NYHA Class II or III Heart Failure: Who Will Need an Implantable Cardioverter Defibrillator (ICD)?

Sudden cardiac death (SCD) is one of the most debilitating and life-threatening complications of heart failure (HF) which has challenged medical care for long. Current guidelines suggest the use of Implantable Cardioverter Defibrillator (ICD) in primary prevention of SCD in both New York Heart Association (NYHA) class II and class III heart failure. This paper critically evaluated the evidence underlying the guideline recommendation. In contrast to recent guidelines, the majority of the intervention trials conducted on the topic till date found a promising role of ICD only in the prevention of SCD in NYHA class II HF. One of the trials which found a significant role of ICD in type III heart failure was underpowered. Thus, further trials are needed to validate the use of ICD in the prevention of SCD in type III HF.

Small bowel capsule endoscopy in patients with cardiac pacemakers and implantable cardioverter defibrillators:Outcome analysis using telemetry review

AIM:To determine if there were any interactions between cardiac devices and small bowel capsules secondary to electromagnetic interference (EMI) in patients who have undergone small bowel capsule endoscopy (SBCE).METHODS:Authors conducted a chart review of 20 patients with a cardiac pacemaker (CP) or implantable cardioverter defibrillator (ICD) who underwent continuous electrocardiographic monitoring during their SBCE from 2003-2008.authors searched for unexplained electrocardiogram (ECG) findings,changes in CP andICD set parameters,any abnormality in transmitted capsule data,and adverse clinical events.RESULTS:There were no adverse events or hemodynamically significant arrhythmias reported.CP and ICD set parameters were preserved.The majority of ECG abnormalities were also found in pre-or post-SBCE ECG tracings and the CP behavior during arrhythmias appeared appropriate.Two patients seemed to have episodes of undersensing by the CP.However,similar findings were documented in ECGs taken outside the time frame of the SBCE.One patient was observed to have a low signal encountered from the capsule resulting in lack of localization,but no images were lost.CONCLUSION:Capsule-induced EMI remains a possibility but is unlikely to be clinically important.CPinduced interference of SBCE is also possible,but is infrequent and does not result in loss of images transmitted by the capsule.

Single lead catheter of implantable cardioverterdefibrillator with floating atrial sensing dipole implanted via persistent left superior vena cava

Persistent left superior vena cava(LSVC) is a congenital anomaly with 0.3%-1% prevalence in the general population. It is usually asymptomatic but in case of transvenous lead positioning, i.e., for pacemaker or implantable cardioverter defibrillator(ICD), may be a cause for significant complications or unsuccessful implantation. Single lead ICD with atrial sensing dipole(ICD DX) is a safe and functional technology in patients without congenital abnormalities. We provide a review of the literature and a case report of successful implantation of an ICD DX in a patient with LSVC and its efficacy in treating ventricular arrhythmias.

Interference between pacemakers/implantable cardioverter defibrillators and video capsule endoscopy

Our Letter to the Editor, related to the article "Small bowel capsule endoscopy in patients with cardiac pacemakers and implantable cardioverter defibrillators: Outcome analysis using telemetry" by Cuschieri et al , comments on some small errors, that slipped into the authors discussions. The given informations concerning the pacemakerand implantable cardioverter defibrillators modes were inaccurate and differ between the text and the table. Moreover, as 8 of 20 patient's pacemakers were programmed to VOO or DOO ("interference mode") and one patient was not monitored by telemetry during capsule endoscopy, 9 of 20 patients (45%) lack the informations of possible interference between capsule endoscopy their implanted device. Another objection refers to the interpretation of an electrocardiogram (figure 1, trace B) presented: in contrast to the author's opinion the marked spike should be interpreted as an artefact and not as "undersensing of a fibrillatory wave". Finally, three comments to cited reviews were not complete respectively not quoted correctly.

Implantable cardioverter defibrillator lead-related methicillin resistant Staphylococcus aureus endocarditis:Importance of heightened awareness

Methicillin resistant Staphylococcus aureus(MRSA) septicemia is associated with high morbidity and mortality especially in patients with immunosuppression,diabetes,renal disease and endocarditis.There has been an increase in implantation of cardiac implantable electronic devices(CIED) with more cases of devicelead associated endocarditis been seen.A high index of suspicion is required to ensure patient outcomes are optimized.The excimer laser has been very efficient in helping to ensure successful lead extractions in patients with CIED infections.We present an unusual case report and literature review of MRSA septicemia from device-lead endocarditis and the importance of early recognition and prompt treatment.

