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Implantable Cardioverter Defibrillators CME Cardiology Implantable an MI and heart failure with significant left ventricular systolic dysfunction con- tinue to have a high rate of SCD. cardioverter The first implantable cardioverter defibrillator (ICD) to manage SCD was defibrillators implanted in a human by Michel Mirowski in 1980 (Fig 1). Since then there has been an explosion in technology and Stuart Harris BSc(Hons) MBBS MRCP(UK), randomised control trial data to support Consultant Cardiologist, Essex Cardiothoracic their use. Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust Mehul Dhinoja BSc(Hons) MBBS MRCP(UK), What are the components of an Specialist Registrar in Cardiology, The Heart implantable cardioverter Hospital, University College London Hospitals defibrillator? NHS Foundation Trust An ICD comprises: Clin Med 2007;7:397–400 • a lithium silver vanadium oxide Fig 1. Michel Mirowski MD (1924–90). battery, which provides low voltage energy patients with symptomatic heart failure Who needs an implantable a transformer which multiplies this • and dyssynchrony of ventricular contrac- cardioverter defibrillator? voltage tion a further lead can be placed in the In the UK, sudden cardiac death (SCD) • an aluminium electrolytic capacitor lateral tributaries of the coronary sinus occurs in 70,000–100,000 patients annu- which can store the high energy for cardiac resynchronisation (Fig 2). ally, mainly caused by ventricular voltage for use, and The basic detection of ventricular arrhythmias. Most of these patients have • sensing circuitry which can sense arrhythmias involves measuring heart recognised heart disease with either a local electrograms and filter out rate above which therapy will be deliv- previous myocardial infarction (MI) or noise like skeletal myopotentials. ered. Rate detection is very reliable, but left ventricular dysfunction, but SCD is ICDs have at least one lead in the right unfortunately susceptible to delivering the first presentation of heart disease in ventricle for pacing, sensing and defibril- inappropriate therapy for sinus tachy- 20% of patients. lation. There may also be a second lead cardia or poorly controlled atrial fibrilla- The mainstay of treatment is neurohor- or coil in the superior vena cava to tion. Modern devices can be monal modulation with beta-blockers and improve the defibrillation threshold. programmed to have multiple detection angiotensin-converting enzyme inhibi- Additional leads can be placed in the zones with detection enhancements to tion. While this reduces morbidity and right atrium for dual chamber pace- help prevent inappropriate shocks. mortality across the spectrum of cardio- maker indications or to help in the detec- When ventricular arrhythmias are vascular disease, patients who have had tion or discrimination of arrhythmias. In detected the device will try to terminate them by either antitachycardia pacing or delivering a shock. Most ICDs can deliver Key Points a maximum energy of 30–41 J via their capacitors as a biphasic waveform from Sudden cardiac death occurs in 70,000–100,000 people annually in the UK, the tip of the right ventricular lead to the mostly in people with pre-existing heart disease but in 20% it is the first generator or ‘active can’. The shocking presentation vector travels superiorly from the right Previous myocardial infarction (MI) and significant left ventricular dysfunction are ventricle to include most of the interven- associated with a high rate of sudden cardiac death tricular septum and left ventricle (Fig 3). Implantable defibrillators are recommended in the absence of a reversible cause for survivors of a cardiac arrest or in sustained ventricular arrhythmias if associated What are the indications for an with syncope, haemodynamic instability or a left ventricular ejection fraction implantable cardioverter (LVEF) below 35% defibrillator? Implantable defibrillators are recommended as primary prophylaxis in patients who Randomised trials comparing ICDs and have had an MI and have an LVEF below 30% based on trial evidence (MADIT II) and the National Institute for Health and Clinical Excellence guidelines medical therapy have been conducted largely in patients with underlying KEY WORDS: ischaemic heart disease, left ventricular dysfunction, sudden cardiac ischaemic heart disease (IHD) who make death, ventricular arrhythmias up the majority of recipients. Other Clinical Medicine Vol 7 No 4 August 2007 397 CME Cardiology CABG Patch,9 SCDHeFT10 and DEFINITE11 trials. The first four included only patients with IHD, but SCDHeFT and DEFINITE included non-ischaemic patients. MADIT I and II, MUSTT, DINAMIT, CABG Patch. The MADIT II trial showed a 31% reduction in all-cause mortality in patients with a previous (more than 30 days) MI and