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implantable cardioverter defibrillator (ICD)

Implantable device to automatically detect & terminate ventricular tachycardia or ventricular fibrillation by delivering or more shocks to the heart to terminate the arrhythmia. Indications: 1) *serious arrhythmias not controlled by medication* - hemodynamically significant ventricular arrhythmia [2] - ventricular fibrillation, cardiac arrest 2) *risk of arrhythmia due to underlying heart disease# - cardiomyopathy with LVEF <= 35% [25] 3) NYHA class II or III heart failure + - predicted survival > 1 year + - ischemic cardiomyopathy > 40 days post MI or non-ischemic cardiomyopathy with LV ejection fraction <= 35% or - history of hemodynamically significant ventricular arrhythmia or cardiac arrest [2] - candidates for left ventricular assist device or cardiac transplantation (out of hospital) [32] 4) ischemic cardiomyopathy with NYHA class I-III heart failure & LV ejection fraction <= 30% [2] 5) for class III or IV NYHA heart failure & ECG QRS duration > 120 msec, cardiac resynchronization therapy with defibrillator indicated [2] 6) hereditary predisposition to fatal arrhythmias - hypertrophic cardiomyopathy 7) high-risk features for sudden death & LVEF < 45% [42] - pulmonary sarcoidosis insufficienty high risk [2] 8) sustained ventricular arrhythmias (> 30 seconds) [2] 9) cardiac arrest without reversible etiology [2] 10) subcutaneous ICD recommended for patients with inadequate vascular access or high infection risk from an ICD, & for whom pacing is not required [32] 11) > 40 days since myocardial infarction or > 3 months since PCI or CABG [2] (see Procedure: below) * The multicenter automatic defibrillator implantation trial (MADIT) showed better survival in patients with inducible ventricular tachycardia with implanted defibrillators than those treated with anti-arrhythmic agents. # ICD may benefit patients with history of myocardial infarction & low LV ejection fractions (< 30-35%) > 40 days after MI. [3,5] * may benefit younger patients (HR=0.65) but not older patients [11] # Life expectancy should be > 1 year Contraindications: - patients with new onset heart failure* [2] - no survival benefit for patients with severe LV dysfunction [11] - no benefit for renal dialysis patients unless LVEF < 35% [37] * left ventricular function may recover [2] Procedure: - these devices may be installed without thoracotomy - some devices have back-up bradycardia & anti-tachycardia pacing - devices are installed in the cardiac catherization laboratory - after electrode placement & testing, a small generator (circuitry, capacitor, battery) is place under the skin in the chest - subcutaneous ICD (without pacemaker) FDA-approved Sept 2012 [17] - no differences in complications or mortality among patients with subcutaneous vs transvenous ICD [39] - the device records when arrhythmias occur & shocks are delivered - battery life of 3-5 years - shocks may occur during sinus rhythm or atrial fibrillation - overall 1 year survival 90% - dual-chamber ICDs are associated with significantly more implant complications & no improvement in outcomes relative to single-chamber devices [21] - placement should be delayed until 40 days post-MI [2] or 3 months after percutaneous coronary intervention (PCI) - echocardiogram prior to ICD placement [44,45] - ICD placement prior to hospital discharge if post MI ventricular tachycardia > 24 hours post MI - routine defibrillation testing may increase complications without improving outcomes [24] Complications: 1) infection a) originate in subcutaneous pocket created for generator box b) etiologic agents - coagulase-negative Staphylococcus - Staphylococcus aureus c) management: - removal of the generator box - do NOT aspirate device pocket - may damage leads or introduce infection [2] - systemic antibiotics for 2 weeks - epicardial & transvenous wires - should also be removed if possible - if not, 6 weeks of antibiotic therapy 2) device malfunction [6,8] - inappropriate shocks increase mortality [9] - women have fewer appropriate shocks and more lead complications [16] 3) electromagnetic interference a) avoid metal detection devices at airports, courthouses ... b) cell