Implantation Of A Cardioverter Defibrillator Implantation Research Articles

The IC-D score for predicting prophylactic cardioverter-defibrillator implantation following acute myocardial infarction.

A reduced left ventricular ejection fraction (LVEF) ≤35% ≥6weeks following an acute myocardial infarction (MI) may indicate prophylactic implantation of a cardioverter-defibrillator (ICD). We sought to find predictors of absence of significant left ventricular (LV) remodeling post-MI. All consecutive patients hospitalized for acute MI with an LVEF ≤35% at discharge in our institution from 2010 were retrospectively included. Patients were assigned to two groups according to the persistence of an LVEF ≤35% (ICD+) or a recovery>35% (ICD-). Logistic regression was performed to build a predictive score, which was then externally validated. Among a total of 1533 consecutive MI patients, 150 met inclusion criteria, 53 (35%) in the ICD+ group and 97 in the ICD group. After multivariable analyses, an LVEF ≤25% at discharge (adjusted OR 6.23 [2.47 to 17.0], p<.0001) and a CPK peak at the MI acute phase>4600 UI/L (adjusted OR 9.99 [4.27 to 25.3], p<.0001) both independently predicted non-recovery at 6weeks. The IC-D (Increased Cpk-LV Dysfunction) score predicted persistent LVEF ≤35% with areas under curve of 0.83 and 0.73, in the study population and in a multicenter validation cohort of 150 patients, respectively (p<.0001). The association of a severely reduced LVEF and a major release of myocardial necrosis biomarkers at the acute phase of MI predict unfavorable remodeling, and prophylactic ICD implantation.

Association Between Industry Payments to Physicians and Device Selection in ICD Implantation

Little is known about the association between industry payments and medical device selection. To examine the association between payments from device manufacturers to physicians and device selection for patients undergoing first-time implantation of a cardioverter-defibrillator (ICD) or cardiac resynchronization therapy-defibrillator (CRT-D). In this cross-sectional study, patients who received a first-time ICD or CRT-D device from any of the 4 major manufacturers (January 1, 2016-December 31, 2018) were identified. The data from the National Cardiovascular Data Registry ICD Registry was linked with the Open Payments Program's payment data. Patients were categorized into 4 groups (A, B, C, and D) corresponding to the manufacturer from which the physician who performed the implantation received the largest payment. For each patient group, the proportion of patients who received a device from the manufacturer that provided the largest payment to the physician who performed implantation was determined. Within each group, the absolute difference in proportional use of devices between the manufacturer that made the highest payment and the proportion of devices from the same manufacturer in the entire study cohort (expected prevalence) was calculated. Manufacturers' payments to physicians who performed an ICD or CRT-D implantation. The primary outcome of the study was the manufacturer of the device used for the implantation. Over a 3-year period, 145 900 patients (median age, 65 years; 29.6% women) received ICD or CRT-D devices from the 4 manufacturers implanted by 4435 physicians at 1763 facilities. Among these physicians, 4152 (94%) received payments from device manufacturers ranging from $2 to $323 559 with a median payment of $1211 (interquartile range, $390-$3702). Between 38.5% and 54.7% of patients received devices from the manufacturers that had provided physicians with the largest payments. Patients were substantially more likely to receive devices made by the manufacturer that provided the largest payment to the physician who performed implantation than they were from each other individual manufacturer. The absolute differences in proportional use from the expected prevalence were 22.4% (95% CI, 21.9%-22.9%) for manufacturer A; 14.5% (95% CI, 14.0%-15.0%) for manufacturer B; 18.8% (95% CI, 18.2%-19.4%) for manufacturer C; and 30.6% (95% CI, 30.0%-31.2%) for manufacturer D. In this cross-sectional study, a large proportion of ICD or CRT-D implantations were performed by physicians who received payments from device manufacturers. Patients were more likely to receive ICD or CRT-D devices from the manufacturer that provided the highest total payment to the physician who performed an ICD or CRT-D implantation than each other manufacturer individually.

