iimplantable cardioverter defibrillators (icds) - dr prithvi puwar
TRANSCRIPT
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Implantable Cardioverter
Defibrillators (ICDs)
Dr. Prithvi Puwar
DNB Cardiology Registrar
Vijaya Hospital, Chennai
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Presentation will cover:
• History of ICDs
• Indications for ICDs
• Major Trials
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Pioneers of ICDs - “M&M”
Martin Mower
Michel Mirowski
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*Dr Chow Wei En©
*
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EVOLUTION OF ICDs:
1947 First human internal defibrillation
1956 First human external defibrillation
1969 First external canine prototype tested
1970 First implantable prototype (895 g)
1975 First implantable Defibin canines (250 g)
1980 First human implant @ Johns Hopkins
1985 ICD market released (350 units)
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1991 Non thoracotomy lead systems
1995 Pectoral ICD systems
1997 ICD & DDD
1999 ICD & Atrial Defibrillation
2001 ICD & Resynchronization Therapy
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Components of ICD –
1. Device
• Battery, Capacitors & Voltage
• Circuitry
• Connector Blocks
2. Leads
• Transvenous / Epicardial
• Electrical Design
• Connectors: IS-1 & DF-1
3. Programmer
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Ventricle
VT prevention
Anti-tachycardia pacing
Cardioversion
Defibrillation
Atrium & Ventricle
Bradycardia sensing
Bradycardia pacing
Anti-tachycardia pacing
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USES OF ICDs:
Secondary prevention:
prior episode of resuscitated
VT/VF or sustained
hemodynamically unstable VT
episodes of spontaneous
sustained VT in the presence of
heart disease (valvular, ischemic,
hypertrophic, dilated, or infiltrative
cardiomyopathies) and other
settings (eg, channelopathies)
Primary prevention:
prior myocardial infarction (at least
40 days ago) and LVEF ≤35%
cardiomyopathy, NYHA II to III with
LVEF<35%
syncope who have structural heart
disease and inducible VT/VF
Long QT, Torsades on Rx,
Brugada, ARVD, HCM
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When ICD therapy is not indicated
• ventricular tachyarrhythmias due to a completely reversi
ble disorder in the absence of structural heart disease
(electrolyte imbalance, drugs, or trauma)
• No reasonable expectation of survival with acceptable
functional status for at least one year
• significant psychiatric illnesses that may be aggravated
by device implantation
• Patient with VF or VT amenable to surgical or catheter a
blation (WPW, LVOT VT)
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Indications for ICDs (ACC)
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ICD Programming and therapy:
Contemporary ICDs have a variety of flexible programming
and therapeutic options:• Arrhythmia discrimination – ability to distinguish arrhythmias
requiring ICD therapy from other heart rhythms
• Multiple available therapies – anti-tachycardia pacing and/or
shock
• Sequential therapies - In each therapy zone, a sequence of up
to five or six therapies (bursts of anti-tachycardia pacing,
cardioversion, or defibrillation) can be delivered. After each
therapy, the device reevaluates the rhythm, and if the
tachyarrhythmia persists, the next therapy is delivered.
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About medical therapy
first?
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SCD Prevention Trials -
Antiarrhythmic Agents
• CAST I [Cardiac Arrhythmia Suppression Trial (1991)]
• ESVEM [Electrophysiologic Study vs ECG Monitoring (1993)]
• GESICA [Grupo de Estudio de la Sobrevida en la Insuficiencia
Cardiaca en Argentina (1994)]
• CHF STAT [Congestive Heart Failure: Survival Trial of
Antiarrhythmic Therapy (1995)]
• SWORD [Survival with Oral d-Sotalol (1996)]
• CAMIAT [Canadian Amiodarone Myocardial Infarction
Arrhythmia Trial (1997)]
• EMIAT (European Myocardial Infarction Amiodarone Trial
(1997)]
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Multicenter,
randomized, double-
blind, placebo-controlled
Patients: 1725
pts with >6 ventricular
premature
depolarizations/h and
LVEF<0.55 at <90 days
after MI or <0.40 at >90
days after MI
Follow up and primary
end point:
Mean 10 months follow
up.
