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PubMed2006

Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part II: ventricular arrhythmias, channelopathies and implantable defibrillators.

This consensus paper on behalf of the Study Group on Sports Cardiology of the European Society of Cardiology follows a previous one on guidelines for sports participation in competitive and recreational athletes with supraventricular arrhythmias and pacemakers. The question of imminent life-threatening arrhythmias is especially relevant when some form of ventricular rhythm disorder is documented, or when the patient is diagnosed to have inherited a pro-arrhythmogenic disorder. Frequent ventricular premature beats or nonsustained ventricular tachycardia may be a hallmark of underlying pathology and increased risk. Their finding should prompt a thorough cardiac evaluation, including both imaging modalities and electrophysiological techniques. This should allow distinguishing idiopathic rhythm disorders from underlying disease that carries a more ominous prognosis. Recommendations on sports participation in inherited arrhythmogenic conditions and asymptomatic gene carriers are also discussed: congenital and acquired long QT syndrome, short QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, arrhythmogenic right ventricular cardiomyopathy and other familial electrical disease of unknown origin. If an implantable cardioverter defibrillator is indicated, it is no substitute for the guidelines relating to the underlying pathology. Moreover, some particular recommendations for patients/athletes with an implantable cardioverter defibrillator are to be observed.

Arrhythmias, Cardiac↗
PubMed1998

Implantation of active can implantable defibrillators in the right pectoral region.

Routinely the active can ICD is placed in the left side pectoral position, which theoretically gives optimal conditions for a low defibrillation threshold. Some patients, however, demand a right pectoral position, which possibly could result in a higher defibrillation threshold. A right pectoral position was used in 3 of 85 active can ICDs implanted in our institution from 1994. The DFT was 12 J in two and 18 J in one patient. Thus, right pectoral implantation is feasible and offers an alternative approach in selected patients.

Adult↗
PubMed2005

[Massive myocardial hypertrophy in hypertrophic cardiomyopathy: a risk factor for sudden death and high defibrillation threshold during cardioverter-defibrillator implantation].

Two cases of hypertrophic cardiomyopathy with massive hypertrophy and high defibrillation threshold (DFT) are described. A 14-year-old boy, whose single risk factor for sudden death was extreme hypertrophy with maximum interventricular septum (IVS) thickness of 43 mm, survived an episode of ventricular fibrillation. During ICD implantation DFT testing showed energy requirements >30 J and the procedure was aborted. Amiodarone and verapamil treatment was discontinued and treatment with oral sotalol was instituted. After a period of amiodarone washout the procedure was repeated and DFT of 24 J was encountered. An 18-year-old female with massive hypertrophy (IVS thickness=35 mm) and other risk factors for sudden death underwent ICD implantation for primary prevention. During the procedure DFT=20 J and ICD with 30 J maximal output was implanted. An increase in DFT to more than 20 J was encountered during pre-discharge test. Lack of 10 J safety margin warranted ICD system revision and upgrade; during the second procedure DFT was 24 J and ICD with 35 J maximal output was implanted. In summary, in both cases ICDs with 35 J maximal output were successfully implanted.

Adolescent↗
PubMedDate not supplied

Securing life through technology acceptance: the first six months after transvenous internal cardioverter defibrillator implantation.

PURPOSE: To understand the experience of living with a transvenous internal cardioverter defibrillator (ICD) during the first 6 months after implantation. DESIGN: A grounded theory approach was used to gain an understanding of the antecedents, conditions, and consequences of the core process. SETTING: Two midwestern community medical centers and patients' homes within a 250-mile radius from the medical centers. SAMPLE: Ten women and 14 men between 22 and 78 years of age, who had undergone a new transvenous ICD implantation within the last week. RESULTS: The core process that described the experience of living with a transvenous ICD during the first 6 months after implantation was the process of "securing life through technology acceptance." This core process was characterized by three major categories: choosing life with technology, integrating technology into life, and living life through technology. IMPLICATIONS: Nursing interventions related to individualized assessment, education, and counseling are warranted to facilitate patient and family understanding and to plan for the cyclic process involved in integrating a transvenous ICD into their lives. Directions for further research are provided.

