patients with icds should be allowed t p iit t ito

January 14-15, 2011 SCA Conference 1

Patients with ICDs Should be Allowed t P ti i t ito Participate in

Competitive SportsIan H. Law, M.D.

Professor of PediatricsUniversity of Iowa Children’s Hospital

Carver College of Medicine


36th Bethesda Conference Recommendations

Maron BJ, Zipes DP. 36Maron BJ, Zipes DP. 36thth Bethesda. JACC 2005; Bethesda. JACC 2005;

Debate Goal

Change PublicPolicy

Allow Patient Autonomy


Definition of a Patientpa·tient

A person who is under medical care orA person who is under medical care or treatment.

Archaic. a sufferer or victim.

http://dictionary.reference.com/

Pt Rights & Responsibilities• To make informed decisions with his/her doctor,

patients need to understand:p– The benefits and risks of each treatment– What s/he can reasonably expect from the

treatment and any long-term effects it might have on quality of life

American Hospital Association


ICD DefinitionICD:

A device that is put within the body and isA device that is put within the body and is designed to recognize certain types of ventricular arrhythmias and correct them.

Assumptions:Patient is not pacemaker dependentp p

http://www.medterms.com/

Competitive Sports DefinitionCompetitive: 1. Of, pertaining to, involving, or decided by competition:

titi t titi i ticompetitive sports; a competitive examination. 2. Having a strong desire to compete or to succeed.

Sport: • An organized, competitive, entertaining, and skillful

activity requiring commitment, strategy, and fair play, in which a winner can be defined by objective means… A ti iti h d d b dActivities such as card games and board games, are classified as "mind sports" … Non-competitive activities, for example as jogging or playing catch are usually classified as forms of recreation.

http://dictionary.reference.com/


Sports?

Mitchell et al. Bethesda 36th, Task Force 8: JACC 2005


Potential Risks• Patients

F il f ICD h h i–Failure of ICD to treat arrhythmia–Inappropriate shocks–Arrhythmia/shock resulting in injury

• ICD–Damage to the device or lead systemDamage to the device or lead system

• Physician –Liability????

Increased ArrhythmiasHigher risk Lower risk?LQT1 LQT3LQT1 LQT3CPVT Brugada SyndromeHCMARVC

Why?Hi h d i t– High adrenergic tone

– Increased stress of “competition”– Electrolyte changes– Changes in hydration status/blood volume


ICD Efficacy

# of ti t

AppropriateICD h k

ICD life-saving

ICD Life-Saving Shocks

128 29 7.3% / yr

patients ICD shocks discharge rate

3.1 yr F/U

Maron, NEJM; 2000

11% 4.5%

2° prevention(after SCA)

1° prevention(prophylactic)

ICD EfficacyN=132 pts with ICDs• Mean age 34 ± 17 yrs• 44 pts (33%) < 20 yrs6 Deaths6 Deaths• 2 children died post-op

with low cardiac output and tamponade

• 1 child died immediate post-transplant

• 1 (24 yrs) died while idi t l

Begley et al. PACE 2003.

riding motorcycle (etiology unknown)

• 2 non-cardiac (53 and 74 yrs)


Effect of Catecholamines32 ICD implants

Test at 1 wk1st No Epi

16 VT

1st No Epi16 VF

15 sinus 16 sinus1 VT

16 VT 16 VF

2nd Epi 1 sinus 2nd Epi

Sousa et al. Am J Cardiol 1992.

16 sinus 3 VF12 sinus 1 VT

4 sinus

* epinephrine included in ACLS guidelines

Recommended Restrictions by Activity

N = 614 respondents: physician members of HRS

contact sports

competitive sports

sports with injury risk

no restrictions

p p y

Lampert, J Cardiovasc Electrophysiol; 2006

0 10 20 30 40 50 60 70 80 90

> vigorous than golf

all vigorous sports


Participation & Shocks


ICD Shocks During Sports• ICD shocks common, cited by 40% of

physiciansphysicians.• 52% of physicians reported ICD shocks with

patients in vigorous sports• 33% of physicians reported ICD shocks with

pts in competitive sportsp p p• <1% failure of shocks to terminate

arrhythmia



Inappropriate Shocks• N = 210 patients (Von Bergen, Ped Card, 2011)

