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An improved method of thoracoscopic implantable cardioverter defibrillators implantation is described. "Mailslot" thoracotomy is more expeditious than thoracoscopic implantation via multiple ports. If required for adequate defibrillation thresholds, subxiphoid, subdiaphragmatic implantation of a defibrillator patch may be performed.
BACKGROUND: Indications for implantable cardioverter defibrillator (ICD) implantation have expanded considerably in recent years, resulting in steadily growing numbers of ICD recipients worldwide. The aim of this study was to review the overall experience with ICDs in Iceland. METHODS: This was a retrospective single centre study set at the University Hospital in Iceland. Data on all ICD implantations in Iceland from the first implantation in 1992 till the end of 2002 was reviewed. RESULTS: Sixty-two patients (71% male) received an ICD during this period. There was an increase in the number of implants by year and the number of new implants in 2001 and 2002 amounted to 56 and 38 per million, respectively. The mean age at implantation was 58 (+/-14) years. Forty patients (65%) had coronary artery disease. The most common indications for ICD implantation were cardiac arrest, 32 (52%) and another 26 (42%) had experienced ventricular tachycardia without cardiac arrest. The most common adverse event was inappropriate shocks. Twenty-eight patients (45%) received therapy from their ICDs, with the majority receiving appropriate therapy. Of the thirteen patients deceased before or during the study period, no case of sudden arrhythmic death was observed. CONCLUSION: This study shows that the experience with ICDs in Iceland is in most respects similar to other Western countries.
The product recall of an implantable cardioverter defibrillator (ICD) creates a potentially stressful event for patients. This study briefly describes the psychological adjustment of patients with implantable devices and makes recommendations for the management of device recalls and adverse outcomes to minimize psychological distress. Because the occurrence of ICD-specific fears and symptoms of anxiety are the most common psychological symptoms experienced by ICD recipients, a comprehensive care plan to attend to recall procedures and patient distress is needed. It is suggested that recalls do not affect all ICD patients equally, with risk factors for poor psychological adjustment to ICDs including younger age (< 50 years), shock experience, and female gender that may be associated with increased recall anxiety. Specific recommendations for device recall management include formalizing clinic responses to recall before and after implantation and innovative uses of patient support systems to communicate recall responses.
The efficacy of implantable cardioverter defibrillator (ICD) therapy and medical therapy in the treatment of patients with ventricular fibrillation and sustained ventricular tachycardia had been compared in large randomized studies. In this section, we aimed to summarize what we have learned from large studies on the effects of amiodarone and ICD therapy in prevention of cardiac arrest in patients with malignant ventricular arrhythmias. The analyzed studies are; The multicenter unsustained Tachycardia Trial (MUSTT), Antiarrhythmics vs. implantable defibrillator (AVID), Cardiac Arrest Study Hamburg (CASH) and the Canadian Implantable Defibrillator Study (CIDS).
Clinical ventricular tachycardia and ventricular fibrillation are associated with a high recurrence rate, and through the 1980s and the early 1990s a variety of therapies have been proposed including the implantable cardioverter defibrillator (ICD). Over the past decade it has been recognized that prospective randomized trials are imperative if the proper role for any therapy is to be defined. The Antiarrhythmic Versus Implantable Defibrillator (AVID) trial recently was concluded and helped define the role of the ICD in high-risk patients. Other trials are studying patients at high risk for sudden death who have not yet had a clinical event. The recently concluded Multicenter Automatic Defibrillator Implantation Trial and CABG Patch Trial helped determine the proper role of the ICD in various pre-event high-risk subsets. These trials are summarized in detail.
Ventricular arrhythmias are the primary cause of sudden death from heart disease in the United States. In the past decade, management of these arrhythmias has been revolutionized by the development of implantable cardioverter-defibrillators (ICDs). Earlier devices required thoracotomy for implantation (Fig. 1). Complications associated with the earlier devices include pneumothorax, pleural effusion, mediastinal infection, and, notably, crinkling of the patch and migration. The morbidity of median sternotomy has led to the development of ICDs that can be implanted without thoracotomy. We illustrate the normal radiographic appearance and complications of two recently developed ICD lead systems.