LVEF less than 30%, given conventional drug therapy and an ICD. Unlike MADIT I and MUSTT, no docu- mented ventricular arrhythmias or elec- trophysiology studies were required. Conversely, the DINAMIT and CABG Patch10 trials both failed to demonstrate any benefit of ICDs. DINAMIT enrolled patients 6–40 days post-MI who also had indicators of autonomic dysfunction suggesting progressive heart failure. Consequently, this study either selected out a higher risk population or the bene- Fig 2. Dual chamber implantable cardioverter defibrillator. fits of ICD implantation may have been attenuated by conventional drug therapy. The lack of benefit from early ICD important patient groups include those sustained VT and syncope, haemo- implantation has also been confirmed by with cardiomyopathies and ion channel dynamic instability or LVEF below 35%.1 retrospective analysis of the MADIT II disorders. The National Institute for population. Clinical Excellence issued a revised tech- CABG Patch implanted ICDs prophy- nology appraisal for ICDs in January What is the trial evidence for lactically in patients with left ventricular 2006.1 These guidelines do not however these guidelines? dysfunction at the time of coronary apply to patients with non-ischaemic Secondary prevention trials artery bypass surgery (CABG). The lack dilated cardiomyopathy. of survival benefit from ICDs in this Primary prevention is prophylaxis The first trials to investigate the benefits study probably highlights the benefits of against a first life-threatening event. It is of ICDs versus antiarrhythmic drugs revascularisation in preventing SCD and recommended for patients at least four were conducted in survivors of SCD. the increased risks of device implanta- weeks after an MI who either have a left Important studies included the AVID,2 tion during cardiac surgery. ventricular ejection fraction (LVEF) of CIDS3 and CASH4 trials (the full names less than 35%, non-sustained ventricular of trials are given at the end of the text). SCDHeFT. SCDHeFT was the first study tachycardia (VT) on Holter monitoring These studies enrolled patients with and in heart failure patients with both and inducible VT during electrophysio- without IHD with LVEF below 40%, ran- ischaemic and non-ischaemic aetiology. logical testing, or LVEF of less than 30% domising them to ICD implantation or It found a 23% reduction in all-cause and QRS duration of at least 120 ms. drug therapy with either amiodarone or mortality in patients with New York Primary prevention is also recom- beta-blockers. The results showed a sig- Heart Association (NYHA) class 2 or 3 mended in familial cardiac diseases with nificant mortality reduction with ICD heart failure and LVEF below 35% given a high risk of SCD such as hypertrophic treatment. conventional drug therapy and an ICD. (HCM) and arrhythmogenic right DEFINITE. The DEFINITE trial11 ran- ventricular cardiomyopathies (ARVC), Primary prevention trials long QT and Brugada syndromes, and in domised patients with non-ischaemic surgically corrected congenital heart Several trials investigated the benefits of dilated cardiomyopathy with LVEF less disease. ICDs for prevention of SCD in patients than 36% and NYHA class 1–3 to best In the absence of a reversible cause, with no previous history of haemo- medical therapy with or without an secondary prevention is advised for dynamically significant ventricular ICD. All-cause mortality was not signifi- survivors of a cardiac arrest due to arrhythmias. Important studies included cantly reduced by ICDs but there was a ventricular arrhythmia, patients with the MADIT,5,6 MUSTT,7 DINAMIT,8 significant reduction in arrhythmic 398 Clinical Medicine Vol 7 No 4 August 2007 CME Cardiology Fig 3. Detection and successful cardioversion for ventricular fibrillation. deaths with the greatest benefit seen in include syncope, family history of SCD, by coved ST elevation in leads V1 and V2 NYHA class 3 patients. Risk stratification non-sustained VT on Holter monitoring, (type 1) that may occur spontaneously or of these patients is difficult since electro- interventricular septal thickness greater be unmasked by sodium channel blockers physiology studies are not helpful at than 30 mm and an abnormal blood such as flecainide and ajmaline. Patients predicting SCD. However, patients pressure response during exercise testing. presenting with aborted SCD, syncope, presenting with syncope who had ICDs seizures or nocturnal agonal respiration implanted go on to have appropriate ICD should undergo ICD implantation,15 12 Arrhythmogenic right ventricular therapies for ventricular arrhythmias. cardiomyopathy although no prospective, randomised Consequently, patients with dilated trials have evaluated ICD therapy in these cardiomyopathy who have a syncopal
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