Implantable Cardioverter-DefibrillatorsStep by StepAN ILLUSTRATED GUIDE

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ImplantableCardioverter-DefibrillatorsStep by Step

AN ILLUSTRATED GUIDE

Roland X. StroobandtMD, PhDProfessor of MedicineHeart Center, University Hospital Ghent, BelgiumDepartment of Cardiology, A.Z. Damiaan Hospital, Ostend, Belgium

S. Serge BaroldMD, FRACP, FACP, FACC, FESC, FHRSClinical Professor of Medicine,University of South Florida Cardiology Division,Tampa General Hospital, Tampa, Florida, USA

Alfons F. SinnaeveIng, MScProfessor Emeritus of Electronic EngineeringTechnical University KHBO, Department of Electronics,Ostend, Belgium

A John Wiley & Sons, Ltd., Publication

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This edition first published 2009, © 2009 R.X. Stroobandt, S.S. Barold and A.F. Sinnaeve

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Library of Congress Cataloging-in-Publication DataStroobandt, R. (Roland)

Implantable cardioverter-defibrillators step by step : an illustrated guide / Roland X. Stroobandt, S. Serge Barold, Alfons F. Sinnaeve.

p. ; cm.Sequel to: Cardiac pacemakers step by step / S. Serge Barold, Roland X. Stroobandt, Alfons F. Sinnaeve. c2004.ISBN 978-1-4051-8638-41. Implantable cardioverter-defibrillators—Handbooks, manuals, etc. I. Barold, S. Serge. II. Sinnaeve,

Alfons F. III. Barold, S. Serge. Cardiac pacemakers step by step. IV. Title.[DNLM: 1. Defibrillators, Implantable—Handbooks. 2. Tachycardia, Ventricular—therapy—Handbooks.

3. Death, Sudden, Cardiac—prevention & control—Handbooks. 4. Ventricular Fibrillation—therapy—Handbooks. WG 39 S924i 2009]

RC684.E4S74 2009617.4’120645—dc22

2008033369ISBN: 9781405186384A catalogue record for this book is available from the British Library.

Set in 9.5/12pt palatino by Graphicraft Limited, Hong KongPrinted in Singapore by Markono Print Media Pte, Ltd1 2009

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Preface vi

Acknowledgments vii

Introduction ix

Illustrations 1

1. Cardiac tachyarrhythmias 1

2. Indications 21

3. ICD hardware 39

Battery, capacitors and leads 39

4. ICD implantation 67

5. Sensing and detection 90

6. SVT/VT discrimination 112

7. ICD therapies 144

8. ICD timing cycles 168

9. Complications of ICD therapy 176

10. Follow-up of ICDs 195

11. Troubleshooting 217

12. Special ICD functions and resynchronization therapy 229

13. ICD function with emphasis on storedelectrograms 255

Representative examples 1 to 65 260

Text 333

1. Cardiac tachyarrhythmias 333

2. Indications for ICD 337

3. ICD hardware 342

4. ICD implantation and lead systems 349

5. Sensing and detection of ventriculartachycardia/fibrillation 354

6. SVT/VT discrimination 357

7. ICD therapies 360

8. Timing cycles of ICDs 367

9. Complications of ICD therapy 368

10. ICD follow-up 374

11. Troubleshooting 382

12. Cardiac resynchronization 388

13. Appendix A: American College of Cardiology/American HeartAssociation/European Society of Cardiology: 2006 Guidelines for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Death 400

14. Appendix B: American College of Cardiology/American HeartAssociation/Heart Rhythm Society: 2008 Guidelines for ICD and CRT 406

Index 409

vContents

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vi Preface

Implantable Cardioverter-Defibrillators Step By Stepis the logical sequel to our first book, CardiacPacemakers Step by Step, published in 2004. The pacemaker book should obviously be studied beforestarting this book because pacing constitutes anintegral part of the function of an implantable cardioverter-defibrillator (ICD). The original pace-maker book was so well received that we decided tokeep the same format. In addition, 65 carefullyselected ICD recordings have been included.

As one picture is worth a thousand words, wehave tried to avoid unnecessary text and focused on visual learning. Many of the figures are self-explanatory and the text in the appendix provides asummary of the field. The relevant figures are citedin the appended text. This arrangement promoteslearning as an enjoyable and fun experience.

We have discussed the electrophysiologic aspectsof ICD implantation but omitted a description of the standard surgical implantation procedures, whichare well described elsewhere. Furthermore, the majorICD trials are mentioned only briefly to avoid reduplication of the abundant literature on the subject. Barring these two issues, which might haverendered the work unwieldy, the book provides acomprehensive review of the basic and clinical

aspects of ICD therapy. A section on cardiac resyn-chronization was added because most patients with such devices also receive an ICD. The rapidevolution of technology made our task a moving target, with the continual need to upgrade some ofthe material. Despite our efforts, it is possible thatsome dated material might have escaped our atten-tion, and we apologize for this.

We have discussed only the devices from thethree US manufacturers as models, merely for thesake of convenience. We are well aware that manu-facturers outside of the United States produce excel-lent devices. Although a full description of non-USICDs is beyond the scope of the book, such ICDsshare many characteristics with US devices so thatthe book will be universally applicable to the clinicalevaluation of all devices regardless of their origin.We are particularly indebted to representatives of Medtronic Inc., St. Jude Medical and BostonScientific for helping and guiding us with this project. However, we remain responsible for anymistakes related to ICD technology.

Roland X. StroobandtS. Serge Barold

Alfons F. Sinnaeve

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viiAcknowledgments

Carsten Israel MD (Frankfurt, Germany), MichaelO. Sweeney MD (Boston, MA), Bengt Herweg MD(Tampa, FL), and representatives from MedtronicInc., Boston Scientific and St. Jude Medical kindlyprovided a number of tracings.