• 28% Appropriate dischargespp p g• 16% “Lifesaving”• 19% Inappropriate discharges• 6% Both inappropriate and appropriate discharges

• N = 443 patients (Registry) (Berul, JACC, 2008)• 26% Appropriate shocks• 23% In pediatric (<18 years)

21% I i t h k• 21% Inappropriate shocks• 14% Lead failure• 9% Sinus or atrial tachycardia• 4% Oversensing

Inappropriate ShocksCauses:• Sinus tachycardia• T-wave over-sensing (double counting)• T-wave over-sensing (double counting)• Diaphragmatic potentials• Loose setscrews and pins • Lead broken – insulation defects, abrasion, lead fracture• Atrial arrhythmiasPrevention:• Program age-appropriate sinus rates• Dual chamber systems (atrial lead)• SVT discriminators• Attention to R/T ratios• Medications (beta-blockers)

Heidbuckel, H. Cardiol Clin 2007.


Patient Risks–Ad E t

Injury During “Sports”

Adverse Events Reported


Injury During “Sports”• 1% of physicians reported known injury to

patientspatients– All but 3 were minor –Two head injuries due to falls (one during

running, one on a treadmill - death).– One neck injury during hunting







Pacemaker Damage During Sports

Repetitive UseRepetitive Use

Direct trauma to lead systems


ICD – System DDamage


ICD – Growth Issues

2003 Ht: 5’ 5” 2006 Ht: 6’ 3”


MethodsPediatric and Congenital Electrophysiology Society Survey

15 sports17 leisure activities

Categorized by pacing siteadequacy of escape rhythmlevel of competition

61 completed surveys~ 10,000 devicesMostly U.S.

Gajewski, Saul, HRS, 2008

Sports Activities• Golf • Tennis

• Hockey• Gymnastics

• Baseball• Soccer• Basketball• Touch football• Tackle football

• Iceskating• Track• Swimming• High jumping• Pole vaultingTackle football

• Wrestling

g• Lacrosse• Weight lifting

*18% approve all listed sports at any competitive level



Leisure and Other Activities• Jumping• Biking

PE l

• Roller-blading• Iceskating

D hill kiii• PE class• Playing catch• Dodgeball• Kickball• Trampoline

• Downhill skiiing• Snowboarding• Skydiving• Dirtbike riding• Hunting• Trampoline

• Roller Coaster• Skate boarding

Hunting• Jungle Gym• Sliding on stairs• Accident (car, …)


Adequate Escape Rhythm

• 18% approve all listed sports at any competitive level



Pacing System Injuries SportsGolf - 1Golf 1Swimming - 3Soccer – 3Gymnastics - 3Hockey – 4Weightlifting - 4Basketball – 5Baseball – 5Football – 5Wrestling - 13


Pacing System Injuries“Leisure” Activities

Hunting – 0Biking - 1Jumping - 2Skateboarding – 4Dirt biking - 4Rollercoaster 5Rollercoaster - 5Jungle gym – 6Car Accidents – 10Sliding down stairs - 12



Summary• Most practitioners allow most paced patients to participate in most sports and leisure activities

• Level of contact, level of competition and adequacy f h th h th l t i flof escape rhythm have the largest influence on

recommendations• Pacing system injuries are:

–Rare with any activity (<<1% per year)–Occur with contact and repetitive use sports–Occur most frequently with:

•car accidents•wrestling •sliding down stairs on your belly


Benefits


BenefitsCardiovascular health (Fletcher Circulation. 1996 Aug 15;94(4):857-62, Franco et al. Arch Intern Med 2005)– Improvement in aerobic power and maximum oxygen uptake– Blood lipid levels– Glucose tolerance– Reduce Obesity

“…athletes high in global self-esteem tend to be more optimistic, have higher physical self-esteem, are more hardy and have better social support than athletes with lowhardy and have better social support than athletes with low global self-esteem. In other words, athletes with high global self-esteem may be better `rounded’ individuals and, consequently, may be better suited to deal with life stress, (Ford, J Sports Sci. 2000)