Primary endpoint death
from arrhythmia
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CHF STAT
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SWORD Trial
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EMIAT (European MI Amiodarone
Trial)
There was no difference in the primary endpoint of all-cause mortality (P=0.95)
However, patients assigned to the amiodarone group did have a statistically
significant reduction in VF or arrhythmic death (4.0% versus 7.9%,P=0.006).
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Summary of drug trials:
1. Anti-arrhythmics may worsen the survival
2. Amiodarone may slightly improve the outcome
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SCD Prevention Trials - ICDs• Secondary Prevention
• CASH [Cardiac Arrest Study Hamburg (1994)]
• AVID [Amiodarone vs Implantable Defibrillator (1995)]
• CIDS [Canadian Implantable Defibrillator Study (2000)]
• Primary Prevention
• MADIT [Multicentre Automatic Defibrillator Implantation Trial (1996)]
• CABG-PATCH (1997)
• MUSTT [Multicentre Unsustained Tachycardia Trial (1999)]
• MADIT II (2002)
• DEFINITE (2004)
• DINAMIT (2004)
• SCD-HeFT (2005)
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ICDs in Secondary
Prevention
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Key Trials: ICD in Secondary
Prevention
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# Mean age 60
# Mostly CAD pts
# Interestingly, in CASH, only VF arrest puts included, and those
that had ICDs implanted did not receive amiodarone, compared to
AVID and CIDS where the ICD arms still had up to 20% of pts on
amiodarone
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• Antiarrhythmics vs
ICDs
• First trial of such
nature to be
completed
• Demonstrated
superiority of ICDs
over AADs
(primarily
amiodarone)
AVID Trial
A Comparison of Antiarrhythmic-Drug Therapy with Implantable Defibrillators in Patients Resuscitated from Near-Fatal Ventricular Arrhythmias
The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. N Engl J Med 1997; 337:1576-1584
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CIDS (Canadian Implantable Defibrillator
Study)
Background: (ICD) terminates VT or VF, but it is not known
whether this device prolongs life in these patients compared with
medical therapy with amiodarone
Conclusions—A 20% relative risk reduction occurred in all-cause
mortality and a 33% reduction occurred in arrhythmic mortality
with ICD therapy compared with amiodarone; this reduction did
not reach statistical significance.
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Sub-optimally Addressed Issues
• Beta-blockade - have we really optimised medical therapy prior
to device implantation?
• Is 35% the magic EF?
• Under-represented population - the impact of ICD in non-
ischaemic CMP?
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JACC
1999
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Are AADs more protective over the long term horizon?
(Results of all three studies are consistent with each other)
Meta-analyses of the ICD Secondary Prevention Trials. Connolly et al. European Heart Journal 2000 (21) 2071-2078
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HRS/ACC/AHA Expert COnsensus Statement on the Use of ICD Therapy in Patients who are not included or not well represented in Clinical Trials.
Heart Rhythm 2014; 11:1270-1303
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HRS/ACC/AHA Expert COnsensus Statement on the Use of ICD Therapy in Patients who are not included or not well represented in Clinical Trials.
Heart Rhythm 2014; 11:1270-1303
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ICDs in Primary
Prevention
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Class I Indication? Not always clear
cut…
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MADIT II
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MADIT I & II
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Matching the
Evidence to the
Guidelines
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Indications for ICDs (ACC)
SCD HeFT
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Indications for ICDs (ACC)
DEFINITE
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Indications for ICDs (ACC)
MADIT II
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Indications for ICDs (ACC)
MUSTT
MADIT I
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Indications for ICDs (ACC)
AVID, CIDS, CASH
Wever EF, Hauer RN, van Capelle FL, et al. Randomized study of implantable defibrillator as first-choice
therapy versus conventional strategy in postinfarct sudden death survivors. Circulation. 1995;91: 2195–203.
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• The Grey Zone: 35% < EF < 40%.
• NSVT post MI, EF > 35%
• NSVT post MI, EF > 35% with negative EPS
• NSVT in NICMP
• Elderly - what is the “age cut-off”?
• Beyond EF
• Dual vs Single Chamber; Programming (minimising inappropriate
shocks)
THANK YOU
Unaddressed Scenarios