The effect of revascularization on mortality and risk of ventricular arrhythmia in patients with ischemic cardiomyopathy

BackgroundThere is clear evidence that patients with prior myocardial infarction and a reduced ejection fraction benefit from implantation of a cardioverter-defibrillator (ICD). It is unclear whether this benefit is altered by whether or not revascularization is performed prior to ICD implantation.MethodsThis was a retrospective cohort study following patients who underwent ICD implantation from 2002 to 2014. Patients with ischemic cardiomyopathy and either primary or secondary prevention ICDs were selected for inclusion. Using the electronic medical record, cardiac catheterization data, revascularization status (percutaneous coronary intervention or coronary bypass surgery) were recorded. The outcomes were mortality and ventricular arrhythmia.ResultsThere were 606 patients included in the analysis. The mean age was 66.3 ± 10.1 years, 11.9% were women, and the mean LVEF was 30.5 ± 12.0, 58.9% had a primary indication for ICD, 82.0% of the cohort had undergone coronary catheterization prior to ICD implantation. In the overall cohort, there were fewer mortality and ventricular arrhythmia events in patients who had undergone prior revascularization. In patients who had an ICD for secondary prevention, revascularization was associated with a decrease in mortality (HR 0.46, 95% CI (0.24, 0.85) p = 0.015), and a trend towards fewer ventricular arrhythmia (HR 0.62, 95% CI (0.38, 1.00) p = 0.051). There was no association between death or ventricular arrhythmia with revascularization in patients with primary prevention ICDs.ConclusionRevascularization may be beneficial in preventing recurrent ventricular arrhythmia, and should be considered as adjunctive therapy to ICD implantation to improve cardiovascular outcomes.

917Appropriate shocks in WCD patients - Results from the Austrian WCD registry

Abstract Background The wearable cardioverter-defibrillator (WCD) is a temporary treatment option for patients at high risk for sudden cardiac death (SCD) and/or for patients in whom implantation of a cardioverter defibrillator (ICD) is temporarily not possible. Purpose To investigate incidence and predictors of appropriate WCD shocks. Methods We performed a retrospective analysis of all patients with appropriate shocks delivered by a WCD in the cohort of the Austrian WCD registry between 2010 and 2018. Within this dataset, we identified predictors within the baseline characteristics, the indication for the WCD and preceding alarms automatically recorded by the WCD. Results: Baseline Within 879 registered in the Austrian WCD registry, 31 patients (3,5%) received appropriate WCD shocks due to ventricular tachycardia (VT) or ventricular fibrillation (VF). Compared to the total cohort, shocked patients were elder (mean age 67 ± 14 vs. 60 ± 14 years, p = 0,001) and the percentage of female patients was lower (11% vs. 21%, p = 0,262). The mean baseline LVEF at prescription was 33 ± 15% in the population with appropriate shocks compared to 32 ± 14% in the all-over cohort (p = ns). In the Austrian WCD population, 378/879 patients had a WCD due to secondary prevention. Within this cohort 5,6% (21/378) had shocks for VT/VF again, compared to 10/501 (2%) shocked patients in the primary prevention cohort. 31/879 (3.5%) patients received 57 appropriate shocks, the per patient shock rate was 2 [1;5]. These shocks were induced by 25 ventricular tachycardia and 26 times ventricular fibrillation. The octagenarians with 11% (7/34) shocked patients, showed a significant higher likelihood to receive shocks (p = 0,008) as well as the cohort of secondary preventive prescribed WCD-patients (p = 0,007). There were more shocks in patients, when prescribed with a WCD due to ICD associated infections (p = 0,001), when used as a bridge to ICD (p = 0,042) and in patients with ongoing risk stratification (p = 0,009). Looking through the automatically recorded alarms preceding a WCD shock, shocked patients experienced significantly more often non sustained VTs (p &amp;lt; 0,0005) and sustained VTs that were haemodynamically tolerated and did not require a treatment (p &amp;lt; 0,0005). Conclusion The WCD is effective in preventing SCD and an important risk stratification tool. We identified advanced age, patients with either already confirmed indication for ICD implantation (either temporary contraindication for implantation or temporary explantation) or risk stratification of an unclear cardiomyopathy, the cohort of secondary prevention and preceding nsVTs and stable VTs as predictors for appropriate WCD therapies.

