indications of icd in 2010 dr mervat aboulmaaty professor of cardiology ain shams university daf 1...
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Indications of ICD in 2010
Dr Mervat AboulmaatyProfessor of CardiologyAin Shams University
DAF 1st EP course 2010
SCD Burden
SCD Risk
ICDImplantable Cardiovertor Defibrillator
• 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
1980:Large Devices, Limited Battery Life, Abdominal Implant, Epicardial 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
Today:Small Devices, Long Battery Life, Pectoral Implant, Endocardial Leads
*Battery longevity information in slide notes.
Atrium & Ventricle
• Bradycardia sensing & Pacing
Atrium AT/AF tachyarrhythmia
detection Antitachycardia pacing Cardioversion
Ventricle VT/ VF detection Antitachycardia pacing Cardioversion Defibrillation
Therapies Provided by Today’sDual-Chamber ICDs
CRT-DMultisite ICD
Indications for ICDs
• Primary– Prevent a SCD event before it occurs
• Define patients at risk
• Secondary– Prevent SCD event after an initial event survival
• Exclude transient or reversible causes for VF
MADIT 1996
(196 patients)
* Mild HF”:NYHA Class I and II ; High-risk”:EF ≤30%; QRS ≥130ms
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)
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;346:877-834 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.
ICD mortality reductions in primary prevention trialsare equal to or greaterthan those in secondaryprevention trials.
1 3, 42
5 76
Reductions in Mortality with ICD Therapy
54%
75%
55%
76%
31%
61%
27 months 39 months 20 months
31%
56%
28%
59%
20%
33%
% M
ort
ali
ty R
ed
uc
tio
n w
/ IC
D R
x%
Mo
rta
lity
Re
du
cti
on
w/
ICD
Rx
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 III
ICD 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
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.
Conclusions
ICD Programming
Zone
Rate
(bpm)
Cycle
Length
(ms)
No. of
Beats to
Detect Therapies
VF > 250 <240 18 of 24 30 J × 6
FVT 201-250 299-240 18 Burst (1), 30 J × 6
VT < 150-200 400-300 16 Burst (2), ramp (1), 20 J, 30 J × 3
How ICD works?
I C D I N T E R R O G A T I O N
VT Burst 1 Sinus
I C D I N T E R R O G A T I O N
Burst Acc. VTVT
I C D I N T E R R O G A T I O N
DC SinusAcc.VT
Cont.
I C D I N T E R R O G A T I O N
Thank you