Implantable Cardioverter-Defibrillator: A Practical Manual

217 Pages·2001·21.681 MB·English

by  L. Bing Liem D.O. (auth.)

Implantable Cardioverter- Defibrilator
Implantable Cardioverter
Defibrillator
A Practical Manual
by
L. Bing Liem
Stan.f(Jrd University Medical Center,
Stanford, CA, U.SA
SPRINGER-SCIENCE+BUSINESS MEDIA, B.V.
A C.LP. Catalogue record for this book is available from the Library of Congress.
ISBN 978-90-481-5627-6 ISBN 978-94-017-1837-0 (eBook)
DOI 10.1007/978-94-017-1837-0
Printed on acid-free paper
AII Rights Reserved
© 200 l Springer Science+Business Media Dordrecht
Originally published by Kluwer Academic Publishers in 2001
No part of the material protected by this copyright notice may be reproduced or
utilized in any form or by any means, electronic or mechanical,
including photocopying, recording or by any information storage and
retrieval system, without written permission from the copyright owner.
To Jim,
whose patience and support
have made this writing possible
Table of Contents
Foreword .................................................................................... ix
Introduction ................................................................................ xi
1 Historical Perspective ........................................................... 1
The Development of the Implantable Defibrillator ................. 1
Other Therapy for Ventricular Tachyarrhythmias .................. 4
The Emerging Role of the Implantable Defibrillator ............. 13
2 Indications for I CD Therapy ................................................ 19
Early Role ofICD ...................................................... 19
Results of Clinical Trials .............................................. 19
Current Practice Guidelines .......................................... 25
Expanding Indications ................................................ 28
Economical Impact of ICD Usage ................................... 30
3 Device Operation ............................................................... 35
The Basic ICD ......................................................... 35
Defibrillation Concept and Technology ............................. 38
Pacing Concept and Technology .................................... 53
Sensing Concept and Technology ................................... 56
Basic Tachyarrhythmia Detection Features ........................ 63
Enhanced Detection Features ........................................ 70
Discrimination Using Dual-Chamber Sensing .....................7 6
4 Implantation Procedure ...................................................... 91
The Open-Chest Surgical Approach ................................. 91
Improvement in Device Hardware .................................. 93
Current Technique ..................................................... 95
Pacing Parameters Measurement. ................................... 99
Defibrillation Testing ................................................ 100
Explantation and Revision Procedures ............................ 108
Perioperative Issues .................................................. 113
5 Patient Management ......................................................... 121
General Considerations .............................................. 121
Basic Programming .................................................. 122
Programming VF Zone and Therapy .............................. 123
Programming VT Zone and Therapy .............................. 125
Utilizing Detection Enhancement Features ....................... 131
Programming Onset and Stability Criteria ........................ 131
Programming QRS Width and Morphology ..................... 132
Programming Detection Enhancement in Dual-Chamber ICD134
Programming Bradycardia Parameters ............................ 141
Follow Up Care ...................................................... 145
vii
VUl
Some Practical Steps of ICD Management. ...................... 154
Radiographic Identification ......................................... 155
Interactions with Drugs and Pacemakers ................. " ....... 157
Interactions with Electromagnetic Field ........................... 161
Quality of Life Aspects .............................................. 164
Trouble Shooting ..................................................... 166
6 New Features .................................................................. 185
Further Technological Refinement. ................................ 185
The incorporation ofTherapy for Atrial Tachyarrhythmias .... 191
Pacing Therapy for Heart Failure .................................. 193
Summary ............................................................... 197
Index ....................................................................................... 203
Foreword
At the dawn of the twenty-first century, ICDs have reached the
mainstream of tachyarrhythrnia therapy. Most ICD recipients have structural
heart disease and receive ongoing care from cardiologists who are not
electrophysiologists. Clinical cardiologists and heart failure specialists are
increasingly involved in the prescription of ICD therapy and follow-up of ICD
patients. If the indications for ICD therapy and the trend for ICD implantation
without antecedent comprehensive electrophysiologic evaluation continue to
increase - as seem likely - cardiologists may be increasingly involved in ICD
implantation.
Comprehensive texts provide excellent references on [CD therapy for the
expert electrophysiologist, but there remains a need for a succinct, focused,
clinical text on ICD therapy both for the non-electrophysiologist and for fellows
in cardiology or cardiac electrophysiology. Dr. Liem's Practical Manual fills this
important role for cardiologists, fellows in cardiology, and physicians in other
specialties who are required to treat ICD patients with increasing frequency, such
as anesthesiologists, radiologists, intensivists, and emergency physicians. It could
only have been written by a leading, experienced implanter and clear-thinking,
hands-on clinician like Dr. Liem.
The Manual begins with succinct summaries of the place of ICDs in
overall antiarrhythrnic therapy and present clinical indications for ICDs. The
section on Device Operation covers clinical application of basic physiologic and
bioengineering principles relevant to defibrillation, basic cardiac pacing issues
relevant to ICDs, as weIl as single-chamber and increasingly complex, dual
chamber tachyarrhythrnia detection algorithms.
The Implantation Procedure sec ti on is a thorough guide for implanters,
including details of [CD explantation and lead revision. The rapidly increasing
simplicity of ICD implantation provides a stark contrast to the even more rapidly
increasing complexity of ICD programrning and troubleshooting. Appropriately,
the most comprehensive section of the Manual addresses patient management.
The detailed, clear, and weIl-illustrated discussions of programrning
considerations and practical aspects of troubleshooting may prove to be the most
