Implantable cardioverter-defibrillator

Implantable cardioverter-defibrillator
Intervention
A Guidant Corporation ICD device
ICD-9:	37.94-37.97
MeSH	D017147
MedlinePlus	007370
eMedicine	1971119

Illustration of Implantable Cardioverter Defibrillator (ICD)

An implantable cardioverter-defibrillator (ICD) is a small battery-powered electrical impulse generator that is implanted in patients who are at risk of sudden cardiac death due to ventricular fibrillation and ventricular tachycardia. The device is programmed to detect cardiac arrhythmia and correct it by delivering a brief electrical impulse to the heart. In current variants, the ability to revert ventricular fibrillation has been extended to include both atrial and ventricular arrhythmias. There also exists the ability to perform biventricular pacing in patients with congestive heart failure or bradycardia.

The process of implantation of an ICD is similar to implantation of a pacemaker. Similar to pacemakers, these devices typically include electrode wire(s) that pass through a vein to the right chambers of the heart, usually lodging in the apex of the right ventricle. The difference is that pacemakers are more often temporary and are generally designed to correct bradycardia, while ICDs are often permanent safeguards against sudden arrhythmias.

The most recent development is the subcutaneous ICD (S-ICD). Current state-of-the-art electronics and batteries have enabled an implantable device to deliver enough energy to defibrillate the heart without the need for a lead in or on the heart. This prevents lead-related problems and the risk of dangerous infections in or near the heart. This ICD is positioned just under the skin and outside the ribcage. It can be placed during a minor procedure under conscious sedation. The S-ICD was approved by the US Food and Drug Administration (FDA) in September 2012.

Indications

Implantable cardioverter-defibrillators are indicated under various conditions, including pacing for acquired atrioventricular block, bifascicular block, trifascicular block, sick sinus syndrome, and other causes of cardiac dysrhythmia; or when certain other traits are present after myocardial Infarction.^[1][2]

If a patient with an ICD changes their health goals and no longer requires the action of an ICD, then the ICD should be deactivated.^[3] Patients who have an ICD and advanced irreversible diseases may find that the ICD is incompatible with their goals of care and could cause painful shocks to them and distress to their family to witness this.^[3] The patient's advance health care directive should include a plan describing the conditions under which an ICD would be deactivated, such as for example when a patient is in hospice and receiving palliative care.^[3]

Living with an ICD

A normal chest X-ray after placement of an ICD, showing the ICD generator in the upper left chest and the ICD lead in the right ventricle of the heart. Note the 2 opaque coils along the ICD lead.

People who have an implanted cardioverter-defibrillator can live full lives. Usually the ICD improves the living conditions of a patient significantly. As with a pacemaker, however, living with an ICD does impose some restrictions on the person's lifestyle.

Quality of life

Implantable cardioverter defibrillators have demonstrated clear life-saving benefits, but concerns about patient acceptance and psychological adjustment to the ICD have been the focus of much research.^[4] Researchers including those from the field of cardiac psychology have concluded that the quality of life (QoL) of ICD patients is at least equal to, or better than, that of those taking anti-arrhythmic medications.^[5] The largest study of examined 2,521 patients with stable heart failure in the SCD-HeFT trial.^[6] Results indicated that there were no differences between ICD-treated and medication-treated groups at 30 months in patient-reported QoL.^[7] Psychological adjustment following ICD implantation has also been well studied. Anxiety is a common psychological side effect, with approximately 13-38% of ICD patients reporting clinically significant anxiety.^[8][9] The primary etiological factors contributing to anxiety in ICD patients have not been determined, however. Depressive symptoms are also common, but the incidence of these problems has been shown to be similar to those observed in other cardiac patient groups, with approximately 24-41% of patients with ICDs experiencing depressive symptoms.^[9]

Problems in psychosocial adjustment to ICDs, including the experience of anxiety, among spouses or other romantic partners are also prevalent.^[10] This phenomenon may be related, at least in part, to shared shock anxiety and avoidance of physical and sexual contact.^[11]

Physical activities

Almost all forms of physical activities can be performed by patients with an ICD. All forms of sports that do not pose a risk of damaging the ICD can be undertaken by the patient. Special care should be taken not to put excessive strain on the shoulder, arm and torso area where the ICD is implanted. Doing so may damage the ICD or the leads going from the unit to the patient's heart.