The implantable atrial defibrillator is a new potential nonpharmacologic treatment for recurrent atrial fibrillation. The results of this study suggest that a simplified lead configuration, with a single-pass, dual-electrode atrial defibrillation lead can be used for both atrial fibrillation detection and defibrillation with an implantable atrial defibrillator.
Appropriate and inappropriate therapies of implantable cardioverter defibrillators have a major impact on morbidity and quality of life in ICD recipients. Intracardiac electrograms (IEGMs) stored in the ICD have been shown to be essential for differentiating appropriate and inappropriate ICD therapies. The recently introduced third generation of ICD Home Monitoring offers remotely transmitted IEGMs (IEGM-online). Hence, the appropriateness of ICD therapies might be remotely assessed. Validation of these electrograms is currently being performed in the RIONI study. A total of 210 episodes will be collected by about 40 European clinical centers. The study primarily investigates whether the IEGM-online based evaluation of the appropriateness of the ICD's therapeutic decision following a tachyarrhythmia episode detection is equivalent to the evaluation based on the complete ICD episode holter. The evaluation is independently performed by an expert board of three experienced ICD investigators. The equivalence of the two methods is accepted if the conclusions deviate for less than 10% of all evaluated IEGMs. Secondary endpoints investigate the IEGM-online usefulness in more detail. The conclusion of the study is expected by mid of 2007. RIONI has successfully been started for proving the reliability of IEGM-online. The expected results will significantly influence the efficacy of Home Monitoring based patient management.
The incorporation of antitachycardia pacing (ATP) into implantable cardioverter defibrillators (ICDs) has provided a better tolerated alternative to shocks. ATP has been shown to be effective in terminating approximately 80% to 90% of spontaneous ventricular tachycardia (VT) episodes. Although ATP is routinely used, little is known about predictors of ATP failure. Based on the evaluation of stored electrograms, we aimed to prospectively follow patients with ICDs, and to analyze parameters affecting ATP effectiveness. One hundred eighteen consecutive patients received ICDs for standard indications. Before discharge, empirical, standardized ATP therapy was programmed in all patients within VT zones. A total of 1,218 spontaneous tachycardia episodes occurred in 51 patients during a mean follow-up of 24.5 +/- 12 months. Among these, 888 VTs were diagnosed. One hundred four fast VTs were detected in the ventricular fibrillation zone and treated with primary shock delivery. ATP was attempted 881 times in the remaining 784 VT episodes. ATP terminated 640 VTs successfully, ATP failed in 55 VTs finally reverted by shocks, and 89 VTs converted to a slower VT outside the VT zone. Fifty-one of these slower VTs reverted spontaneously, and 38 were redetected and treated. Finally, in primary intention-to-treat basis, ATP was successful in 691 VTs (88%) and unsuccessful in 93 VTs (12%). There was no influence of VT cycle length on ATP success rate. Furthermore, ATP efficacy was similar between patients with left ventricular ejection fraction < or =35% or >35%, between daytime and nighttime, as well as between patients with ischemic or nonischemic cardiomyopathy. A faster heart rate immediately preceding the onset of VT (103 +/- 19 vs 78 +/- 14 beats/min, respectively, hazard ratio 4.08, 95% confidence interval 2.11 to 7.89, p <0.001), and absence of beta-blocker therapy (82% vs 93%, respectively, hazard ratio 2.71, 95% confidence interval 1.72 to 4.29, p = 0.02) were found, by Cox proportional-hazard analysis, to be the sole independent predictors of ATP ineffectiveness in ICD recipients. Thus, the present study identified both preceding sinus tachycardia (reflecting an increased sympathetic tone) and lack of beta-blocker use as independent risk factors for reduced success of ATP therapy in terminating VT. Therefore, modification of sympathetic tone may be beneficial for patients with ICDs.
