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

Indications of ICD in 2010

Dr Mervat Aboulmaaty

Professor of Cardiology

Ain Shams University

DAF 1st EP course 2010


Scd burden

SCD Burden


Scd risk

SCD Risk


Icd implantable cardiovertor defibrillator

ICDImplantable Cardiovertor Defibrillator


1980 large devices limited battery life abdominal implant epicardial leads

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

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 s dual chamber icds

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 d multisite icd

CRT-DMultisite ICD


Indications for icds

Indications for ICDs

  • Primary

    • Prevent a SCD eventbeforeitoccurs

      • Definepatients at risk

  • Secondary

    • Prevent SCD eventafter an initialeventsurvival

      • Excludetransientor reversible causesfor VF


Indications of icd in 2010

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

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

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

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

Indications for ICD in HF patients


Guidelines of icd in a pocket

Guidelines of ICD in a Pocket


Indications for icd implantation class iii icd is not indicated in

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

55 yr old, first hour of Acute MI


Conclusions

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

ICD Programming


How icd works

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


I c d i n t e r r o g a t i o n1

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 n2

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 n3

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

Cont.

Sinus

Acc.VT

DC


Indications of icd in 2010

Thank you


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