Shifting paradigms in ICD tachytherapy deactivation in the final phase of life: eighteen years of perspective

AIMS: Implantable cardioverter-defibrillators (ICDs) may deliver painful shocks in the final phase of life. The European Heart Rhythm Association (EHRA) and Heart Rhythm Society (HRS) recommend advanced care planning and timely tachytherapy deactivation to prevent this. This study aims to evaluate anticipatory tachytherapy deactivation practices over an 18-year period and identify implementation gaps to explore strategies for improvement. METHODS AND RESULTS: Records of 1606 ICD or cardiac resynchronization therapy-defibrillator (CRT-D) patients (79% male; mean age 67 ± 10 years at implantation, 73 ± 10 at death) who died between 2006 and 2022 were reviewed. Heart failure (32%) and malignancy (15%) were the most common causes of death. Anticipatory tachytherapy deactivation occurred in 42% of patients. Deactivation rates increased 5.2% annually from 2006 to 2014 (P < 0.001), but plateaued from 2015 to 2022 (P = 0.403). Among deactivations, 33% occurred on the final day of life, mainly during hospitalization. CONCLUSION: Despite improvements in anticipatory tachytherapy deactivation practices, a plateau has been reached. Many deactivations still occur on the final day of life, underscoring the need for earlier and more proactive counselling. Integrating deactivation discussions into routine care, particularly for heart failure patients, will be essential to ensure patient-centered advanced care planning.