Antitachycardia pacing programming in implantable cardioverter defibrillator:A systematic review

Implantable cardioverter defibrillator(ICD) programminginvolves several parameters. In recent years antitachycardia pacing(ATP) has gained an increasing importance in the treatment of ventricular arrhythmias, whether slow or fast. It reduces the number of unnecessary and inappropriate shocks and improves both patient's quality of life and device longevity. There is no clear indication regarding the type of ATP to be used, except for the treatment of fast ventricular tachycardias(188 bpm-250 bpm) where it has been shown a greater efficacy and safety of burst compared to ramp; 8 impulses in each sequence of ATP appears to be the best programming option in this setting. Beyond ATP use, excellent clinical results were obtained with programming standardization following these principles: extended detection time in ventricular fibrillation(VF) zone; supraventricular discrimination criteria up to 200 bpm; first shock in VF zone at the maximum energy in order to reduce the risk of multiple shocks. The MADIT-RIT trial and some observational registries have also recently demonstrated that programming with a widespread use of ATP, higher cut-off rates or delayed intervention reduces the number of inappropriate and unnecessary therapies and improves the survival of patients during mid-term follow-up.

Critical analysis of ineffective post implantation implantable cardioverter-defibrillator-testing

AIM To test of the implantable-cardioverter-defibrillator is done at the time of implantation. We investigate if any testing should be performed.METHODS All consecutive patients between January 2006 and December 2008 undergoing implantable cardioverterdefibrillator(ICD) implantation/replacement(a total of 634 patients) were included in the retrospective study.RESULTS Sixteen patients(2.5%) were not tested(9 with LA/LVthrombus, 7 due to operator's decision). Analyzed were 618 patients [76% men, 66.4 + 11 years, 24% secondary prevention(SP), 46% with left ventricular ejection fraction(LVEF) < 20%, 56% had coronary artery disease(CAD)] undergoing defibrillation safety testing(SMT) with an energy of 21 + 2.3 J. In 22/618 patients(3.6%) induced ventricular fibrillation(VF) could not be terminated with maximum energy of the ICD. Six of those(27%) had successful SMT after system modification or shock lead repositioning, 14 patients(64%) received a subcutaneous electrode array. Younger age(P = 0.0003), non-CAD(P = 0.007) and VF as index event for SP(P = 0.05) were associated with a higher incidence of ineffective SMT. LVEF < 20% and incomplete revascularisation in patients with CAD had no impact on SMT.CONCLUSION Defibrillation testing is well-tolerated. An ineffective SMT occurred in 4% and two third of those needed implantation of a subcutaneous electrode array to passa SMT > 10 J.

Induced atrial fibrillation during defibrillation test on implantation of subcutaneous implantable cardioverter defibrillator

The subcutaneous implantable cardioverter defibrillator(S-ICD)has become an alternative to the transvenous ICD in indicated patients.However,inappropriate shock or failed ventricular tachycardia/fibrillation conversion is the most alarming complication of S-ICD.Therefore,defibrillation test(DFT)is recommended for the S-ICD implantation.

Anesthetic management of patient with hypertrophic cardiomyopathy and automatic implantable cardioverter defibrillator with a hand fracture

A 26-year-old male with a history of hypertrophic cardiomyopathy(HCM) and ventricular arrhythmias s/p automatic implantable cardioverter defibrillator(AICD) placement presented for open reduction and internal fixation of an open third metacarpal fracture and extensor tendon repair. He underwent successful surgery after placement of an ultrasound-guided infraclavicular brachial plexus block with ropivacaine 0.5% as the main anesthetic. This case report discusses the anesthetic management of patients with HCM and AICD, different approaches available for brachial plexus blockade, and potential complications of anesthesia and surgery in this group of patients.