Benefits• Habitual exercise ⇓ the risk of SCD during

i 7exercise 7x• Compliance with target heart rate ⇓ risk of

lethal arrhythmias as well as ischemia• Patient recognition of normal heart rates may ⇓

risk of inappropriate shock• Psychological benefit of sports participationPsychological benefit of sports participation

Lampert, J Cardiovasc Electrophysiology 2006


Conclusion• Patients

–Failure of ICD to treat arrhythmia


–Failure of ICD to treat arrhythmia• ICD failure rate relatively low (<1%)ICD failure rate relatively low ( 1%)




–Inappropriate shocks



–Inappropriate shocks• ICD type and reprogramming should reduce risk





–Arrhythmia/shock resulting in injury




–Arrhythmia/shock resulting in injury• Risk of injury during sports is low (≤ 1%), most minor






• ICD–Damage to the device or lead system





• ICD–Damage to the device or lead system

• ICD system injury ≤ 5%, <<1% in children with pacemakers


Conclusion

• Benefits–Sports are beneficial for physical, emotional, and psychosocial well-being

Conclusion

• Liberalization of the Bethesda guidelines forBethesda guidelines for medically compliant patients with normal hemodynamics or no significant structural heart disease isheart disease is reasonable.


Athletic patients test defibrillator’s limitsRegistry to track device’s abilities because recipients ignore medical advice

A d K ki 16 h ld

Full story athttp://www.msnbc.msn.com/id/20362336/

updated 6:13 p.m. ET, Mon., Aug. 20, 2007

Amanda Kurovski, 16, holds a teddy bear she received after having heart surgery in 2006. Amanda had a heart-zapping defibrillator implanted in her chest in July 2006 after collapsing from irregular heart beats, but returnedirregular heart beats, but returned to her favorite sports, high school track and volleyball.

Extra Support•Kevin Shannon: Enrolling physician in the ICD Sports Registry


Extra Support – Life’s Short•CAUSE DAYS LOST (on average)/lifetime•being an unmarried male 3500 •being a smoker (male) 2250 •heart disease (average) 2100 •being an unmarried female 1600 •being 30% overweight 1300•being 30% overweight 1300 •being a coal miner 1100 •being 20%overweight 900•consuming an additional 100 Cal/day 210 •average vehicle accidents 207•alcohol (US av) 130 •accident in home 95 •suicide 95 •homocide 90 •legal drug misuse 90 •drowning 41 •job with radiation exposure 40job with radiation exposure 40 •having an accident (safe job) 30 • illicit drug use 18• poison 17 •firearm accident 13 •natural radiation 11 •medical x-rays 7 •coffee (contains carcinogens) 6 • bicycle accident 5 •4 diet drinks (carcinogens) 2

Safety of Sports for Patients with Implantable Cardioverter-Defibrillators: A Multicenter Registry

Principal InvestigatorsRachel Lampert, MD Yale University School of MedicineBrian Olshansky, MD University of Iowa School of MedicineDavid Cannom, MD Los Angeles Cardiology AssociatesChristine Lawless, MD University of OhioElizabeth Saarel, MD University of Utah

Steering CommitteeMichael Ackerman, Mayo ClinicMark Estes, MD, New England Medical Center (Tufts)M k Li k MD N E l d M di l C t (T ft )Mark Link, MD, New England Medical Center (Tufts)Frank Marcus, MD, University of ArizonaMelvin Scheinman, MD, University of California, San FranciscoBruce Wilkoff, MD, Cleveland Clinic FoundationDouglas Zipes, MD, Indiana University

Funding SourcesBoston Scientific/GuidantMedtronic, IncSt. Jude Medical


Safety of Sports for Patients with Implantable Cardioverter-Defibrillators: A

Multicenter RegistryPrimary aim:To determine the safety of sports participation for patientsTo determine the safety of sports participation for patients

with ICDs.

