Introduction: Patients with implantable cardioverter defibrillator (ICD) receiving appropriate ICD-shocks are known to have a worse prognosis. We recently developed a new treatment concept for ICD-patients with appropriate ICD shock, the ToVAMI protocol, which consists of the following three steps: Trigger optimization, Ventricular Arrhythmia treatment and Medical and Interventional prognostic heart failure treatment. This protocol was implemented into clinical practice since 9/2018. Aim of the study was to evaluate the impact of the ToVAMI protocol on the outcome of patients with first appropriate ICD shock. Methods and Results: A total of 255 consecutive patients of a prospective single-centre ICD-registry who received a first appropriate ICD shock between 2012 and 8/2022 were analyzed. Patients with first ICD shock between 2012 and 8/2018 (control group, n = 175) were compared with patients with first ICD shock between 9/2018 and 6/2021 who were treated according to the ToVAMI protocol (ToVAMI group n = 80). Prospective use of the ToVAMI approach increased the rate of identified triggers (42% vs. 60%), VA therapy (34% vs. 51%), and tripled the rate of optimised heart failure treatment.  Patients treated according to the ToVAMI protocol had better survival without recurrent ICD shock (73% versus 55% at two years, p = 0.02) (Figure 1). This was mainly due to a decrease in recurrent ICD-shocks from 48% to 25% at two years (p = 0.01), while all-cause mortality showed only a trend towards lower mortality at two years (19% versus 10%, p = 0.32). In a multivariate analysis adjusting for 10 parameters, the ToVAMI approach was independently associated with a lower combined endpoint of mortality and repeated ICD shocks. Conclusion: The use of ToVAMI in patients with first ICD shock is associated with a reduction of the combined endpoint of mortality and recurrence of appropriate ICD shocks.

Table 1. Clinical characteristics of patients at first ICD shock