Indications of icd in 2010
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Indications of ICD in 2010. Dr Mervat Aboulmaaty Professor of Cardiology Ain Shams University DAF 1 st EP course 2010. SCD Burden . SCD Risk . ICD Implantable Cardiovertor Defibrillator. 1980: Large Devices, Limited Battery Life, Abdominal Implant, Epicardial Leads.

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Indications of ICD in 2010

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Indications of ICD in 2010

Dr Mervat Aboulmaaty

Professor of Cardiology

Ain Shams University

DAF 1st EP course 2010


SCD Burden


SCD Risk


ICDImplantable Cardiovertor Defibrillator


1980:Large Devices, Limited Battery Life, Abdominal Implant, Epicardial Leads

  • First human implants

  • Thoracotomy, multiple incisions

  • Primary implanter= cardiac surgeon

  • General anesthesia

  • Long hospital stays

  • Complications from major surgery

  • Perioperative mortality up to 9%

  • Nonprogrammable therapy

  • High-energy shock only

  • Device longevity  1.5 years

  • Fewer than 1,000 implants/year


Today:Small Devices, Long Battery Life, Pectoral Implant, Endocardial Leads

  • First-line therapy for VT/VF patients

  • Treatment of atrial arrhythmias

  • Cardiac resynchronization therapy for HF

  • Transvenous, single incision

  • Local anesthesia; conscious sedation

  • Short hospital stays and few complications

  • Perioperative mortality < 1%

  • Programmable therapy options

  • Single- or dual-chamber therapy

  • Battery longevity up to 9 years*

  • More than 100,000 implants/year

*Battery longevity information in slide notes.


Therapies Provided by Today’sDual-Chamber ICDs

Atrium & Ventricle

  • Bradycardia sensing & Pacing

  • Atrium

  • AT/AF tachyarrhythmia detection

  • Antitachycardia pacing

  • Cardioversion

  • Ventricle

  • VT/ VF detection

  • Antitachycardia pacing

  • Cardioversion

  • Defibrillation


CRT-DMultisite ICD


Indications for ICDs

  • Primary

    • Prevent a SCD eventbeforeitoccurs

      • Definepatients at risk

  • Secondary

    • Prevent SCD eventafter an initialeventsurvival

      • Excludetransientor reversible causesfor VF


MADIT 1996

(196 patients)

MADIT II 2002

(1232 patients)

MADIT-CRT 2005

(1820 patients)

Clinical Question:

Can prophylactic ICD therapy improve survival in high risk HF patients when compared to medical therapy alone?

Endpoint:All-cause mortality.

Key Finding:

Use of ICDs resulted in a 54% reduction in the mortality rate in the ICD group as compared to the conventional medical therapy group (p value: 0.009)

Clinical Question:

Can heart attack survivors with impaired heart function (EF≤30%), and no other risk stratification, benefit from ICD therapy versus conventional therapy alone?

Endpoint:All-cause mortality.

Key Finding:

Use of ICDs resulted in a 31% reduction in the risk of death in heart attack survivors (p value: 0.016). As a result , patients no longer have to undergo invasive electrophysiological testing to receive the ICD therapy

Clinical Question:

Does early intervention with CRT-D slow the progression of HF in high-risk patients* with mild HF* when compared to ICD-only therapy?

Endpoint: All-cause mortality OR first HF event.

Key finding:

CRT-D therapy is associated with a significant 34% reduction in death or first HF event when compared to ICD therapy alone (p value: 0.001)

* Mild HF”:NYHA Class I and II ; High-risk”:EF ≤30%; QRS ≥130ms


Reductions in Mortality with ICD Therapy

75%

76%

61%

55%

54%

31%

% Mortality Reduction w/ ICD Rx

ICD mortality reductions in primary prevention trialsare equal to or greaterthan those in secondaryprevention trials.

1

2

3, 4

27 months

39 months

20 months

59%

56%

33%

% Mortality Reduction w/ ICD Rx

31%

28%

20%

1 Moss AJ. N Engl J Med. 1996;335:1933-40.

2 Buxton AE. N Engl J Med. 1999;341:1882-90.

3 Moss AJ. N Engl J Med. 2002;346:877-83

4 Moss AJ. Presented before ACC 51st Annual Scientific Sessions, Late Breaking Clinical Trials, March 19, 2002.

5 The AVID Investigators. N Engl J Med. 1997;337:1576-83.

6 Kuck K. Circ. 2000;102:748-54.

7 Connolly S. Circ. 2000:101:1297-1302.

6

7

5

3 Years

3 Years

3 Years


Class I

  • Documented survivors of SCD due to VF

  • 40days post MI + LVEF≤ 35 + NYHA II/III

  • 40 days post MI + LVEF≤ 30 + NYHA I

  • Non ischemic cardiomyopathy + LVEF≤ 35 + NYHA II/III

  • Non sustained VT post MI + sustained VT/VF by EPS+ LVEF ≤ 40

  • Structural heart disease + sustained VT

  • Syncope + unstable VT/VF by EPS


Class IIA

  • LQTS + syncope/VT (on β blockers)

  • Unexplained syncope + DCM + significant LV dysfunction

  • Sustained VT + normal LV

  • CPVT + syncope/VT (on β blockers)

  • High risk ARVD

  • High risk HCM

  • Brugada syndrome + syncope/VT


Indications for ICD in HF patients


Guidelines of ICD in a Pocket


Indications for ICD implantationClass IIIICD is NOT indicated IN

  • Syncope of undetermined cause no VT induced NO structural HD

  • Incessant VT VF

  • VT/VF resulting from arrhythmias amenable for ablation as WPW Fasicular VT

  • VT due to reversible disorder

  • Significant psychological disorder

  • Terminal illness life expectancy <6months


55 yr old, first hour of Acute MI


Conclusions

  • ICDs are reliable devices that have the potential to add quality years of life for appropriate candidates.

  • There are scientifically-derived guidelines for their prescription that are limited by the scope of the clinical trials and observational data.

  • Cardiologists should recommend ICD devices to their individual patients based on the current guidelines.


ICD Programming


How ICD works?


I C D I N T E R R O G A T I O N


I C D I N T E R R O G A T I O N

Burst 1

Sinus

VT


I C D I N T E R R O G A T I O N

Acc. VT

VT

Burst


I C D I N T E R R O G A T I O N

Cont.

Sinus

Acc.VT

DC


Thank you


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