Original Investigation |

FDA Approval of Cardiac Implantable Electronic Devices via Original and Supplement Premarket Approval Pathways, 1979-2012

Benjamin N. Rome, BA1,2; Daniel B. Kramer, MD1,2,3,4; Aaron S. Kesselheim, MD, JD, MPH1,2
[+] Author Affiliations
1Harvard Medical School, Boston, Massachusetts
2Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
3Beth Israel Deaconess Medical Center, Boston, Massachusetts
4Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts
JAMA. 2014;311(4):385-391. doi:10.1001/jama.2013.284986.
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Importance  The US Food and Drug Administration (FDA) evaluates high-risk medical devices such as cardiac implantable electronic devices (CIEDs), including pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy devices, via the premarket approval (PMA) process, during which manufacturers submit clinical data demonstrating safety and effectiveness. Subsequent changes to approved high-risk devices are implemented via “supplements,” which may not require additional clinical testing.

Objective  To characterize the prevalence and characteristics of changes to CIEDs made through the PMA supplement process.

Design  Using the FDA’s PMA database, we reviewed all CIEDs approved as original PMAs or supplements from 1979 through 2012. For each supplement, we collected the date approved, type of supplement (panel-track, 180-day, real-time, special, and 30-day notice), and the nature of the changes. We calculated the number of supplements approved per PMA and analyzed trends relating to different supplement regulatory categories over time. For supplements approved via the 180-day regulatory pathway, which often involve significant design changes, from 2010-2012, we identified how often additional clinical data were collected.

Results  From 1979-2012, the FDA approved 77 original and 5829 supplement PMA applications for CIEDs, with a median of 50 supplements per original PMA (interquartile range [IQR], 23-87). Excluding manufacturing changes that do not alter device design, the number of supplements approved each year was stable around a mean (SD) of 2.6 (0.9) supplements per PMA per year. Premarket approvals remained active via successive supplements over a median period of 15 years (IQR, 8-20), and 79% of the 77 original PMAs approved during our study period were the subject of at least 1 supplement in 2012. Thirty-seven percent of approved supplements involved a change to the device’s design. Among 180-day supplements approved from 2010-2012, 23% (15/64) included new clinical data to support safety and effectiveness.

Conclusions and Relevance  Many CIED models currently used by clinicians were approved via the PMA supplement process, not as original PMAs. Most new device models are deemed safe and effective without requiring new clinical data, reinforcing the importance of rigorous postapproval surveillance of these devices.

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Figure 1.
Trends in Premarket Approval Supplements for Cardiac Implantable Electronic Devices, 1980-2012

Mean number of premarket approval (PMA) supplements, by type, approved per active PMA each year from 1980-2012. The first supplement for a cardiac implantable electronic device was approved in 1981. The right-side axis (black line) displays the number of active PMAs, which increased steadily to 61 in 2012.

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Figure 2.
Life Span of 77 Premarket Approvals for Cardiac Implantable Electronic Devices

Each black diamond represents 1 of the 77 original premarket approvals (PMAs) for a cardiac implantable electronic device, organized by date of approval from oldest (bottom) to newest (top). The first original PMA was approved in 1979. Each colored mark depicts the approval of one of the types of supplements for each PMA. Three original PMAs underwent 0 supplements.

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