Pathologic findings related to the lead system and repeated defibrillations in patients with the automatic implantable cardioverter-defibrillator

Abstract

The purpose of the present study was to examine at autopsy the effect of multiple defibrillations on the myocardium and the pathologic consequences of short- and long-term placement of the intravascular and interpericardial leads of the automatic implantable cardioverter-defibrillator. Twenty-five patients were examined at autopsy; 8 of them underwent lead implantation only and 17 received both leads and the automatic implantable cardioverter-defibrillator. Twelve patients (48%) died of ventricular tachycardia or ventricular fibrillation; seven (28%) died of other causes. Acute pericarditis occurred in all patients, resulting in a localized, progressive fibrosis around the apical patch lead without giving rise to pericardial restriction. Thrombus formation was associated with the superior vena cava spring electrode in four patients (17%) and the right ventricular rate-sensing electrode in one patient (4%). Asymptomatic pulmonary emboli occurred in two patients (8%). In one patient who underwent defibrillation 59 times, superior vena cava changes consisted of vein wall destruction, fibrosis and thrombus formation. Pathologic changes under the apical patch related to defibrillation were observed in seven patients; two of these had fewer than 5 defibrillations, one had 8 defibrillations and four had 21 to 74 defibrillations. These changes consisted of contraction band necrosis in four patients, vacuolar cytoplasmic clearing and loss of myocytes confined to the myocardium under the patch electrode in five patients who had multiple defibrillations. The observed pathologic changes were estimated to affect less than 2% of the total myocardial mass. Thus, the automatic implantable cardioverter-defibrillator lead system and multiple defibrillations result in localized myocardial injury confined to the tissue under the patch electrode.(ABSTRACT TRUNCATED AT 250 WORDS)

Electroporation induced by internal defibrillation shock with and without recovery in intact rabbit hearts

“…Autopsy studies of patients who have received defibrillation shocks from ICDs show only a small amount of necrosis around the active lead (43). This suggests that 45 min is insufficient for membrane healing to be completed and that the heart requires a longer period to recovery from a defibrillation shock.…”

Electrical storm in patients with implantable cardioverter-defibrillator in the era of catheter ablation: Implications for better rhythm control

“…Initial studies have shown that ES occurs in 10-28% of ICD recipients and is associated with increased mortality. 1-8 This could be explained by different factors: i) myocardial injury and ventricular remodeling due to neurohormonal activation, caused directly by the shocks, 14 ii) the adverse effects of a heavy pharmacological regimen or iii) ES could just be a relatively "innocent bystander" in a rapidly deteriorating cardiac condition.…”

Incidence of venous obstruction following insertion of an implantable cardioverter defibrillator. A study of systematic contrast venography on patients presenting for their first elective ICD generator replacement

“…In one of the first published series of patients, Marchlinski et al [11] described one case of 14 with transvenous leads, exhibiting perioperative symptomatic thrombosis of the subclavian vein. A post-mortem autopsy study by Singer et al [13] found that four of 23 patients (17%) who had undergone transvenous implantation of a superior vena cava spring defibrillation electrode, as well as a right ventricular sensing electrode, exhibited large thrombi adherent to the spring electrode. Two of the patients had experienced asymptomatic pulmonary emboli as demonstrated by autopsy.…”

“…Different results may be anticipated with ICD leads due to their greater diameter and complexity. The available information is derived mostly from acute observations [11,12] or post-mortem studies [13]. Only one small-scale study examined patients with chronically implanted ICD leads by means of contrast angiography [14].…”