Figure 13.381 was reproduced with permissionfrom Mehdirad A, Fredman C, Bierman K, BaroldSS. AV interval-dependent crosstalk. Pacing ClinElectrophysiol 2008;31:232–4.

Figure 13.36 was reproduced with permissionfrom Stroobandt R, Hagers Y, Provenier F, Van BelleY, Hamerlijnck R, Barold SS. Silent lead malfunctiondetected only during defibrillator replacement.Pacing Clin Electrophysiol 2006;29:67–9.

Figure 13.44 was reproduced with permissionfrom Sung RJ, Lauer MR (eds) Implantable cardioverter-defibrillator therapy. In: FundamentalApproaches to the Management of CardiacArrhythmias. Dordrecht, The Netherlands: KluwerAcademic Publishers, 2000:287–416.

Parts of the following guideline were reproducedby permission of the American Heart Association.

Zipes DP, Camm AJ, Borggrefe M, Buxton AE,Chaitman B, Fromer M, Gregoratos G, Klein G,Moss AJ, Myerburg RJ, Priori SG, Quinones MA,Roden DM, Silka MJ, Tracy C, Smith SC Jr, JacobsAK, Adams CD, Antman EM, Anderson JL, HuntSA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J,Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for Management ofPatients With Ventricular Arrhythmias and thePrevention of Sudden Death—Executive Summary:A Report of the American College of Cardiology/American Heart Association Task Force and theEuropean Society of Cardiology Committee forPractice Guidelines (Writing Committee to DevelopGuidelines for Management of Patients With

Ventricular Arrhythmias and the Prevention ofSudden Cardiac Death). Developed in collabora-tion With the European Heart Rhythm Associationand the Heart Rhythm Society. J Am Coll Cardiol.2006;48:e247-346.

Epstein AE, DiMarco JP, Ellenbogen KA, EstesNA 3rd, Freedman RA, Gettes LS, Gillinov AM,Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ,Stevenson LW, Sweeney MO, Smith SC Jr, JacobsAK, Adams CD, Anderson JL, Buller CE, CreagerMA, Ettinger SM, Faxon DP, Halperin JL, HiratzkaLF, Hunt SA, Krumholz HM, Kushner FG, LytleBW, Nishimura RA, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology/American Heart Association TaskForce on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 GuidelineUpdate for Implantation of Cardiac Pacemakers andAntiarrhythmia Devices); American Association forThoracic Surgery; Society of Thoracic Surgeons.ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Prac-tice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers andAntiarrhythmia Devices) developed in collabora-tion with the American Association for ThoracicSurgery and Society of Thoracic Surgeons. J Am CollCardiol. 2008;51:e1-62.

The authors would also like to thank the nursesand technicians: Veerle De Meyer, Myriam Peleman,Rudy Colpaert, Guy De Cocker of the UniversityHospital, Ghent, Belgium, and Filiep Vandenbulckeof the A.Z. Damiaan Hospital, Ostend, Belgium, fortheir dedicated care of ICD patients and ability torecognize the teaching value of a number of record-ings included in this book.

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ixIntroduction

Sudden cardiac death remains a major public healthproblem and accounts for 450 000 deaths annu-ally in the United States and 400 000 in Europe.Michel Mirowski began developing an implantabledefibrillator in the mid-1960s. The first automaticdefibrillator was finally implanted in a humanpatient in 1980. The device presently known as animplantable cardioverter-defibrillator (ICD) hasproven effective in preventing sudden cardiacdeath. Since 1980, technologic advances in devicetherapy including miniaturization, improved leads,optimal waveforms and transvenous implantationhave revolutionized the treatment of malignant ven-tricular tachyarrhythmias and sudden cardiac death.These advances have made ICDs easier and safer toimplant and better accepted by patients and physi-cians. Thus, ICDs have evolved from a treatment of last resort to the gold standard for patients at highrisk for life-threatening ventricular arrhythmias.Recent advances include dual-chamber ICDs, additional therapy for atrial arrhythmias, and ICDscombined with biventricular pacing for selectedheart failure patients. Device-based monitoring ofcontemporary ICDs can also record data unrelatedto arrhythmias such as activity and the status oflung fluid in patients with congestive heart failure.Finally, ICDs provide health benefits with efficiencycomparable to other well-accepted forms of healthcare such as renal dialysis.

The ICD does not prevent arrhythmias fromoccurring, and it is sometimes likened to having aminiature ambulance crew inside the chest. Shockdelivery is the final step in a cascade of events beginning with arrhythmia detection. The devicecan detect ventricular tachyarrhythmias, determinewhether they should be converted to a normalrhythm with a shock or rapid ventricular pacing,and then administer therapy. After successful treat-ment, the device must recognize the nontachycardicrhythm and reset the therapy sequences for the next event. Afterwards, the device keeps a completerecord of what it has done. An ICD also gives bradycardia and post-shock bradycardia supportlike a conventional pacemaker.

Cardioversion and defibrillation are both forms of high-energy therapy or shocks. If the patient isconscious at the time of a shock, it is painful andusually described as feeling like a kick in the chest.Patients should be advised of this in advance. Theirfamilies should be advised that someone touchingthem is not harmed if the ICD discharges.

ICDs are multiprogrammable devices capable ofdelivering therapy for ventricular tachyarrhythmiasin the form of high-energy defibrillation shocks,low-energy (cardioversion) shocks or antitachy-cardia pacing, and conventional pacing therapy forbradyarrhythmias (Fig. 0.01). Today’s devices havea longevity of about 5–7 years, depending on shockand pacing frequency.

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