Despite the absence of data to support benefit for patients receiving a dual-chamber implantable cardioverter-defibrillator (ICD) compared with a single-chamber ICD for a nonpacing indication, most implants are of dual-chamber ICDs. In contrast to the lack of data for benefit, there are data from multiple randomized and observational trials suggesting increased harm. A recent National Cardiovascular Data Registry (NCDR) analysis found that procedural complications, including in-hospital mortality, were at least 40% greater for dual-chamber compared with single-chamber devices. In this issue, in an analysis of NCDR data from 2006 to 2009, Matlock et al found wide geographic variation with a 4-fold difference in the chance of receiving dual-chamber ICDs. This varied and widespread use of dual-chamber devices for nonpacing indications has no known benefit and definite harms, and is designated as Less Is More.
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