Hypothesis:The incidence of serious adverse events occurring during

sports, defined as

1) tachyarrhythmic death (due to failure to convert VT/VF or post-shock PEA) or externally resuscitated arrest, or

2) significant injury due to syncopal arrhythmia or shock, will be less than 1% over 2 years.

Patient enrollment(as of May 2010)

N=310 (November, 2010)

75 < 20 years old (May 2010)36% women/girls (May 2010)

Median 31 months since ICD implant (May 2010)

DSMB convened 1/10:recommended continuation of study


Table 2.2 Cardiac Diagnosis 9as of 9/09)

Primary cardiac diagnosis Frequency PercentLQTS 45 23.1HCM 36 18.5

ARVD--registry diagnosis 7 3 6ARVD--registry diagnosis 7 3.6ARVD--other diagnosis 18 9.2

Congenital 20 10.3CAD 19 9.7

Idiopathic VT / VF 17 8.7Dilated CM 14 7.2

CPVT 5 2.6Brugada 1 0.5

Valvular heart disea 1 0.5Other 1 0.5

None, family history 3 1.5None, other 4 2.1

pending 4 2.1

BaseballBasketball

Cross CountryCross Country

Scuba DivingSnow Boarding

SkiingSoccer

Sports Represented

ySkiing

CyclingFootball (Tackle)Football (Touch)

HandballHockey

LacrosseRacquetball

SoccerSoftball

Speed SkatingSquashSurfingTennis

Track and FieldTriathlonsVolleyball

Rock ClimbingRunningMarathons

Ultra-Marathons1/2 Marathons

10K and 5K

yWater Polo

Water Skiing / Wake BoardingWrestling


Athletic patients test defibrillator’s limitsRegistry to track device’s abilities because recipients ignore medical advice

A d K ki 16 h ld

Full story athttp://www.msnbc.msn.com/id/20362336/

updated 6:13 p.m. ET, Mon., Aug. 20, 2007

Amanda Kurovski, 16, holds a teddy bear she received after having heart surgery in 2006. Amanda had a heart-zapping defibrillator implanted in her chest in July 2006 after collapsing from irregular heart beats, but returnedirregular heart beats, but returned to her favorite sports, high school track and volleyball.


35

40

NCAA AED UseSCA

10

15

20

25

30

35

Num

ber R

epor

ted

AED Success

AED Shock

0

5

Total

Older nonstudent

Intercollegiate athlete

Recreational athlete

Unavailable

Drezner, Med Sci in Sports & Ex; 2004

AED – SCA in AthletesSurvey of colleges and media9 intercollegiate athletes identified with SCA

4 b k tb ll 2 f tb ll4 basketball– 2 football2 lacrosse – 1 swimming

Setting7 practice – 1 competition1 weight-training

CPR6 < 30 2 < 1 i6 cases < 30 sec – 2 cases < 1 min

AED5 athletic trainer – 4 EMS


AED – SCA in Athl t

Rhythm7 V-fib – 1 pulseless idioventricular 1 unknown

AED shock delivered in 7 casesAverage time to shock 3.1 min (range 1 – 7.5)Earlier shock if AED brought by ATC (1.6 v 5.2 min)

Outcome AthletesOutcome8 of 9 athletes died

Diagnosis5 HCM – 2 commotio cordis1 myocardial infarct – Survivor: no etiology found

Working Groups of the AHA Working Groups of the AHA Committee on Exercise, Cardiac Committee on Exercise, Cardiac

Rehabilitation, and iiRehabilitation, and iiNo specific recommendations regarding ICD’s for nonNo specific recommendations regarding ICD’s for non--competitive sports, except:competitive sports, except:–– Recommendation for dualRecommendation for dual--chamber ICDchamber ICD

–– Placement does not mean that they do not need to be limited in sportsPlacement does not mean that they do not need to be limited in sports

Maron et al. Circulation 2004; 109: 2807Maron et al. Circulation 2004; 109: 2807--2816.2816.


ICD Sports Safety RegistryICD Sports Safety Registrynn Primary Aim: Prospectively determine the safety of sports Primary Aim: Prospectively determine the safety of sports participation for patients with ICDs from 10 to 60 years of age.participation for patients with ICDs from 10 to 60 years of age.