Electrochemotherapy and heart function:Treatment in a patient with implantable cardioverter defibrillator/pacemaker

Electrochemotherapy(ECT) is a recently described therapy that relies on the permeation of cancer cell membranes by electrical pulses to enhance cytotoxic drug penetration. It has been successfully used in the treatment of primary and metastatic skin cancer. Systemic chemotherapy is the most commonly used therapeutic strategy, and the prevailing orientation calls for the administration of the maximum tolerated dose; however, considerable limitations exist including toxicities to healthy tissues and low achievable drug concentrations at tumor sites. We reported a case of an 83-years-old patient with a laterocervical metastasis of a squamous epidermoidal lip cancer. The patient had a complex medical history and an implantable cardioverter defibrillator(ICD)/pace-maker. The lesion was localized in the supraclavicular right side with a distance from the pace-maker/ICD about 5 cm, but the nodule was not deeply located. The ECT was performed un-der general anesthesia and particular attention we put on the interference with the functioning of the heart. The synchronization algorithm currently implemented in Clinoporator Vitae device coupled with the external triggering device Accu Sync proved to be effective in preventing external stimulation of the heart during the so-called vulnerable period of the ventricles. As a result all electroporation pulses in our study were delivered outside the vulnerable period and no heart arrhythmias or any other pathological morphological changes were observed. The safety of treatment was demonstrated also by absence of side effects during and after ECT.

A MEDIAN FOLLOW-UP OF TWENTY-TWO MONTHS FOR CARDIOVERTER DEFIBRILLATOR IMPLANTATION IN SYMPTOMATIC OR ASYMPTOMATIC PATIENTS WITH BRUGADA SYNDROME

Objective To explore the outcome of patients with Brugada syndrome by remedial or prophylactic implantable cardioverter defibrillator （ ICD ） for ventricular tachyarrhythmia. Methods Sixteen single chamber ICDs and 5 double chamber ICDs in 21 consecutive patients [ 17 males, 4 females; mean age, （ 36 ± 11） years ] with Brugada syndrome were involved. Fifteen patients with spontaneous or induced ventricular tachycardia/ventricular fibrillation （VT/VF） received the remedial and prophylactic ICD implantation. Six patients only with positive family history or syncope accepted the ICD implantation for prophylaxis. Results After a median follow-up of （22.3 ± 13. 4） months, all patients were alive. One patient was suspected with febrile syndrome due to endocarditis on the auricular face of the lead of defibrillator 18 months after 1CD implantation and disappearance of vegetation was found after receiving one-month antibiotic treatment. Nine appropriate ICD interventions took place in 3 individuals with documented spontaneous ventricular arrhythmias. Multivariable analysis suggested that occurrence of appropriate interventions was related to the spontaneous ventricular arrhythmias （ P 〈 0. 0001 ）. Eleven inappropriate ICD interventions occurred in 3 patients for atrial fibrillation or atrial flutter with rapid ventricular rate. Multivariable analysis suggested that occurrence of inappropriate interventions was related to documented spontaneous supraventricular arrhythmias （P 〈 O. 0062 ）. All appropriate interventions and inappropriate interventions occurred within six months after ICD implantation. Conclusion Appropriate interventions may associate to spontaneous ventricular arrhythmias before 1CD implantation in patients with Brugada syndrome. Patients may suffer from inappropriate ICD intervention for supraventricular arrhythmias with rapid ventricular rate when they had a history of supraventricular arrhythmias.

Remote monitoring of implantable defibrillators is associated with fewer inappropriate shocks and reduced time to medical assessment in a remote and rural area

BACKGROUND Implantable cardioverter defibrillators(ICDs)and cardiac resynchronisation therapy with defibrillators(CRT-D)reduce mortality in certain cardiac patient populations.However,inappropriate shocks pose a problem,having both adverse physical and psychological effects on the patient.The advances in device technology now allow remote monitoring(RM)of devices to replace clinic follow up appointments.This allows real time data to be analysed and actioned and this may improve patient care.AIM To determine if RM in patients with an ICD is associated with fewer inappropriate shocks and reduced time to medical assessment.METHODS This was a single centre,retrospective observational study,involving 156 patients implanted with an ICD or CRT-D,followed up for 2 years post implant.Both appropriate and inappropriate shocks were recorded along with cause for inappropriate shocks and time to medical assessment.RESULTS RM was associated with fewer inappropriate shocks(13.6%clinic vs 3.9%RM;P=0.030)and a reduced time to medical assessment(15.1±6.8 vs 1.0±0.0 d;P<0.001).CONCLUSION RM in patients with an ICD is associated with improved patient outcomes.

