Recurrent pericardial chest pain: a case of late right ventricular perforation after implantation of a transvenous active-fixation ICD lead

A 36-year-old woman with a history of recurrent syncopal episodes presumably due to ventricular tachyarrhythmia in mitral valve prolapse underwent implantation of a transvenous ICD system. During a 23-month follow-up, she developed recurrent pericardial chest pain with pericardial friction rub. The first episode of chest pain occurred without any detectable change in pacing or sensing parameters. The second episode was associated with an increase in pacing threshold and drop in intracardiac signal amplitude. Right ventricular perforation was suspected fluoroscopically and confirmed by right ventriculography. This case report emphasizes the key steps in the diagnosis of this rare complication of an ICD implantation.     

The first year experience with the dual chamber ICD

In July 1997, a dual chamber pacemaker combined with a tiered therapy implantable cardioverter defibrillator (ICD) first became available in the United States. We report the first-year experience of one center in the United States with this dual chamber ICD. Of a total of 174 ICDs, 95 (55%) were dual chamber devices and 79 (45%) were single chamber. New dual chamber ICD insertions averaged 57.4 +/- 8.9 minutes, though there was a learning curve as the last 30 implants averaged 45.1 +/- 6.1 minutes with a negative slope to the regression line of procedure duration (-0.52, P < 0.05). New single chamber ICD implants were 18.5 minutes quicker (38.9 +/- 7.2 minutes). The most challenging implants were dual chamber upgrades (mean procedure duration 64.9 +/- 15.8 minutes), especially if there was a previously implanted pacemaker and ICD at separate sites. Indications for a new dual chamber device were grouped into classic pacemaker indications (52.5%), which comprised the Class I ACC/AHA guidelines, ICD-specific indications (24.6%), and other (23.0%). In the 34 patients undergoing dual chamber upgrade, the classic and ICD-specific groups were equal (47.0% each). Complications were rare (2.8%), though 3 (8.8%) of 34 undergoing a dual chamber upgrade developed late infections requiring explantation. In its first year, the dual chamber ICD has become a common device at our institution comprising 55% of new implants. As experience grows, we anticipate similar usage at most institutions.     

Factors determining ICD implantation in drug therapy patients after termination of antiarrythmics versus implantable defibrillators trial

Because of a significant survival benefit in the defibrillator arm of the Antiarrhythmics versus Implantable Defibrillator (AVID) Trial, patients in the antiarrhythmic drug (AAD) arm were advised to undergo ICD implantation. Despite this recommendation, ICD implantation in AAD patients was variable, with a large number of patients not undergoing ICD implantation. Patients were grouped by those who had been on AAD < 1 year (n = 111) and those on AAD > 1 year (n = 223). Multiple clinical and socioeconomic factors were evaluated to identify those who might be associated with a decision to implant an ICD. The primary reason for patients not undergoing ICD implantation was collected, as well as reasons for a delayed implantation, occurring later than 3 months from study termination. Of 111 patients on AAD for less than 1 year, 53 received an ICD within 3 months compared to 40/223 patients on AAD for more than 1 year (P < 0.001). Patient refusal was the most common reason to not implant an ICD in patients on drug < 1 year; physician recommendation against implantation was the most common in patients on drug > 1 year. Multivariate analysis showed ICD recipients on AAD < 1 year were more likely to be working and have a history of myocardial infarction (MI), while those on AAD > 1 year were more likely to be working, have a history of MI and ventricular fibrillation, and less likely to have experienced syncope, as compared to those who did not get an ICD. Having private insurance may have played a role in younger patients receiving an ICD.     

Patient evaluation of ICD recall communication strategies: a vignette study

INTRODUCTION: Communication about the unprecedented number of implantable cardioverter defibrillator (ICD) recalls has proved challenging. While initial studies have explored the psychological impact of recalls on patients, the optimal way to communicate recalls is not currently known. This study investigated the way communication of a recall can affect patients' responses. METHODS: Sixty-six ICD patients read one of six vignettes that detailed a hypothetical device recall. Vignette variables included the source of recall dissemination (physician vs. media vs. device manufacturer) and the personal relevance (own brand is recalled vs. different brand is recalled). Subsequently, patients rated their agreement to 12 statements concerning their response to the recall on a scale from 1 (Strongly Disagree) to 5 (Strongly Agree). RESULTS: Patients were significantly more confident in the accuracy of recall information from both their physician and their manufacturer compared with the media, F (2, 63) = 36.10, P < 0.01, eta(2)= 0.53. Interestingly, patients were concerned about the recall regardless of whether their brand of ICD was recalled. Survey results indicated that 78.6% of patients reported learning about recalls from the media. In stark contrast, 77.0% of patients asserted preferring to learn about recalls from their physician. CONCLUSIONS: ICD patients report increased confidence in the accuracy of the recall information from physicians and manufacturers compared with the media in reporting recalls. Because it seems that most ICD patients learn about recalls from the media, these results demonstrate a disconnect between the initial source of recall information and the patients' desired sources.     