H th i Ad t d i t ill b l th 1% 2H th i Ad t d i t ill b l th 1% 2nn Hypothesis: Adverse events during sports will be less than 1% over 2 Hypothesis: Adverse events during sports will be less than 1% over 2 years.years.nn Tachyarrhythmic deathTachyarrhythmic death-- failure to convert VT/VFfailure to convert VT/VF-- postpost--shock PEAshock PEA-- externally resuscitated arrestexternally resuscitated arrestnn Significant injury due to the syncopal arrhythmia or shock.Significant injury due to the syncopal arrhythmia or shock.

nnCompetitive sports more than Bethesda class 1aCompetitive sports more than Bethesda class 1a-- OR dangerous ports (skiing, windsurfing)OR dangerous ports (skiing, windsurfing)

nnData obtained via patient interviews and medical record extractionData obtained via patient interviews and medical record extraction

Sports Registry Sports Registry -- DiagnosesDiagnosesPrimary cardiac diagnosisPrimary cardiac diagnosis FrequencyFrequency PercentPercent

LQTSLQTS 4545 23.123.1

HCMHCM 3636 18.518.5

ARVDARVD----registry diagnosisregistry diagnosis 77 3.63.6

nn 278 total patients278 total patients

nn 39 High school athletes39 High school athletesARVDARVD----other diagnosisother diagnosis 1818 9.29.2

CongenitalCongenital 2020 10.310.3

CADCAD 1919 9.79.7

Idiopathic VT / VF Idiopathic VT / VF 1717 8.78.7

Dilated CMDilated CM 1414 7.27.2

CPVTCPVT 55 2.62.6

BrugadaBrugada 11 0.50.5

Valvular heart diseaValvular heart disea 11 0.50.5

OtherOther 11 0.50.5

gg

nn 9 College athletes9 College athletes

None, family historyNone, family history 33 1.51.5

None, otherNone, other 44 2.12.1

pendingpending 44 2.12.1


Sports RepresentedSports Represented

BaseballBaseballBasketballBasketballCross CountryCross CountryCross Country SkiingCross Country SkiingCyclingCyclingFootball (Tackle)Football (Tackle)Football (Touch)Football (Touch)HandballHandball

Scuba DivingScuba DivingSnow BoardingSnow BoardingSkiingSkiingSoccerSoccerSoftballSoftballSpeed SkatingSpeed SkatingSquashSquashSurfingSurfingTennisTennisTrack and FieldTrack and FieldTriathlonsTriathlonsVolleyballVolleyballWater PoloWater Polo

Most commonMost common

RunningRunningCyclingCyclingBasketballBasketballSkiingSkiingSoccerSoccerSoftballSoftballTennisTennis

HockeyHockeyLacrosseLacrosseRacquetballRacquetballRock ClimbingRock ClimbingRunningRunning

MarathonsMarathonsUltraUltra--MarathonsMarathons1/2 Marathons1/2 Marathons10K and 5K10K and 5K

Water PoloWater PoloWater Skiing / Wake Boarding WrestlingWater Skiing / Wake Boarding Wrestling

DSMB met twice (most recently January 2009) and recommended continuation of the study….

Results???Results???

Principal InvestigatorsEmail:[email protected]@yale.edu

Phone: 866-207-9813

Website: http://www.icdsports.org

Principal InvestigatorsRachel Lampert, MD Yale University School of MedicineBrian Olshansky, MD University of Iowa School of MedicineDavid Cannom, MD Los Angeles Cardiology AssociatesChristine Lawless, MD University of OhioElizabeth Saarel, MD University of Utah

Steering CommitteeMichael Ackerman, Mayo ClinicMark Estes, MD, New England Medical Center (Tufts)Mark Link, MD, New England Medical Center (Tufts)Frank Marcus, MD, University of ArizonaMelvin Scheinman, MD, University of California, San FranciscoyBruce Wilkoff, MD, Cleveland Clinic FoundationDouglas Zipes, MD, Indiana University