Adaptation, Psychological↗
PubMed1990

A technique for intraoperative arrhythmia induction during automatic implantable defibrillator placement.

In 14 patients (12 men, 2 women, mean age 51 +/- 4 years) we evaluated a new technique for intraoperative arrhythmia induction during Ventak 1550 automatic implantable cardioverter defibrillator (AICD), pulse generator placement. At the time of surgery (nine new implants, five pulse generator replacements), when the AICD pulse generator is in its final configuration with the rate sensing and patch electrodes leads inserted into the header, a #2 hex wrench was inserted into each of the rate sensing lead set screw sites. The alligator clips of a temporary pacing cable were placed on each of the hex wrenches and the remainder of the cable passed off field for attachment to a programmed stimulator or AC fibrillator. In all 14 patients, the clinical arrhythmia was induced at least twice (ventricular tachycardia in eight patients, ventricular fibrillation in six patients). No difficulties with arrhythmia induction or AICD sensing as discharge were encountered. We conclude that this technique is both a safe and effective means of intraoperative arrhythmia induction during placement or replacement in the Ventak AICD 1550 and 1600 series pulse generators.

Cardiac Pacing, Artificial↗
PubMed2006

Neuronal injury after repeated brief cardiac arrests during internal cardioverter defibrillator implantation is associated with deterioration of cognitive function.

To determine the degree of neurocognitive dysfunction after placement of internal cardioverter defibrillators (ICD) and its relationship to the extent of neuronal injury, we studied 42 patients undergoing ICD (n = 21) or pacemaker (PM) insertion (control patients, n = 21). The Mini Mental State Examination, the Trailmaking A test and the forward and backward Digit Span tests were used and P300 latencies were determined preoperatively and postoperatively. Serum neuron-specific enolase (NSE) was determined before and at the end of, as well as 2, 6, and 24 h after surgery. Preoperatively, PM patients scored worse in the Digit Span backward and the Trailmaking tests and showed prolonged P300 latencies. Postoperatively, the Digit Span backward scores declined and NSE levels increased only in the ICD group (P < or = 0.05). The difference between preoperative and postoperative Digit Span backward scores correlated with the increase in serum NSE levels (r2 = 0.3, P < or = 0.05). Moreover, P300 latencies increased in 13 of 17 ICD patients, but decreased in 7 of 10 PM patients (P < or = 0.05). PM patients even improved in the Trailmaking test (P < or = 0.05). Neuronal injury from even brief periods of global brain ischemia seems to be associated with deteriorating neurocognitive function.

Aged↗
PubMed1992

Implantable defibrillators for prevention of sudden death. Technology at a medical and economic crossroad.

Implantable cardioverter-defibrillator therapy is now widely used for the treatment of symptomatic patients with documented or suspected life-threatening VTs. Although sudden death recurrence in ICD recipients is virtually eliminated, the extent of benefit both with respect to cardiac mortality and total survival in this patient population remains to be accurately quantitated, particularly vis-à-vis alternative antiarrhythmic therapies. Advanced device and lead systems can be expected to further improve both patient survival and quality of life after implant. The economic impact of unrestrained proliferation in ICD therapy can be enormous; however, available cost-benefit analyses support judicious use of this therapy with comparable economic impact to other accepted cardiovascular therapies. Such prospective risk stratification becomes economically essential when considering expanding its application to asymptomatic or minimally symptomatic populations at potential risk for future cardiac arrest.

Clinical Trials as Topic↗
PubMed1999

Frozen shoulder syndrome associated with subpectoral defibrillator implantation.

Pectoral implantation of transvenous non-thoracotomy internal cardioverter defibrillators (ICD) has resulted in very few complications whether placed subpectorally or subcutaneously. We report the case of a 68 year old man with a subpectorally implanted MINI-plus (Cardiac Pacemakers, Incorporated, St. Paul, Mn.) transvenous ICD who developed nearly instantaneous severe ipsilateral shoulder pain and immobilization. The symptoms progressed despite aggressive physical therapy. We elected to remove the device from the pectoral site and place it in a traditional abdominal position due to the severity, duration and refractoriness of his symptoms. This procedure utilized the chronic Endotak DSP (Model 0125, Cardiac Pacemakers, Incorporated) transvenous lead, a compatible Endotak DSP lead extender (Model 6952, Cardiac Pacemakers, Incorporated) and the above described ICD. Immediate relief of symptoms was accomplished by relocation of the device to an abdominal site. This intervention should be reserved for patients with severely debilitating symptoms. Prospective comparison of subpectoral and subcutaneous surgical approaches with respect to patient comfort and acceptance and complications may be warranted.