B-Cell lymphoproliferative disorder of an ICD pocket: a diagnostic puzzle in an immunosuppressed patient

We present a case of a patient with lymphoma in an ICD pocket in the setting of posttransplant immune suppression. Infection of the ICD system was suspected and the correct diagnosis was established by biopsy.     

Complete loss of ICD programmability after magnetic resonance imaging

The purpose of this case report is to describe the effects of an MRI performed on a patient without realizing that an ICD has been previously implanted. After a few seconds of imaging the adversity was recognized and the examination was stopped immediately. The patient was not pacemaker dependent and had neither physical complaints nor electrocardiographic changes in the surface ECG. A consecutively performed ICD assessment showed a backup mode with standard parameters for pacing (VVI 50 beats/min) and arrhythmia detection and treatment. The device could not be programmed by the external programmer. With the exception of printing out the parameters, all software functions were no longer feasible. A device examination by the manufacturer after ICD replacement showed that a major portion of the device memory was corrupt. Even ICDs of a newer generation are susceptible to magnetic interference, with the danger of complete loss of programmability.     

Temporal and geographical trends in indications for implantation of cardiac defibrillators in Europe 1993-1998. Medtronic ICD System Investigators

Despite the demonstrated efficacy of implantable cardioverter defibrillators (ICDs) in reducing sudden and total mortality in selected populations, their implantation rates vary greatly between countries. The aim of our study was to analyze temporal and geographical trends in ICD implantations in countries with similar health related expenditure in Western Europe. A total of 2,257 patients from ten European evaluation studies of Medtronic defibrillators and defibrillation electrodes, conducted between 1993 and 1998, representing 12 countries, was included in this analysis. Rates of implantation and clinical characteristics were compared between countries and years of implantation. Rates of implantation differed greatly between Western European countries and did not correlate with indices of health related expenditure (i.e., number of patients per physician and number of patients per hospital bed). However, there was a strong and statistically significant negative correlation between the use of amiodarone and the rates of implantation (r = -0.66, P = 0.02). Temporal trends showed a significant increase in the age of the patients receiving an ICD between 1993 and 1998 (57 +/- 14 vs 61 +/- 12 years, mean +/- SD, P < 0.001). There was also a temporal trend towards an increased incidence of coronary artery disease and a significant decrease in the incidence of cardiomyopathy. There was a temporal increase in implantations in patients with a history of ventricular tachycardia. Despite a general scientific agreement that ICDs are a first line treatment for patients at high risk of sudden cardiac death, their acceptance remains low in several developed countries. This low acceptance may not be entirely related to budget constraint but may also be related to their perceived efficacy by physicians and health authorities.     

The ICD shock and stress management program: a randomized trial of psychosocial treatment to optimize quality of life in ICD patients

BACKGROUND: Implantable cardioverter defibrillator (ICD) patients potentially face significant psychological distress because of their risk for life-threatening arrhythmias and the occurrence of ICD shock. METHODS: The purpose of this study was to test an ICD stress and shock management program delivered in either a six-week format or a one-day workshop format. This intervention was aimed at reducing psychological (anxiety) and physiological (salivary cortisol) markers of distress in ICD patients. Secondary endpoints included measures of quality of life (QOL) and patient acceptance of device therapy, as well as biological mediators of inflammation (TNFalpha and IL-6). RESULTS: The ICD stress and shock management program resulted in the reduction of anxiety (P < 0.05) and cortisol levels (P < 0.05) in both the six weekly sessions format and the one-day workshop. Measures of anxiety decreased more rapidly with weekly intervention (P = 0.05). Both formats also resulted in a significant increase in patient acceptance of the ICD (P < 0.01). Follow-up assessment from posttreatment (T2) to four-month follow-up (T4) indicated no significant change in depression scores from posttreatment for all groups taken together, but there was a significant group by time effect, such that the workshop group displayed an increase in depression scores from T2 (M = 8.71, SD = 4.39) to T4 (M = 13.57, SD = 11.90), P < 0.05. CONCLUSIONS: These results suggest that structured interventions for shocked ICD patients involving ICD education and cognitive-behavioral strategies can reduce psychological distress and improve quality of life, regardless of format.     