Funding SourcesBoston Scientific/GuidantMedtronic, IncSt. Jude Medical


ICD’s in college sportsICD’s in college sportsnn Nicholas Knapp v. Northwestern UniversityNicholas Knapp v. Northwestern University

»» 1995 1995 -- Northwestern barred him from playing on basketball teamNorthwestern barred him from playing on basketball team»» Trial court Trial court –– he can play with courtside defibrillator and cardiologist at all gameshe can play with courtside defibrillator and cardiologist at all games»» Appeal court Appeal court -- said university had right to establish legitimate physical qualifications for its intercollegiate athletessaid university had right to establish legitimate physical qualifications for its intercollegiate athletes»» Transferred to another school, where cleared to play. Shortly after, ICD delivered an apparently appropriate shock during a Transferred to another school, where cleared to play. Shortly after, ICD delivered an apparently appropriate shock during a gamgame.e.

nn Kayla Burt Kayla Burt –– played collegiate basketball with ICD 2004played collegiate basketball with ICD 2004–– Subsequently had two shocks (during a time out)Subsequently had two shocks (during a time out)q y ( g )q y ( g )

–– No longer safe for her to playNo longer safe for her to play

–– Only Division I athlete with ICDOnly Division I athlete with ICD

65

ConclusionsConclusionsnn Until more data available, sports decisions in ICD’s should remain an individual decisionUntil more data available, sports decisions in ICD’s should remain an individual decision

–– Both risks and benefits should be consideredBoth risks and benefits should be considered

nn If sports allowed, precautions can be takenIf sports allowed, precautions can be taken

nn ICD placement is not a free ticket to all sportsICD placement is not a free ticket to all sports


Patient’s with ICDs should be allowed to participate in

titi tIan H. Law, M.D.Ian H. Law, M.D.

Professor of PediatricsProfessor of PediatricsUniversity of Iowa Children’s HospitalUniversity of Iowa Children’s Hospital

competitive ports

University of Iowa Children s HospitalUniversity of Iowa Children s HospitalUniversity of IowaUniversity of Iowa

Efficacy of Bystander Cardiopulmonary Resuscitation and Out-of-Hospital Automated External Defibrillation as Life-Saving Therapy in Commotio Cordis Erik A. Salib DO,Stephen E. Cyran MD, Robert E. Cilley MD, Barry J. Maron MD and Neal J. Thomas MD, MscThe Journal of Pediatrics, Volume 147, Issue 6, December 2005, Pages 863-866


Higher risk diseaseTraining itself may result in disease progressionTraining itself may result in disease progression

HCMHCMHCMHCMExerciseExercise--induced myocardial ischemia during intensive induced myocardial ischemia during intensive trainingtraining

cell death and myocardial replacement fibrosiscell death and myocardial replacement fibrosisenhances ventricular electrical instability.enhances ventricular electrical instability.

ARVDARVDregular and intense physical activity may provoke RVregular and intense physical activity may provoke RVregular and intense physical activity may provoke RV regular and intense physical activity may provoke RV volume overload and cavity enlargementvolume overload and cavity enlargement

may accelerate fibrofatty atrophymay accelerate fibrofatty atrophy..

Maron et al. Circ 2004; 109: 2807Maron et al. Circ 2004; 109: 2807--2816.2816.

Arrhythmogenicity of SportsArrhythmogenicity of Sportsnn Relative risk for sudden death in athletes (versus nonRelative risk for sudden death in athletes (versus non--athletes) in Italyathletes) in Italy

nn 19791979--1999 1999 –– 12 to 35 years of age12 to 35 years of age

nn Population of 1,386,600Population of 1,386,600

–– 112,790 athletes112,790 athletes

nn 300 cases of SD (1 in 100,000 per year)300 cases of SD (1 in 100,000 per year)

–– 55 SD in athletes (2.3 in 100,000 per year)55 SD in athletes (2.3 in 100,000 per year)

–– 245 SD in non245 SD in non--athletes (0.9 per 100,000 nonathletes (0.9 per 100,000 non--athletes)athletes)

Corrado et al. JACC 2003; 1: 1959Corrado et al. JACC 2003; 1: 1959--6363


nn 20 swine studied, 3020 swine studied, 30--45 kg 45 kg

nn Methods:Methods:

–– 10 minutes of electrically induced VF.10 minutes of electrically induced VF.