Electro-magnetic equipment

Equipment using large magnets or generating magnetic fields, or any similar environment, must be avoided by patients with an ICD. As with other metallic objects, an ICD is a contraindication to the use of magnetic resonance imaging (MRI).

Clinical trials

A number of clinical trials have demonstrated the superiority of the ICD over AAD (antiarrhythmic drugs) in the prevention of death from malignant arrhythmias. The SCD-HeFT trial (published in 2005) showed a significant all-cause mortality benefit for patients with ICD. Congestive heart failure patients that were implanted with an ICD had an all-cause death risk 23% lower than placebo and an absolute decrease in mortality of 7.2 percentage points after five years in the overall population.¹ Reporting in 1999, the Antiarrhythmics Versus Implantable Defibrillators (AVID) trial consisted of 1,016 patients, and deaths in those treated with AAD were more frequent (n=122) compared with deaths in the ICD groups (n=80, p < 0.001). In 2002 the MADITII trial showed benefit of ICD treatment in patients after myocardial infarction with reduced left ventricular function (EF<30).

Initially ICDs were implanted via thoracotomy with defibrillator patches applied to the epicardium or pericardium. The device was attached via subcutaneous and transvenous leads to the device contained in a subcutaneous abdominal wall pocket. The device itself acts as an electrode. Most ICDs nowadays are implanted transvenously with the devices placed in the left pectoral region similar to pacemakers. Intravascular spring or coil electrodes are used to defibrillate. The devices have become smaller and less invasive as the technology advances. Current ICDs weigh only 70 grams and are about 12.9 mm thick.

A recent study by Birnie et al. at the University of Ottawa Heart Institute has demonstrated that ICDs are underused in both the United States and Canada.^[12] An accompanying editorial by Dr. Chris Simpson of Queen's University explores some of the economic, geographic, social and political reasons for this.^[13]

Working mechanism

ICDs constantly monitor the rate and rhythm of the heart and can deliver therapies, by way of an electrical shock, when the heart rate exceeds a preset number. More modern devices can distinguish between ventricular fibrillation and ventricular tachycardia (VT), and may try to pace the heart faster than its intrinsic rate in the case of VT, to try to break the tachycardia before it progresses to ventricular fibrillation. This is known as fast pacing, overdrive pacing, or anti-tachycardia pacing (ATP). ATP is only effective if the underlying rhythm is ventricular tachycardia, and is never effective if the rhythm is ventricular fibrillation.

Many modern ICDs use a combination of various methods to determine if a fast rhythm is normal, ventricular tachycardia, or ventricular fibrillation.

Rate discrimination evaluates the rate of the lower chambers of the heart (the ventricles) and compares it to the rate in the upper chambers of the heart (the atria). If the rate in the atria is faster than or equal to the rate in the ventricles, then the rhythm is most likely not ventricular in origin, and is usually more benign. If this is the case, the ICD does not provide any therapy.

Rhythm discrimination will see how regular a ventricular tachycardia is. Generally, ventricular tachycardia is regular. If the rhythm is irregular, it is usually due to conduction of an irregular rhythm that originates in the atria, such as atrial fibrillation.

Morphology discrimination checks the morphology of every ventricular beat and compares it to what the ICD believes is a normally conducted ventricular impulse for the patient. This normal ventricular impulse is often an average of a multiple of beats of the patient taken in the recent past.

Lead II electrocardiogram showing Torsades being shocked by an implantable cardioverter-defibrillator back to the patient's baseline cardiac rhythm.

History

The development of the ICD was pioneered at Sinai Hospital in Baltimore by a team including Michel Mirowski, Morton Mower, and William Staewen.^[14] Mirowski teamed up with Mower and Staewen and together they commenced their research in 1969 but it was 11 years before they treated their first patient. Similar developmental work was carried out almost coincidentally by Schuder and colleagues at the University of Missouri.