phones may be used, but it is prudent to keep cellphone on opposite side of body from ICD c) avoid magnets or strong magnetic fields, i.e. MRI is contraindicated - MRI-conditional devices are those that that FDA has determined do not pose additional hazards under prespecified conditions - older ICDs (pre-2015) with asynchronous pacing capabilities (although not MRI-conditional devices) also generally safe with MRI [33,43] d) iphone 12 circular array of magnets around a central charging coil may interfere with function of ICD [40] e) common electromagnetic devices may interfere with operation of defibrillators - these include Apple iPhone 12, Apple AirPods Pro & their wireless charging case, Microsoft Surface Pen, & Apple Pencil 2nd generation [41] 4) failure to prevent sudden death - recurrent myocardial infarction & cardiac rupture account for 50% of deaths after myocardial infarction [10] 5) perforation of the ventricular wall by ICD lead causing pericarditis, pericardial effusion, hemopericardium, pleural effusions & hemothorax [27] 6) venous thrombosis, possibly superior vena cava syndrome [35] 7) 6.1 complications/100 patient-years follow-up [30] - 2.6/100 require reoperation (generally device malfunction, infection) - risks higher with cardiac resynchronization therapy- defibrillator (CRT-D) devices vs single-chamber devices [30] 8) brief episodes of atrial tachyarrhythmia are not associated with increased risk for stroke or other cardiovascular events [31] 9) patients with chronic kidney disease & heart failure have greater risk of hospitalization for heart failure with than without ICD (17 vs 11/100 person years) [34] 10) inappropriate shock more likely in elderly with multiple corbidities (RR=2.1) when implanted for primary prevention [38] Management: 1) monitoring needed 2) programming of ICDs to prevent inappropriate therapy for supraventricular tachycardia & nonsustained ventricular tachyarrhythmias: [18] a) reduces unnecessary shocks b) improves survival c) does not increase the frequency of syncope [18] 2) amiodarone effectively blocks many ICD shocks [6] 3) metal detectors (hand-held & gates) used at airports are "probably safe" for patients with cardiac pacemakers or implantable cardioverter-defibrillators (ICDs) [13,15] 4) many patients with ICDs can safely participate in vigorous sports [20] 5) surgery: perioperative management - shock therapy should be turned off - electrocautery during surgery cause the ICD to interpret the electrical activity as ventricular fibrillation & initiate a shock [2] - pacing function should be change to asynchronous mode [2] - the asynchronous mode allows the pacing to continue regardless of cardiac electrical activity or electrocautery [2] 6) end-of-life - do not resuscitate (DNR) order: - discuss with patient reasons for the DNR order [46] 7) see ICD driving guidelines Notes: 1) 20% of implantable cardioverter-defibrillators are placed contrary to evidence-based guidelines [12] - use of carvedilol rather than metoprolol associated with lower rate of inappropriate ICD placement [23] 2) < 10% of eligible older adults receive ICDs within 1 year after myocardial infarction [26] 3) implantable cardioverter-defibrillators (ICDs) & cardiac resynchronization therapy (CRT) devices often include a feature that measures intrathoracic impedance, potentially providing an early warning system for decompensation by detecting pulmonary fluid retention [14] 4) explanted ICDs can be reused safely to help people who otherwise would not be able to afford them [19] 5) may be covered by Medicare [5] 6) potential cybersecurity vulnerabilities with Medtronic's implantable cardioverter defibrillators (ICDs) & cardiac resynchronization therapy defibrillators (CRT-Ds) [36] - wireless telemetry system used for communication does not use encryption, authentication, or authorization [36]

Related

cardiac device infection cardiac pacemaker cardiac resynchronization therapy ICD driving guidelines multicenter automatic defibrillator implantation trial (MADIT)

Specific

automatic implantable cardioverter/defibrillator (AICD)

General

cardiovascular implantable electronic device (CIED) defibrillator

References

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