–– Administer either 1 mg epinephrine or 10 cc of normal salineAdminister either 1 mg epinephrine or 10 cc of normal saline

Are ICD shocks less effective Are ICD shocks less effective during sports?during sports?

–– Resuscitated for 5 minutes followed by 40 J shockResuscitated for 5 minutes followed by 40 J shock

nn Results:Results:

–– Shock successful in 1 of 10 receiving salineShock successful in 1 of 10 receiving saline

–– Successful in 10 of 10 receiving epinephrineSuccessful in 10 of 10 receiving epinephrine

nn Epinephrine:Epinephrine:

–– Shortened cycle lengthShortened cycle length

–– improved synchronization (action potential termination of endocardium versus epicardium)improved synchronization (action potential termination of endocardium versus epicardium)

–– Decreased dispersion of action potential durationDecreased dispersion of action potential duration

Suddath el al. Ann Emerg Med 2001; 38: 201Suddath el al. Ann Emerg Med 2001; 38: 201--206.206.

ICD – Lead Fracture


0 0 -- 11 Generally not advised or strongly Generally not advised or strongly discourageddiscouraged

Recommendations for nonRecommendations for non--competitive competitive sports (without ICD) depend on disease sports (without ICD) depend on disease type.type.

discourageddiscouraged

2 2 -- 3 3 assess clinically on an individual assess clinically on an individual basisbasis

4 4 -- 5 5 Probably permittedProbably permitted

Maron et al. Circ 2004; 109: 2807Maron et al. Circ 2004; 109: 2807--2816.2816.

Multicenter Retrospective ICD Registry of Multicenter Retrospective ICD Registry of Pediatric and Congenital Heart DiseasePediatric and Congenital Heart Disease

Appropriate shocksAppropriate shocksInappropriate shocksInappropriate shocks

Berul et al. J Am Coll Cardiol. 2008; 51: 1685Berul et al. J Am Coll Cardiol. 2008; 51: 1685--16911691

Appropriate shocksAppropriate shocks

in 105 / 409 (26%)in 105 / 409 (26%)

Mean of 4 shocks per patientMean of 4 shocks per patient

nn Pediatrics (<18 years)Pediatrics (<18 years)

nn 66 of 290 (66 of 290 (23%23%))

nn Adults (over 18 years)Adults (over 18 years)

nn 39 of 119 (39 of 119 (33%33%))

in 87 / 409 (21%)in 87 / 409 (21%)Mean of 6 shocks per patientMean of 6 shocks per patient(Lead failure, Sinus or atrial tachycardia, (Lead failure, Sinus or atrial tachycardia,

oversensing)oversensing)nn Pediatrics (<18 years)Pediatrics (<18 years)nn 70 of 290 (70 of 290 (24%)24%)nn Adults (over 18 years)Adults (over 18 years)nn 17 of 119 (17 of 119 (14%14%))


ICD’s less likely to work???ICD’s less likely to work???2 reported cases of shock failure during exercise2 reported cases of shock failure during exercise

Intractable VT during a treadmill test. EthmozineIntractable VT during a treadmill test. Ethmozine--induced increase in DFT had been notedinduced increase in DFT had been noted

Exercise flowing very heavy alcohol ingestion.Exercise flowing very heavy alcohol ingestion.

Papaioannou et al. PACE 2002;25:1144Papaioannou et al. PACE 2002;25:1144--1145.1145.Lambert et al. Heart Rhythm 2008;5:861Lambert et al. Heart Rhythm 2008;5:861--863.863.