Aged↗
PubMed1992

The implantable defibrillator: an electronic bridge to cardiac transplantation.

BACKGROUND: Sudden cardiac death (SCD) is common among patients awaiting heart transplantation. Medical management of SCD may fail due to lack of efficacy or adverse side effects. The implantable cardioverter-defibrillator (ICD) may extend patient survival until a donor heart is available. METHODS AND RESULTS: We reviewed 16 patients listed for transplantation between November 1988 and October 1991 who underwent ICD implantation for ventricular arrhythmias refractory to medical management. Mean age was 51.4 +/- 11.4 years (range, 19-66 years), mean ejection fraction was 15.4 +/- 3.0% (range, 10-21%), and underlying cardiomyopathy was ischemic (12 patients), valvular (one patient), or dilated (three patients). There was no mortality from ICD insertion. Fourteen patients were discharged before transplantation, and two patients remained in the hospital until transplantation. Twelve patients underwent transplantation after a mean of 155.7 +/- 113.7 days (range, 3-319) on the transplant list. The ICD delivered shocks for tachyarrhythmia associated with near syncope in 15 of 16 patients. ICD shocks numbered > 10 in five patients, 5-9 in three patients, and 1-4 in seven patients. There was no morbidity or mortality attributed to patch electrode removal. CONCLUSIONS: We conclude that the ICD can be implanted with minimal morbidity in transplant candidates, allowing the patients to be ambulatory and to leave the hospital while awaiting heart transplantation. In patients at risk of SCD, the ICD is an effective electronic bridge to transplantation.

Anti-Arrhythmia Agents↗
PubMed2005

Predictors of appropriate implantable defibrillator therapies in patients with arrhythmogenic right ventricular dysplasia.

BACKGROUND: Arrhythmogenic right ventricular dysplasia (ARVD) is an inherited cardiomyopathy characterized by ventricular arrhythmias and sudden cardiac death. The risk factors for sudden death and indications for implantable cardioverter-defibrillator (ICD) placement in patients with ARVD are not well defined. OBJECTIVES: The purpose of this study was to determine which clinical and electrophysiologic variables best predict appropriate ICD therapies in patients with ARVD. Particular attention focused on whether the ICD was implanted for primary or second prevention. METHODS: We enrolled 67 patients (mean age 36 +/- 14 years) with definite or probable ARVD who had undergone ICD placement. Appropriate ICD therapies were recorded, and Kaplan-Meier analysis was used to compare the event-free survival time between patients based upon the indication for ICD placement (primary vs secondary prevention), results of electrophysiologic testing, and whether the patient had probable or definite ARVD. RESULTS: Over a mean follow-up of 4.4 +/- 2.9 years, 40 (73%) of 55 patients who met task force criteria for ARVD and 4 (33%) of 12 patients with probable ARVD had appropriate ICD therapies for ventricular tachycardia/ventricular fibrillation (VT/VF; P = .027). Mean time to ICD therapy was 1.1 +/- 1.4 years. Eleven of 28 patients who received an ICD for primary prevention (39%) and 33 of 35 patients who received an ICD for secondary prevention (85%) experienced appropriate ICD therapies (P = .001). Electrophysiologic testing did not predict appropriate ICD interventions in patients who received an ICD for primary prevention. Fourteen patients (21%) received ICD therapy for life-threatening (VT/VF >240 bpm) arrhythmias. There was no difference in the incidence of life-threatening arrhythmias in the primary and secondary prevention groups (P = .29). CONCLUSION: Patients who meet task force criteria for ARVD are at high risk for sudden cardiac death and should undergo ICD placement for primary and secondary prevention, regardless of electrophysiologic testing results. Further research is needed to confirm that a low-risk subset of patients who may not require ICD placement can be identified.

Adolescent↗