BACKGROUND: Adjustment to living with an implantable cardioverter defibrillator (ICD) is a dynamic process that varies among individuals. The purpose of this study was to describe patterns of recovery and to examine the relationships among demographic and clinical factors, illness appraisal and coping behaviors, and outcomes of physical and emotional function in the early recovery period of the first 3 months after initial ICD insertion. METHODS: Data were collected in the acute care setting and again at 1 and 3 months after ICD insertion. Subjects were 213 patients (83% men), ages 24-85 (mean 59.6) years. Demographic and clinical variables representing personal and situational factors, illness appraisal, and coping variables were examined using hierarchical multiple-regression analyses to predict outcomes of mood disturbance and functional status. RESULTS: The data revealed that symptoms, illness appraisal, and coping behaviors significantly explained additional variance in both functional status and mood disturbance above that accounted for by the less modifiable demographic and clinical variables. CONCLUSIONS: Symptoms, illness appraisal, and coping behaviors were predictors of outcomes in ICD patients. These factors are modifiable aspects of the recovery process, and interventions aimed at symptom management, appraisal reframing, and coping training should be tested to improve mood and functional outcomes for ICD patients.
The implantable cardioverter defibrillator (ICD) may be associated with some degree of psychological maladjustment, especially in patients experiencing high rates of discharge. This article reviews the psychological literature related to ICDs and presents two case examples illustrating common psychological complications related to multiple discharges. A brief, psychological intervention can be implemented to improve patient adjustment. To explain possible processes by which psychological complications may develop in ICD patients, two well-established psychological theories of learning and behavior, classical conditioning and learned helplessness, are reviewed. Multidisciplinary teams that include consultation with clinical psychologists are suggested for the routine care of ICD patients.
Few studies have prospectively examined characteristics of implantable cardioverter defibrillator (ICD) patients as predictors of postimplant outcome. In this study the authors considered the association between preimplant psychological characteristics, ICD shocks, and postimplant quality of life at short- and long-term follow-ups, controlling for age and ejection fraction (N=88). Hierarchical regression analyses revealed that history of depression, trait anxiety, optimism, social support, and ICD shocks accounted for 41.8% to 64.5% of the variance in quality of life indices at 8- and 14-month follow-ups, depending on the outcome assessed. Further, psychological variables were as strong as, or stronger than, age, ejection fraction, and ICD shocks in predicting quality of life outcomes.
BACKGROUND: Implantable cardioverter defibrillators (ICDs) can prevent premature death from an arrhythmia but may also prolong the dying process and make it more distressing. OBJECTIVE: To describe the frequency, timing, and correlates of discussions about deactivating ICDs. DESIGN: Retrospective cohort study. SETTING: Telephone survey. PARTICIPANTS: Next of kin of patients with ICDs who died of any cause. Of 136 next of kin contacted, 100 (74%) participated. MEASUREMENTS: Incidence of discussions about deactivating ICDs and timing of last shock from ICD. RESULTS: Next of kin reported that clinicians discussed deactivating the ICD in only 27 of the 100 cases. Most discussions occurred in the last few days of life. Family members reported that 8 patients received a shock from their ICD in the minutes before death. LIMITATIONS: This retrospective survey relied on the reports of next of kin. CONCLUSIONS: Next of kin reported that clinicians discussed deactivating ICDs with few patients. Individuals who choose to receive this device should have the opportunity to choose to discontinue it as death approaches.
Since 1980, the automatic implantable cardioverter defibrillator (ICD) has evolved as effective therapy for prevention of sudden cardiac death following documented sustained ventricular tachycardia or fibrillation. During a 5-year period, 412 ICD devices were implanted at the University of Michigan Hospitals with a wound complication rate of 4.1%. In this group, there were 13 infections, 3 erosions of the generator pocket, and 1 wound hematoma. Of the 16 patients with infection or erosion, 12 patients were treated with a rectus abdominis muscle flap closure and 4 with ICD generator removal. In 83% (n = 12) of the muscle flap patients, the wound healed uneventfully. Preoperative chest CT scanning was found to be helpful in identifying probable infection of the epicardial leads. In these cases, all hardware had to be removed to achieve resolution of the infection. We concluded that rectus abdominis muscle flaps were helpful in salvaging infected or exposed ICD generators in the absence of infected epicardial leads.
