The automatic implantable cardioverter defibrillator: Efficacy, complications and survival in patients with malignant ventricular arrhythmias

Kelly, P. M.; Cannom, David S.; Garan, Hasan; Mirabal, Gloria S.; Harthorne, J. Warren; Hurvitz, Richard J.; Vlahakes, Gus J.; Jacobs, Marshall L.; Ilvento, Joseph P.; Buckley, Mortimer J.; Ruskin, Jeremy N.

doi:10.1016/0735-1097(88)90292-6

Cited by 376 publications

(45 citation statements)

References 18 publications

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“…52 However, underreporting is unlikely to be the cause for our finding that antiarrhythmic drug use, especially amiodarone, is associated with high defibrillation thresholds since the prevalence of antiarrhythmic drug use, including amiodarone, in our patients does exceed that in most other previously reported series. [53][54][55][56]58 Interestingly, in the one study in which amiodarone use was more frequent than in our study, patient entry was restricted to those with defibrillation thresholds .20 J,57 i.e., patients with high defibrillation thresholds were excluded.…”

Section: Study Limitationsmentioning

confidence: 99%

Clinical characteristics and outcome of patients with high defibrillation thresholds. A multicenter study.

et al. 1992

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BACKGROUND Successful defibrillation by an implantable cardioverter-defibrillator (ICD) depends on its ability to deliver shocks that exceed the defibrillation threshold. This study was designed to identify clinical characteristics that may predict the finding of an elevated defibrillation threshold and to describe the outcome of patients with high defibrillation thresholds. METHODS AND RESULTS The records of 1,946 patients from 12 centers were screened to identify 90 patients (4.6%) with a defibrillation threshold greater than or equal to 25 J. Excluding three patients who received ICDs that delivered greater than 30 J, there were 81 men and six women with a mean age of 59.5 +/- 10.1 years, a mean left ventricular ejection fraction of 0.32 +/- 0.14, and a 76% prevalence of coronary artery disease. Sixty-one patients (70%) were receiving antiarrhythmic drugs, and 45 (52%) were receiving amiodarone. Seventy-one patients (82%) received an ICD. Death occurred in 27 patients--19 of the 71 (27%) with an ICD (eight arrhythmic), and eight of the 16 (50%) without an ICD (four arrhythmic). Actuarial survival for all patients at 5 years was 67%. Actuarial survival rates at 2 years for patients with and without an ICD were 81% and 36%, respectively (p = 0.0024). Actuarial survival at 5 years for the ICD patients was 73%; no patient without an ICD has lived longer than 32 months. Actuarial survival free of arrhythmic death in the ICD patients at 5 years was 84%. Although the only variable to predict survival was ICD implantation (p = 0.003), it is entirely possible that in this retrospective analysis, clinical selection decisions to implant or to not implant an ICD differentiated patients destined to have better or worse outcomes, respectively. CONCLUSIONS Antiarrhythmic drug use may be causally related to the finding of an elevated defibrillation threshold. When patients with high defibrillation thresholds receive an ICD, arrhythmic death remains an important risk (42% of deaths in these patients were arrhythmia related, with 16% actuarial incidence at 5 years). Vigorous testing to optimize patch location can potentially benefit patients by enhancing the margin of safety for effective defibrillation.

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Section: Study Limitationsmentioning

confidence: 99%

Clinical characteristics and outcome of patients with high defibrillation thresholds. A multicenter study.

et al. 1992

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“…In fact, this therapy is now widely applied in clinical practice and considered by some to be the treatment of choice in cardiac arrest survivors.22-24 Previous studies have reported a low incidence of sudden See p 1348 cardiac death in patients with life-threatening ventricular arrhythmias who receive an implantable defibrillator. [25][26][27] However, since the introduction of the implantable defibrillator into clinical practice in the early 1980s, no large studies have specifically examined the impact of this new therapy on the long-term outcome of survivors of out-of-hospital cardiac arrest. The objective of this study was to examine the influence of the implantable defibrillator and other variables on long-term outcome in survivors of out-of-hospital cardiac arrest.…”

mentioning

confidence: 99%

Influence of implantable cardioverter-defibrillators on the long-term prognosis of survivors of out-of-hospital cardiac arrest.