Antitachycardia pacing for rapid VT during ICD charging: a method to prevent ICD shocks

In patients with ICDs, rapid VTs are usually treated with shocks. It is unknown, if antitachycardia pacing (ATP) delivered once for rapid VT during capacitor charging can avoid painful shocks without increasing the risk of syncope. In patients in whom rapid monomorphic VT (cycle length 300-220 ms) could be reproducibly induced during predischarge ICD testing, the success of cardioversion (defibrillation threshold plus 10 J) and a single ATP attempt (burst with 8 or 16 stimuli) was compared using a randomized crossover study design. Consciousness of the patients was checked by the signal from a button constantly pushed by the patient. In 20 patients (ejection fraction 0.50 +/- 0.19) rapid VTs (253 +/- 26 ms) were reproducibly induced. A single burst successfully terminated 11 (55%) of 20 rapid VTs, 6 episodes could not be terminated with a single burst pacing and 3 VTs accelerated. Rapid VTs not terminated by ATP were significantly faster than those that could be terminated (246 vs 258 ms, P = 0.026). Cardioversion (19 +/- 3 J) terminated the VTs in all cases. No patient suffered syncope during rapid VTs. A single ATP may terminate rapid VT with cycle lengths < 300 ms in 55% of patients without increasing the risk of syncope. Therefore, in rapid VTs one attempt of ATP may be suitable as an additional therapy option during ICD capacitor charging to avoid painful shocks without compromise of safety. Thus, future ICDs should implement the option of ATP during charging of capacitors.     

The Effect of Coronary Bypass Graft Surgery for the Prevention of Sudden Cardiac Death: Recurrent Episodes After ICD Implantation and Review of Literature

Sudden cardiac death (SCD) accounts for at least 50% of the mortality of patients with ischemic heart failure. Ventricular arrhythmias are responsible for most cases of sudden cardiac death. There is some evidence that coronary artery bypass graft (CABG) surgery may reduce the incidence of recurrent episodes of SCD by prevention of myocardial ischemia. To test the hypothesis that CABG surgery is effective in the prevention of SCD, we compared the recordings of implantable cardioverter defibrillators (ICD) in patients who underwent ICD implantation alone (n = 64) or ICD implantation and concomitant CABG surgery respectively (n = 11). All patients had experienced out of hospital cardiac arrest. ICD recordings were obtained every 3 months and the number of recurrent episodes of ventricular tachycardia (VT) for each time period was noted. Three months foilowing ICD implantation patients in the surgically treated group had an average of one episode of VT per patient as compared to 2.7 episodes in the nonsurgical group. This difference was observed during the following months as well. However, at nlo time (up to 18 months of follow-up) this difference reached statistical significance. There were no deaths in the surgically treated group. Although we could not demonstrate a statistical significant difference between the two groups, there was a tendency in the surgically treated group to have less episodes of recurrent VT than in the medically treated group. We, therefore, conclude that survivors of SCD presenting with multivessel coronary artery disease (CAD) should undergo coronary artery bypass grafting to prevent myocardial ischemia as the triggering event for lethal ventricular arrhythmias.     

Distinct clinical features in the recipients of the implantable cardioverter defibrillator in Taiwan: a multicenter registry study