valuable sections for clinicians involved in follow-up of ICD patients. Sections
on drug and pacemaker interactions, electromagnetic interference, ICD
radiography, and quality of life focus on how these subjects relate to clinical
management.
This Manual provides a succinct guide to the basic principles guiding
ICD therapy and a comprehensive approach to the management of ICD patients.
ix
x
It should serve as an especially important resource for fellows in cardiology and
non-electrophysiologists who participates in the care of ICD patients.
Charles D. Swerdlow, M.D.
Research Scientist II -Cedars Sinai Medical Center
Clinical Associate Professor of Medicine -University of California Los Angeles
Los Angeles, California
Introduction
Many significant developments in the field of medicine evolved from an
intricate collaborative work between scientists, engineers, and clinicians. The
progress of implantable cardioverter-defibrillator (reD) therapy is of no
exception. The idea was born from a clinician' s desire to prevent sudden death
and carried on to an early concept of a wearable and, eventually, potentially
implantable defibrillator. The early struggles in conceptual and engineering feats
were supported by dedicated scientists and clinicians and maintained by
unrelenting preservation amidst some skepticism and criticism. The unyielding
effort eventually resulted in the production of asolid device system with proven
efficacy, practical applicability and comprehensive performance capability.
The developmental steps in the progress of reD technology occurred as a
result of an integrative effort between clinicians and engineers. The field was
regarded as highly specialized and its application was expected to be limited only
to the experts specializing in that field. However, as device implantation
becomes progressively simpler and the application of therapy continues to evolve
to include a much broader range of patients, it is inevitable that the general
cardiologists become also closely involved in the selection and follow-up of the
patients and, in some instances, the implantation procedure. Unfortunately, even
though the application of the therapeutic concept has become simpler, the
operation of the device has become more sophisticated and complex. The
assumption that the clinical management of a patient with an reD would be
similar to that of a patient with a pacemaker would certainly be an erroneous and
overly simplified one. The management of the patient with an reD would. in the
first place, pose a clinical ehallenge of understanding the operation of both a
bradyeardia and tachycardia device. The elinician should be familiar with the
operation of these devices both as separate entities and as a unit. Additionally,
the management of tachyarrhythmia prevention involves sudden death risk, and
the consequences of any error are usually much less forgiving than of an
inadequate programming of a pacemaker. Finally, the automation of
tachyarrhythmia therapy does not always result in a simpler algorithm; in fact,
the added features for tier-therapy and arrhythmia discrimination would pose the
clinician with decision that would require a thorough understanding of the
various arrhythmias.
The indication for IeD therapy is a continuing evolving concept. The
scope of therapy far malignant ventricular tachyarrhythmia is an ever-changing
one. The role of anti arrhythmie drug is eonstantly challenged. The concept of
arrhythmia suppression was graduaHy replaced by a method utilizing cardiac
eleetrophysiology (EP) study as weIl as empirie prescription of a "broad
speetrum" antiarrhythmic drug such as amiodarone and sotalol. At the same
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xii
time, data from clinical studies involving Icn indicate the superiority of device
therapy and therefare, it is likely that secondary and primary prevention of
arrhythmia will be managed primarily with an Icn. Even the role of EP study in
the management of these patients is being challenged, both in terms of therapy
selection and risk stratification. It is conceivable that the recommendation of
Icn therapy is made on the basis of clinical criteria alone, without the
involvement of the electrophysiologist. Thus, it is prudent that the clinicians
from all disciplines to understand the clinical scope of Icn therapy and the
complexity of its operation.
This publication is intended to expose those clinicians that are likely to
be involved in the decision making far Icn therapy and its follow-up with a
comprehensive knowledge of availability, capability and intricacy of such
therapy. We believe that the historical view is of some importance, especially in
placing the indication of such therapy in the proper perspective. The
development of device and lead technology is also of great significance in the
appreciation of the current units and the management of older models and will
therefore be included also. Closely related to this topic is the implantation
procedure, because it requires a thorough understanding and appreciation of the
various units, leads and their general and unique operation. The choice of unit
and system would obviously be based on the patient's need and the device's
system scope of operation, and the clinician must make the clear decision and
offer the options to the patient prior to the surgery. The most important portion
of the book is, obviously, the clinical management of the patient with the device,
and therefore, the bulk of the content is devoted to topics related to this subject.
Finally, and not of least importance, are the non-medical issues, such as the
technical, physical, psychological, social, economical, legal, and logistics factors
of this "technological" therapy. The role of the patient and family as individuals
is often only considered as an after thought and not given enough priorities. To
include all of the psychological and social aspects of Icn therapy into the picture
would undoubtedly require more than the clinicians involved in the care of the
patient. The involvement of other health care providers, such as the arrhythmia
nurse specialists and counselors, and technical specialists from the manufacturer,
is not only of significant importance; it is mandatory. The economical impact,
and burdens, of this form of therapy is not known yet, but the assumption of its
significance has greatly influenced its application. The logistics of this therapy
in the society is also being feIt. All of these issues will be discussed to the extent
of available scientific and anecdotal data.
At present, Icn technology has reached a level that is satisfactory to its
purpose. It remains an effective therapy for the prevention of sudden death
despite the addition of tiered therapy and arrhythmia discrimination features. It
has also incorporated dual-chamber pacing with satisfactory performance,
including rate-responsiveness and mode-switching. This stage of development
is, in terms of general clinical application, optimal and has therefore set the new
platform "basic" modern ICns. This publication is intended to include all of the