et al. 1993

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BACKGROUND Survivors of out-of-hospital cardiac arrest not associated with acute myocardial infarction are at high risk for recurrent cardiac arrest and sudden cardiac death. The impact of the implantable cardioverter-defibrillator on long-term prognosis in these patients is uncertain. METHODS AND RESULTS Three hundred thirty-one survivors of out-of-hospital cardiac arrest (age, 56 +/- 13.7 years) underwent electrophysiologically guided therapy. Implantable defibrillators were placed in 150 patients (45.3%), and 181 patients (54.7%) received pharmacological and/or surgical therapy alone. Left ventricular ejection fraction was 35.2 +/- 16.6% in defibrillator recipients and 45.3 +/- 18.2% in nondefibrillator patients. Median patient follow-up was 24 months in the defibrillator group and 46 months in the nondefibrillator group. In a proportional hazards model, the independent predictors of total cardiac mortality were left ventricular ejection fraction of less than 0.40 (relative risk, 4.55; 95% confidence interval, 2.44 to 8.33; P = .0001), absence of an implantable defibrillator (relative risk, 2.70; confidence interval, 1.41 to 5.00; P = .017), and persistence of inducible sustained ventricular tachycardia (relative risk, 1.84; 95% confidence interval, 0.97 to 3.49; P = .045). The 1- and 5-year probabilities of survival free of cardiac mortality in patients with left ventricular ejection fraction of less than 0.40 were 94.3% and 69.6% with a defibrillator and 82.1% and 45.3% without a defibrillator, respectively. For patients with left ventricular ejection fraction of 0.40 or more, the 1- and 5-year probabilities of survival free of cardiac mortality were 97.7% and 94.6% with a defibrillator and 95.4% and 86.9% without a defibrillator, respectively. CONCLUSIONS In survivors of out-of-hospital cardiac arrest, the implantable defibrillator is associated with a reduction in cardiac mortality, particularly in patients with impaired left ventricular function.

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“…The incidence of supraventricular arrhythmias causing device therapy is reported to be 20% to 30% [7,8]. Despite the use of antiarrhythmic drugs and programming of the arrhythmia discrimination algorithms, the incidence of inappropriate ICD therapies remains high.…”

Section: Inappropriate Therapiesmentioning

confidence: 98%

Should all implantable cardioverter defibrillators for ventricular arhythmias be dual-chamber devices?

Lee

Lau

2001

Curr Cardiol Rep

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The advantages of a dual-chamber implantable cardioverter defibrillator (ICD) over a single-chamber ICD include physiologic pacing capability, atrial electrogram storage, enhanced arrhythmia discrimination algorithms, and a potential to treat atrial arrhythmia by pacing or defibrillation. Current evidence supports the supposition that dual-chamber ICDs are definitely indicated in patients who have a concomitant indication for physiologic pacing, such as bradycardia or bradycardia-dependent ventricular tachyarrhythmias. Refined dual-chamber arrhythmia discrimination algorithms and enhanced atrial therapies are probably required for patients with frequent supraventricular arrhythmias. Furthermore, in patients with systolic heart failure, low ejection fraction, and intraventricular conduction delay, triple-chamber ICDs with biventricular pacing may improve their functional status and prevent sudden arrhythmic death. Careful patient selection is required to optimize the cost-effectiveness of these sophisticated technologies.

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The automatic implantable cardioverter defibrillator: Efficacy, complications and survival in patients with malignant ventricular arrhythmias

Cited by 376 publications

References 18 publications

Clinical characteristics and outcome of patients with high defibrillation thresholds. A multicenter study.

Clinical characteristics and outcome of patients with high defibrillation thresholds. A multicenter study.

Influence of implantable cardioverter-defibrillators on the long-term prognosis of survivors of out-of-hospital cardiac arrest.

Should all implantable cardioverter defibrillators for ventricular arhythmias be dual-chamber devices?

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