Little information about the ICD is available from the Asian Pacific region. The purpose of this study was to characterize the clinical features in ICD patients in Taiwan and to compare these features with those in patients in the Western populations, mainly the Canadian Implantable Defibrillator Study (CIDS), the Antiarrhythmics versus Implantable Defibrillator (AVID) trial, and the Cardiac Arrest Study Hamburg (CASH) trial. From February 1995 to October 2001, 101 ICDs were implanted in 92 patients (78 [84%] men) in 12 hospitals. Clinical presentations included sudden cardiac death due to VF/VT in 35 (38%) patients, syncopal VT in 25 (27%), drug refractory nonsyncopal VT in 27 (29%), and unexplained syncope with inducible sustained VT/VF in 5 (6%). The mean age was significantly younger than that in CIDS or AVID (59 +/- 16 vs 63 +/- 9 years in CIDS, P = 0.02; vs 65 +/- 11 years in AVID, P < 0.001), but was comparable to that in CASH (59 +/- 16 vs 58 +/- 11 years in CASH, P = 0.75). The mean LVEF was significantly higher than that in CIDS or AVID (48 +/- 19% vs 34 +/- 15% in CIDS, P < 0.001; vs 32 +/- 13% in AVID, P < 0.001), but was comparable to that in CASH (48 +/- 19 vs 46 +/- 19% in CIDS, P = 0.83). The ICD patients in the current study also showed a higher incidence of normal heart (23 vs 4% in CIDS, P < 0.001; vs 3% in AVID, P < 0.001; vs 9% in CASH, P < 0.001) and cardiomyopathy (41% vs 10% in CIDS, P < 0.001; vs 15% in AVID, P < 0.001; vs 11% in CASH, P < 0.001), but a lower incidence of coronary artery disease (29% vs 83% in CIDS, P < 0.001; vs 82% in AVID, P < 0.001; vs 73% in CASH, P < 0.001). During a mean follow-up of 28 +/- 24 months, 13 (14%) patients died. Older age was the only factor associated with poorer survival after ICD implantation. Forty-seven (51%) patients received appropriate ICD discharges during follow-up. History of prior myocardial infarction was the only factor associated with an earlier first appropriate ICD discharge and LVEF < 0.35 the only factor associated with subsequent poorer survival after the first ICD discharge. In conclusion, this study demonstrated many distinct clinical features in our ICD population that were different from those in the Western populations.     

Pneumothorax: An Unusual Cause of ICD Defibrillation Failure

We describe two patients with defibrillation failure of implantable cardioverter defibrillators (ICDs) resulting from large left pneumothoraxes following subclavian vein puncture during the implantation. Following pneumothorax drainage, low defibrillation thresholds (DFTs) were attained without further manipulations. The absence of other signs and symptoms of pneumothorax and the presence of satisfactory pacing function during the procedure, resulted in a significant delay in diagnosis. Pneumothorax should be included in the differential diagnosis when unexpected high DFTs are found during ICD implantation or predischarge testing. This complication is avoidable by a different surgical approach, cephalic vein cutdown.     

植入型心律转复除颤器患者体验的Meta整合

目的 系统评价植入型心律转复除颤器患者体验的质性研究。方法 检索中国知网、万方、维普、中国生物医学数据库、PubMed、Embase、The Cochrane Library、CINAHL、PsycINFO、Scopus、Web of Science关于植入型心律转复除颤器患者体验的定性研究,检索时限为建库至2021年12月5日。依据澳大利亚循证卫生保健中心质性研究质量评价标准对文献进行质量评价,采用Meta整合法对纳入文献进行整合。结果 共纳入21项研究,提炼出126个主题,归纳成9个类别,整合出3个主题：设备植入带来的身心变化及生死边缘的放电体验;康复期进行自我调整,接受并适应设备存在;与设备共存中存在诸多挑战,寻求外界支持与帮助。结论 护理人员需关注患者的身心体验,放电后及时给予心理干预,同时重视设备接受程度的个体差异,及时、动态性评估患者照护需求,逐步完善延续性护理服务,提升患者的生存质量。     

Retromammary Implantation of an ICD Using a Single Lead System: An Alternative Approach to Pectoral Implantation in Women

Pectoral ICD implantation, although feasible with the release of smaller devices, can be cosmetically disturbing to some patients due to the device protruding under the skin. An ICD was implanted using the retromammary approach in a 25-year-old female patient. Retromammary implantation of an ICD is feasible and offers an alternative approach in women.     

Inadequate ICD discharges due to diaphragmatic electromyopotential oversensing as the first sign of right ventricular lead perforation

Right ventricular lead perforation, when acute, is a rare but potentially life-threatening complication of implantable cardioverter defibrillator (ICD) therapy. We report about a patient with early lead perforation presenting with repetitive ICD discharges due to oversensing of diaphragmatic electromyopotentials and describe the management of this complication.     

The importance of tricuspid regurgitation and right ventricular overload in ICD/CRT recipients: beside the left, beyond the left

Device therapy for advanced heart failure has become increasingly employed in the last 10 years. Several retrospective studies have postulated a harmful effect of implantable cardioverter-defibrillator (ICD) lead placement on tricuspid valve function and right heart hemodynamics, in particular among patients with preexisting pulmonary vascular overload and both left and right ventricular remodeling/dysfunction. This functional hypothesis is also supported by long-term clinical follow-up analyses of ICD and cardiac resynchronization therapy recipients. In this viewpoint, we propose that the possibility of worsening tricuspid regurgitation and consequent hemodynamic deterioration following device implantation should be considered in future studies, as well as in the preimplant evaluation of individual candidates among other clinical factors.