [range: 1-8] during the implantation procedure, and 1 [1-7] for both static and dynamic pain, 6 hours after the end of the procedure. Significantly lower values were recorded during implantation in the SAPB group (p=0.010) and among those who did not undergo the defibrillation testing (p=0.008). The adoption of the SAPB (coefficient: -0.54, p=0.047) and the omission of defibrillation testing (coefficient: -0.70, p=0.028) remained associated with less pain during implantation after correction for age, sex, body habitus, ejection fraction. Six hours after the end of the procedure the static and dynamic pain intensity remained lower among those with omitted testing (p=0.018 and 0.004, respectively). CONCLUSIONS: In current clinical practice, S-ICD implantation is associated with very little discomfort. The adoption of novel anesthetic techniques and the omission of defibrillation testing is associated with lower pain levels.