176: Long-term follow-up after implantable cardioverter defibrillator in patients with Brugada syndrome: a multicenter French experience

Implantation of a cardioverter defibrillator (ICD) is a frequently recommended treatment for symptomatic Brugada syndrome (BrS). However, complications related to the device have been reported. We assessed the benefit / morbidity ratio of this mode of therapy in a cohort of 34 patients implanted in 3 French experienced centers between January 1, 2002 and November 30, 2010. The mean age was 48±14 years, 4 (12%) female. Twenty nine (85%) patients had spontaneous typical coved Type I ECG pattern, 15 (44%) had family history of sudden cardiac death (SCD) and 24 (88%) had positive EP study. ICD implantation was based on aborted sudden cardiac arrest (SCA) in 3 (9%), syncope in 19 (56%) or high risk status (spontaneous type 1 ECG in conjunction with a family history of SCD and/or a positive EP study) in 12 (35%). The median follow-up period was 74±23 (9-127) months. One patient with prior cardiac arrest died of a non-cardiac cause, 5 (15%) patients had appropriate device therapy; all with spontaneous type I ECG and previous syncope but none with prior cardiac arrest. Overall complication rate was 26%. Six (27%) symptomatic and 3 (25%) asymptomatic patients experienced complications. Five (14%) patients (4 with previous syncope and 1 asymptomatic) experienced inappropriate shocks and 4 (12%) had other complications: 2 patients had lead rupture, 1 lead displacement, and 1 pneumothorax during device replacement. These complications occurred in 2 asymptomatic and 2 symptomatic (1 syncope and 1 prior aborted SCA) patients. No case of SCD was observed in ICD carriers. Appropriate device therapy after a median follow-up period of 6 years was observed in patients with prior syncope and none in asymptomatic patients. Complication rate was leading not to recommend ICD implantation in asymptomatic Brugada patients and to carefully evaluate the risk /morbidity ratio in subject with non spontaneous coved type ECG pattern.

Implante de eletrodo em veia ázigos: uma opção terapêutica para limiar de desfibrilação elevado

The evaluation of the defibrillation threshold (DFT) during the implantation of a cardioverter-defibrillator (ICD) is an important stage of the procedure, as a high DFT can be found in up to 16% of patients. We report a patient with idiopathic dilated cardiomyopathy (DCM) submitted to a biventricular ICD implantation. During the procedure, the patient showed a high DFT and showed to be resistant to usual therapeutic modalities. We opted for the azygos vein defibrillation lead implantation, with good resolution.

Implante de cardio-desfibrilador em gestantes com cardiomiopatia hipertrófica

We describe the successful implantation of a cardioverter-defibrillator (ICD) in two pregnant women with hypertrophic cardiomyopathy at high risk. The indication of ICD and the necessary care for ICD implantation during pregnancy are discussed and were the main objectives of this case report.

Attenuation of Diastolic Heart Failure and Life-Threatening Ventricular Tachyarrhythmia After Peripheral Blood Stem Cell Transplantation Combined With Cardioverter-Defibrillator Implantation in Myeloma-Associated Cardiac Amyloidosis

A patient had multiple myeloma and associated cardiac amyloidosis, which caused diastolic dysfunction and recurrent ventricular fibrillation. After implantation of a cardioverter-defibrillator (ICD), the patient underwent autologous peripheral blood stem cell transplantation (PBSCT). The life-threatening arrhythmias, such as ventricular fibrillation, disappeared, and diastolic dysfunction assessed by quantitative gated single photon emission computed tomography and Doppler echocardiography improved 7 months later. This may be the first report to document improvement of both a lethal rhythm disorder and diastolic dysfunction by PBSCT following ICD implantation in a case of cardiac amyloidosis associated with multiple myeloma.