Subcutaneous implantable defibrillator: State-of-the art 2013

The subcutaneous implantable cardioverter-defibrillator(S-ICD)has recently been approved for commercial use in Europe,New Zealand and the United States.It is comprised of a pulse generator,placed subcutaneously in a left lateral position,and a parasternal subcutaneous lead-electrode with two sensing electrodes separated by a shocking coil.Being an entirely subcutaneous system it avoids important periprocedural and long-term complications associated with transvenous implantable cardioverter-defibrillator(TV-ICD)systems as well as the need for fluoroscopy during implant surgery.Suitable candidates include pediatric patients with congenital heart disease that limits intracavitary lead placements,those with obstructed venous access,chronic indwelling catheters or high infection risk,as well as young patients with electrical heart disease(e.g.,Brugada Syndrome,long QT syndrome,and hypertrophic cardiomyopathy).Nevertheless,given the absence of intracavitary leads,the S-ICD is unable to offer pacing(apart from shortterm post-shock pacing).It is therefore not suitable in patients with an indication for antibradycardia pacing or cardiac resynchronization therapy,or with a history of repetitive monomorphic ventricular tachycardia that would benefit from antitachycardia pacing.Current data from initial clinical studies and post-commercialization"real-life"case series,including over 700 patients,have so far been promising and shown that the S-ICD successfully converts induced and spontaneous ventricular tachycardia/ventricular fibrillation episodes with associated complication and inappropriate shock rates similar to that of TV-ICDs.Furthermore,by using far-field electrograms better tachyarrhythmia discrimination when compared to TV-ICDs has been reported.Future results from ongoing clinical studies will determine the S-ICD system’s long-term performance,and better define suitable patient profiles.

Prospective evaluation of health status, quality of life and clinical outcomes following implantable defibrillator generator exchange

BACKGROUND Little is known about health status and quality of life(QoL)after implantable cardioverter-defibrillator(ICD)generator exchange(GE).METHODS We prospectively followed patients undergoing first-time ICD GE.Serial assessments of health status were performed by administering the 36-Item Short Form Survey(SF-36).RESULTS Mean age was 67.5±14.3 years,left ventricle ejection fraction(LVEF)was 36.5%±15.0%and over 40%of the cohort had improved LVEF to>35%at the time of GE.SF-36 scores were significantly worse in physical/general health domains compared to domains of emotional/social well-being(P<0.001 for each comparison).Physical health scores were significantly worse among those with medical comorbidities including diabetes,chronic obstructive pulmonary disease and atrial fibrillation.Mean follow-up was 1.6±0.5 years after GE.Overall SF-36 scores remained stable across all domains during follow-up.Survival at 3 years post-GE was estimated at 80%.Five patients died during follow-up and most deaths were adjudicated as non-arrhythmic in origin.Four patients experienced appropriate ICD shocks after GE,three of whom had LVEF which remains impaired LVEF(i.e.,<35%)at the time of GE.CONCLUSION Patients undergoing ICD GE have significantly worse physical health compared to emotional/social well-being,which is associated with the presence of medical comorbidities.In terms of clinical outcomes,the incidence of appropriate shocks after GE among those with improvement in LVEF is very low,and most deaths post-procedure appear to be non-arrhythmic in origin.These data represent an attempt to more fully characterize the spectrum of QoL and clinical outcomes after GE.