The implantable cardioverter defibrillator (ICD) has been in clinical use for 20 years and its clinical role is becoming increasingly clear. A number of well-designed trials demonstrated its effectiveness in high-risk patients who have already experienced a malignant arrhythmia. A more controversial role for the ICD is in patients who are at high risk but have not yet had an arrhythmic event. Randomized clinical trials published in the late 1990s demonstrated survival benefit with the ICD in narrowly defined high-risk populations. These populations are presently defined by a low ejection fraction and inducible ventricular tachyarrhythmia. Clinical trials still in progress will determine whether broader populations will benefit from prophylactic ICD implantation. These trials will have broad clinical importance.
Implantable cardioverter defibrillator (ICD) therapy has become the mainstay of therapy for patients with a history of sudden cardiac death or life-threatening ventricular arrhythmias. The current generation of ICDs used for secondary prevention combines features for tachycardia reversion with demand ventricular pacing, antitachycardia pacing, programmable shock therapy, and tachycardia events memory. Although demand pacing and defibrillation is indicated for primary prevention usage of ICDs, the application of antitachycardia pacing modes is more controversial. High energy cardioversion and defibrillation shocks remaining the mainstay of sudden death prevention will be redefined as more effective defibrillation shock modes and lead systems are developed. Fourth-generation ICD systems accomplished a significant reduction of device size and almost universal success using an endocardial lead configuration and pectoral implant. A variety of new directions of ICD therapy in clinical practice such as primary prevention applications and the adjunctive role of antiarrhythmic drug therapy are currently being examined in clinical trials. The concepts underlying initiation of tachyarrhythmias are being studied to develop new approaches to tachycardia prevention. These include rate support, subthreshold stimulation, and multiple site pacing. The current developments of ICD therapy promise continued growth of this technology.
Appropriate and inappropriate therapies of implantable cardioverter defibrillators have a major impact on morbidity and quality of life in ICD recipients, but have not been systematically studied in children and young adults during long-term follow-up. ICD implantation was performed in 20 patients at the mean age of 16 +/- 6 years, 11 of which had prior surgical repair of a congenital heart defect, 9 patients had other cardiac diseases. Implant indications were aborted sudden cardiac death in six patients, recurrent ventricular tachycardia in 9 patient, and syncope in 5 patients. Epicardial implantation was performed in 6 and transvenous implantation in 14 patients. Incidence, reasons and predictors (age, gender, repaired congenital heart disease, history of supraventricular tachycardia, and epicardial electrode system) of appropriate and inappropriate ICD therapies were analyzed during a mean follow-up period of 51 +/- 31 months range 18-132 months. There were a total 239 ICD therapies in 17 patients (85%) with a therapy rate of 2.8 per patient-years of follow-up. 127 (53%) ICD therapies in 15 (75%) patients were catagorized as appropriate and 112 (47%) therapies in 10 (50%) patients as inappropriate, with a rate of 1.5 appropriate and 1.3 inappropriate ICD therapies per patient-years of follow-up. Time to first appropriate therapy was 16 +/- 18 months. Appropriate therapies were caused by ventricular fibrillation in 29 and ventricular tachycardia in 98 episodes. Termination was successful by antitachycardia pacing in 4 (3%) and by shock therapy in 123 episodes (97%). Time to first inappropriate therapy was 16 +/- 17 months. Inappropriate therapies were caused by supraventricular tachycardia in 77 (69%), T wave oversensing in 19 (17%), and electrode defect in 16 episodes (14%). It caused shocks in 87 (78%) and only antitachycardia pacing in 25 episodes (22%). No clinical variable could be identified as predictor of either appropriate or inappropriate ICD therapies. There is a high rate of ICD therapies in young ICD recipients, the majority of which occur during early follow-up. The rate of inappropriate therapies is as high as 47% and is caused by supraventricular tachycardia and electrode complications in the majority of cases. Prospective trials are required to establish preventative strategies of ICD therapies in this young patient population.
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