Abstract 1657: Prophylactic Implantation Of Cardioverter Defibrillators In Patients With Severe Cardiac Amyloidosis

Objectives: Benefit of prophylactic implantation of a cardioverter defibrillator (ICD) in patients with cardiac light-chain amyloidosis (CA) was assessed. Background: CA carries a high risk for sudden cardiac death (SCD). Methods: Implantation of ICD was performed in 19 patients with histologically proven CA because of a high risk for SCD. These 19 patients were compared to historical controls of CA without ICD. Survival was defined as absence of death or heart transplantation. Definition of high risk for SCD was based on heart failure (NYHA ≥II), a history of unexplained syncope, interventricular septal thickness ≥15mm (IVS), left ventricular ejection fraction ≤45% (LVEF), ventricular premature contractions Lown ≥IVa, serum level of troponin T ≥0.03 μg/l (TnT) and/or a N-terminal-proBNP level ≥3500 ng/l. Results: Patients had NYHA class ≥II (n=17; 89%), syncopes (n=9; 47%), IVS ≥15mm (n=17; 89%), LVEF ≤45% (n=5; 26%), Lown ≥IVa (n=15; 79%), TnT &gt;0.03 μg/l (n=9; 47%), and NT-proBNP ≥3500 ng/l (n=12; 63%). There were no severe perioperative complications. During a median follow-up of 380 days 2 patients with sustained ventricular tachyarrhythmias were successfully treated by the ICD. There were 9 deaths from electromechanical dissociation (n=5), heart transplantation (n=2) or non-cardiac causes (n=2). Survival of ICD patients did not differ from matched controls. Non-survivors had higher NT-proBNP plasma levels (7576±1571 ng/l) than survivors (4036±737 ng/l, p&lt;0.05). Conclusions: ICD implantation in high-risk patients with CA is feasible, but while selected patients may benefit from an ICD, routine prophylactic implantation is not recommended. More specific predictors of SCD need to be identified.

Transoesophageal echocardiographic evaluation of ventricular function during transvenous defibrillator implantation.

Intraoperative testing and defibrillation threshold determination may jeopardise patients, scheduled for implantation of a cardioverter-defibrillator (ICD). The purpose of this study was the assessment of the influence of consecutive defibrillation attempts on left ventricular systolic and diastolic function by means of transoesophageal echocardiography (TEE). Eighteen patients with malignant ventricular arrhythmias that were resistant to antiarrhythmic drugs were monitored with TEE before, during and after implantation of a cardioverter-defibrillator. Left ventricular fractional area contraction as a measure of ejection fraction was assessed before and after each defibrillation attempt. Transmitral and right upper pulmonary venous flow parameters were evaluated before and after the whole implantation procedure. Adequate data were available in 14 patients during 4 consecutive attempts. No major alterations were observed in heart rate or fractional area contraction, measured at 30 s and 3 min after defibrillation. Overall, the ratio of early-to-late transmitral filling decreased significantly after the implantation procedure (from 0.91 +/- 0.12 to 0.82 +/- 0.14; P < 0.05). Systolic pulmonary venous flow velocity decreased from 0.49 +/- 0.11 to 0.41 +/- 0.10 m/s (P = 0.04); this decrease was observed in both groups. A significant increase of the atrial contraction wave (from 0.25 +/- 0.06 to 0.34 +/- 0.07 m/s; P < 0.03) was seen. Subdividing patients related to their precperative ejection fraction, a significant decrease of the early-to-late transmitral filling of the LV was revealed in patients with ejection fraction less than 35% (group 1). Also, a significantly lower systolic fraction of the pulmonary venous flow after ICD implantation in conjunction with a significantly longer diastolic flow time was shown in this patient group in comparison with patients with a preoperative ejection fraction of more than 35% (group 2). Defibrillation threshold testing of the ICD system changes LV inflow characteristics and impedes diastolic function of the left ventricle and may thus precipitate heart failure by this mechanism. No deleterious effects of threshold testing were observed with respect to fractional area contraction nor any deterioration of LV function was found in a clinically significant amount due to consecutive defibrillation attempts.