心力衰竭患者ICD植入治疗替代决策者决策困境现状及影响因素

目的调查心力衰竭患者植入型心律转复除颤器(ICD)植入治疗替代决策者的决策困境现状及影响因素。方法选取2020年4月至2023年3月在郑州大学第一附属医院心力衰竭中心就诊的ICD植入治疗患者及其替代决策者为调查对象,收集患者及代理决策者的社会人口学资料及患者疾病相关资料,由研究者代理患者填写中文简化版堪萨斯城心肌病问卷(KCCQ),由替代决策者填写决策困境量表、决策参与期待量表、维克森林医师信任量表、领悟社会支持量表和状态焦虑问卷,分析状态焦虑得分、维克森林医师信任得分、领悟社会支持得分、心力衰竭患者健康状况与决策困境的相关性,分析人口学特征与疾病特征与决策困境的关系,通过多重线性回归分析决策困境的影响因素。结果共纳入148例心力衰竭ICD植入治疗患者的替代决策者,决策者决策困境得分为(36.03±8.79)分,70.95%的替代决策者得分≥25分,存在决策困境;单因素分析结果显示决策困境的影响因素包括替代决策者年龄、受教育程度、婚姻、月收入、替代决策者角色、与患者关系、疾病了解程度、患者医疗保险类型、是否参与决策、病程等(P<0.05)。相关性分析结果显示:患者健康水平(KCCQ得分)、替代决策者焦虑水平、对医生的信任水平、社会支持水平与决策困境相关(P<0.05)。多重线性回归结果显示决策困境的影响因素包括替代决策者焦虑水平、对医生的信任水平、社会支持水平、月收入及患者病程。结论大多数心力衰竭患者ICD植入治疗替代决策者存在决策困境,医护人员在进行ICD植入手术知情同意沟通时应关注替代决策者的心理特征、调动决策者的社会支持力量,采用适当的沟通技巧,必要时采取决策辅助工具进行决策辅助。

Impact of LDB3 gene polymorphisms on clinical presentation and implantable cardioverter defibrillator(ICD) implantation in Chinese patients with idiopathic dilated cardiomyopathy

Objective:Mutations in LIM domain binding 3(LDB3)gene cause idiopathic dilated cardiomyopathy(IDCM),a structural heart disease with a complicated genetic background.However,the association of polymorphisms in the LDB3 gene with susceptibility to IDCM in Chinese populations remains unexplored as dose the impact on clinical presentation.Methods:We sequenced all exons and the adjacent part of introns of the LDB3 gene in 159 Chinese Han IDCM patients and 247 healthy controls.Then we detected the distribution of polymorphisms in the LDB3 gene in all participants and assessed their associations with risk of IDCM.Additionally,we conducted a stratified genotype–phenotype correlation analysis.Results:The A allele of rs4468255 was significantly associated with IDCM(P<0.01).The rs4468255,rs11812601,rs56165849,and rs3740346 were also associated with diastolic blood pressure(DBP)and left ventricular ejection fraction(LVEF)(P<0.05).Notably,a higher frequency of rs4468255 polymorphism was observed in implantable cardioverter defibrillator(ICD)recipients under a recessive model(P<0.01),whereas the significant association disappeared after adjusting for potential confounders.However,in the dominant model,notable correlations could only be observed after adjusting for multi parameters.Conclusions:The rs4468255 was significantly correlated with IDCM of Chinese Han population.A allele of rs4468255 is higher in IDCM patients with ICD implantation,suggesting the influence of genetic background in the generation of this response.In addition,rs11812601,rs56165849,and rs3740346 in LDB3 show association with brain natriuretic peptide,DBP,and LVEF levels in patients with IDCM but did not show any association with IDCM susceptibility.

Primary prevention of sudden cardiac death by implantable cardioverter-defibrillator therapy in Chinese patients with heart failure： a single-center experience

Background An implantable cardioverter-defibrillator （ICD） has been suggested for heart failure patients for primary prevention of sudden cardiac death. However, few data have been reported on the application of ICD as primary prevention of sudden cardiac death in China. We evaluated the value of primary prevention ICD therapy in Chinese patients with heart failure.Methods Thirty-four patients at an average age of （60.2±13.7） years seen in Peking Union Medical College Hospital were treated with ICD implantation for primary prevention of sudden cardiac death from November 2005 to July 2009. Single-chamber ICDs were implanted in 16 （47.0%） cases, and dual-chamber or cardiac resynchronization therapy defibrillators in 18 （53.0%） cases. The patients had an average left ventricular ejection fraction of （26.9±5.5）% （11% to 35%）, of which 18 （53.0%） patients had ischemic cardiomyopathy and 16 （47.0%） patients had non-ischemic cardiomyopathy. All patients were followed up at three months after the implantation and every six months thereafter or when prompted by an ICD event.Results There were five （14.7%） deaths, including two of heart failure and three with a non-cardiac course, during an average follow-up of （15.0±11.9） months. Forty-one ICD therapy events were recorded, including 19 （46.3%） appropriate ICD therapies in six patients and 22 （53.7%） inappropriate ICD therapies in four patients with single chamber leads. Inappropriate ICD therapies were mainly due to supraventricular tachyarrhythmias, especially atrial fibrillation. Patients with ischemic cardiomyopathy and non-ischemic cardiomyopathy did not differ in the incidence of either appropriate or inappropriate therapy.Conclusions ICD for primary prevention of sudden cardiac death in China prevents patients from arrhythmia death. Relatively high incidence of inappropriate therapies highlights the importance of an atrial lead.