More than a decade of research went into the development of an implantable defibrillator that would automatically sense the onset of ventricular fibrillation and deliver an electric countershock within 15–20 seconds, converting the rhythm to sinus rhythm. Improved versions were programmed to be able to detect ventricular tachycardia, often a forerunner of ventricular fibrillation. These were then called implantable cardioverters.

The work was commenced against much skepticism even by leading experts in the field of arrhythmias and sudden death. There was doubt that their ideas would ever become a clinical reality. In 1972 Bernard Lown, the inventor of the external defibrillator, stated in the journal Circulation - "The very rare patient who has frequent bouts of ventricular fibrillation is best treated in a coronary care unit and is better served by an effective anti-arrhythmic program or surgical correction of inadequate coronary blood flow or ventricular malfunction. In fact, the implanted defibrillator system represents an imperfect solution in search of a plausible and practical application."

The problems to be overcome were the design of a system which would allow detection of ventricular fibrillation or ventricular tachycardia. Despite the lack of financial backing and grants, they persisted and the first device was implanted in February 1980 at Johns Hopkins Hospital by Dr. Levi Watkins, Jr. Modern ICDs do not require a thoracotomy and possess pacing, cardioversion, and defibrillation capabilities.

Internal cardioverter defibrillators have also been used twice in dogs to prevent sudden death from arrhythmia. The first defibrillator was implanted at Washington State University by a team of cardiologists led by Dr Lynne Johnson in 2003. The patient was a Boxer dog with life threatening arrhythmias from arrhythmogenic right ventricular cardiomyopathy, an inherited disease. On July 21, 2008, a second ICD was implanted in a 6-month-old German Shepherd dog with inherited ventricular arrhythmias. The 5-hour long surgery took place at Louisiana State University and was led by Dr Romain Pariaut. So far, these pets are the only two client-owned dogs that have received such a high-tech treatment.

See also

• CPR
• Advanced cardiac
• Defibrillation
• Artificial pacemaker
• Boston Scientific
• Cameron Health
• Medtronic
• St Jude Medical
• Sorin Group
• Biotronik
• Wearable Cardioverter Defibrillator
• Samuel Sears

Notes

References

• Bardy GH, Lee KL, Mark DB, et al. for the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigators. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005; 352:225-237
• Stevenson W, Chaitman B, Ellenbogen K, Epstein A, Gross W, Hayes D, Strickberger S, Sweeney M (2004). "Clinical assessment and management of patients with implanted cardioverter-defibrillators presenting to nonelectrophysiologists". Circulation 110 (25): 3866–9. doi:10.1161/01.CIR.0000149716.03295.7C. PMID 15611390. Full text
• Kumar and Clarke. Internal Medicine. 2009.
• Sears S, Matchett M, Conti J. Effective management of ICD patient psychosocial issues and patient critical events. J Cardiovasc Electrophysiol 2009;20(11):1297-304.
• Sears SF, Jr., Todaro JF, Lewis TS, Sotile W, Conti JB. Examining the psychosocial impact of implantable cardioverter defibrillators: a literature review. Clin Cardiol 1999;22:481-489.
• Burns JL, Serber ER, Keim S, Sears SF. Measuring patient acceptance of implantable cardiac device therapy: initial psychometric investigation of the Florida Patient Acceptance Survey. J Cardiovasc Electrophysiol 2005;16:384-390.
• Mark DB, Anstrom KJ, Sun JL, Clapp-Channing NE, Tsiatis AA, Davidson-Ray L, Lee KL, Bardy GH. Quality of life with defibrillator therapy or amiodarone in heart failure. N Engl J Med 2008; 359(10):999-1008.
• Bilge AK, Ozben B, Demircan S, et al. Depression and anxiety status of patients with implantable cardioverter defibrillator and precipitating factors. Pacing Clin Electrophysiol. 2006 Jun;29(6):619-26.

External links

• A Defibrillator in Action
• Information on ICDs from the charity Arrhythmia Alliance
• East Carolina Heart Institute at ECU, Cardiac Psychology Lab, Focus on ICD
• Samuel F. Sears, Jr., Ph.D., East Carolina University, Cardiac Psychology, ICD QoL Specialist
• Video, Coping with an ICD