Bad time for loss of consciousnessBad time for loss of consciousnessnn Hang glidingHang gliding

nn Downhill skiingDownhill skiing

nn Auto racingAuto racing

nn Rock climbingRock climbing

nn Water sports:Water sports:–– Water skiingWater skiing

–– SwimmingSwimming

–– Boogie boardingBoogie boarding

–– SurfingSurfing

–– Scuba DivingScuba Diving

nn Free weightsFree weights

nn Partner sportsPartner sports


Protective EquipmentProtective Equipmentnn Downhill skiing: HelmetDownhill skiing: Helmet

nn Water sports: Life PreserverWater sports: Life Preserver– Offshore Vest (Type I Personal Flotation Device)

– Designed to turn an unconscious person face up

– Two types: adult (>90 lbs), child (<90 lbs).

– Must be US Coast Guard Approved

Effect of Device Location Adequate Escape Rhythm (≥Recreational)

80

100

g

TransvenousAbdominal

20

40

60

80

% A

ppro

ving

0

Golf

Tenn

isBa

sket

ball

Trac

kBa

seba

llSo

ccer

Gymna

stic

sW

eigh

tlift

High

Jum

pHo

ckey

Foot

ball


80

100g

AdequateInadequate

Effect of Escape Rhythm≥High School (Transvenous)

20

40

60

80

% A

ppro

ving

Inadequate

0

%

Golf

Tenn

isBa

sket

ball

Trac

kBa

seba

llSo

ccer

Gymna

stic

sW

eigh

tlift

High

Jum

pHo

ckey

Foot

ball

80

100

ng

AdequateInadequate

Leisure ActivitiesEffect of Escape Rhythm

0

20

40

60

80

% A

ppro

vin q

0

Kick

ball

Rolle

rbla

ding

Dodg

ebal

lSk

iing

Snow

boar

ding

Skyd

iving

Dirt

biki

ngTr

ampo

line


80

100g

AdequateInadequate

Effect of Escape Rhythm ≥Recreational (Transvenous)

20

40

60

80

% A

ppro

ving

Inadequate

0

%

Golf

Tenn

isBa

sket

ball

Trac

kBa

seba

llSo

ccer

Gymna

stic

sW

eigh

tlift

High

Jum

pHo

ckey

Foot

ball






Physician Experience

70% of physicians reported “patients in their practice engaged in some form of sporting activity”42% of physicians reported “patients in their practice engaged in competitive-level sports

Lampert et al. J Cardiovasc Electrophysiology 2006; 17: 11Lampert et al. J Cardiovasc Electrophysiology 2006; 17: 11--1515

Pacemakers and sportsn Survey of the Pediatric EP Society (PACES).n Patients ≤21 years of age (15 sports, 17 leisure activities)n 61 responded, representing ~10,000 patients

n Most (>75%) approved all by the highest contact sports – Football approved by 30%– Hockey approved by 53%– Lacrosse approved by 66%

n 18% approved all sportsn Add no adequate escape

n Most “leisure activities” (running, biking, PE) approved by nearly alln Trampoline dirt biking skydiving approved by 50%n Trampoline, dirt biking, skydiving approved by 50%n 10% did not approve anything (kickball, roller-skating, dodgeball)

n Specialized protector recommended by 47% for at least one of the sportsn Estimated 75 cases (0.75%) of device damage thought to be due to trauma. (usually car

accidents, trampoline, weight-lifting).

Gajewski et al. HRS Scientific Sessions 2008. Heart Rhythm. 2010, 5S: S95.


What’s Really Done...

Survey of 1,687 US physician members of Survey of 1,687 US physician members of y , p yy , p yHeart Rhythm Society Heart Rhythm Society –– October 2003October 2003

614 responses614 responses

Recommendations of Physicians

10%10%10%10%

12%12%

76%76%

45%45%

35%35%

10%10%

Lampert et al. J Cardiovasc Electrophysiology 2006; 17: 11Lampert et al. J Cardiovasc Electrophysiology 2006; 17: 11--1515


Pacing System Injuries

• 53% of respondents were aware of at least one traumatic injury to a pacing systemone traumatic injury to a pacing system from sports or activities

• 90 specific injuries were reported (0.9%)

Recommended Restrictions by Disease


patients with icds should be allowed t p iit t ito

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