Externalized conductors and insulation failure in Biotronik defibrillator leads: History repeating or a false alarm?

Conductor externalization and insulation failure are frequent complications with the recalled St. Jude Medical Riata implantable cardioverter-defibrillator(ICD) leads. Conductor externalization is a "unique" failure mechanism: Cables externalize through the insulation("inside-out" abrasion) and appear outside the lead body. Recently, single reports described a similar failure also for Biotronik leads. Moreover, some studies reported a high rate of electrical dysfunction(not only insulation failure) with Biotronik Linox leads and a reduced survival rate in comparison with the competitors. In this paper we describe the case of a patient with a Biotronik Kentrox ICD lead presenting with signs of insulation failure and conductor externalization at fluoroscopy. Due to the high risk of extraction we decided to implant a new lead, abandoning the damaged one; lead reimplant was uneventful. Subsequently, we review currently available literature about Biotronik Kentrox and Linox ICD lead failure and in particular externalized conductors. Some single-center studies and a nonprospective registry reported a survival rate between 88% and 91% at 5 years for Linox leads, significantly worse than that of other manufacturers. However, the preliminary results of two ongoing multicenter, prospective registries(GALAXY and CELESTIAL) showed 96% survival rate at 5 years after implant, well within industry standards. Ongoing data collection is needed to confirm longer-term performance of this family of ICD leads.

Effects of medically generated electromagnetic interference from medical devices on cardiac implantable electronic devices: A review

As cardiac implantable electronic devices(CIED)become more prevalent,it is important to acknowledge potential electromagnetic interference(EMI)from other sources,such as internal and external electronic devices and procedures and its effect on these devices.EMI from other sources can potentially inhibit pacing and trigger shocks in permanent pacemakers(PPM)and implantable cardioverter defibrillators(ICD),respectively.This review analyzes potential EMI amongst CIED and left ventricular assist device,deep brain stimulators,spinal cord stimulators,transcutaneous electrical nerve stimulators,and throughout an array of procedures,such as endoscopy,bronchoscopy,and procedures involving electrocautery.Although there is evidence to support EMI from internal and external devices and during procedures,there is a lack of large multicenter studies,and,as a result,current management guidelines are based primarily on expert opinion and anecdotal experience.We aim to provide a general overview of PPM/ICD function,review documented EMI effect on these devices,and acknowledge current management of CIED interference.

Transvenous pectoral implantation of single lead implantable cardioverter defibrillator

Objective To report our initial experience of transveneous pectoral implantation of single lead implantable cardioverter defibrillator (ICD) in fifteen patients. Methods Fifteen patients (male 13, female 2, mean age of 51.7 years), including dilated cardiomyopathy in 4, hypertrophic cardiomyopathy in 2, coronary artery disease in 5 and syncope of unknown etiology in 2, underwent ICD implantation. Indications for ICD implantation were ventricular fibrillation (8 patients) and refractory ventricular tachycardia (7 patients). All patients had syncope out of hospital. The ICD system were Medtronic Jewel active can in 5 patients (Model 7219C in 2, 7220C in 3) and CPI Ventak PRxⅢ in 9 patients. For active can, shocks were delivered through distal coil to ICD shell and for PRxⅢ through the endotak lead of proximal to distal coil. Successful implantation criteria was 2 consecutive defibrillation at less than 24 J. Results All 15 patients had successful implantation using single lead ICD system in catheter laboratory. The mean defibrillation threshold was 12.8 J (5-15 J) and R wave was 9.9 mV (3.7-14.6 mV). All devices were of pectoral implantation. No operative and perioperative complications occurred. In 7.6 months (1-18 months) of follow up, 3 patients had VT terminated by antitachycardia pacing (ATP) and 1 patient VF terminated by shock. Conclusion Transveneous pectoral implantation of single lead ICD is easy to perform and has high defibrillation efficacy and should be a preferred approach.