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The automated internal cardiac defibrillator or shock box is the common name given to the Implantable Cardioverter Defibrillator (ICD). ICD is a state-of-the-art device that treats arrhythmias specifically those of ventricular origin like ventricular tachycardia and fibrillation. It has become the first line of defense in patients who are at high risk for sudden cardiac death (SCD) and has shown consistent survival benefit in cardiac arrest survivors (SCA), in patients with Heart failure and severe systolic dysfunction (left ventricular ejection fraction-LVEF less than or equal to 35%) as well as in patients with hypertrophic cardiomyopathy (HCM). This activity reviews the indications for an AICD and highlights the role of the interprofessional team in the management of patients with ventricular arrhythmias. Objectives: Identify the indications for an AICD. Describe the contraindications for an ACID. Recall the clinical benefits of an AICD. Discuss interprofessional team strategies for improving care coordination and communication to advance the insertion of an AICD and improve outcomes. Access free multiple choice questions on this topic.

The automated internal cardiac defibrillator or shock box is the common name given to the Implantable Cardioverter Defibrillator (ICD). ICD is a state-of-the-art device that treats arrhythmias specifically those of ventricular origin like ventricular tachycardia and fibrillation. It has become the first line of defense in patients who are at high risk for sudden cardiac death (SCD) and has shown consistent survival benefit in cardiac arrest survivors (SCA), in patients with Heart failure and severe systolic dysfunction (left ventricular ejection fraction-LVEF less than or equal to 35%) as well as in patients with hypertrophic cardiomyopathy (HCM).[1][2] ICD is essentially a pacemaker with the ability to recognize abnormally fast cardiac rhythm and provide an immediate treatment which can be in the form of overdrive pacing called anti-tachycardia pacing (ATP) or shock therapy which could be synchronized or asynchronized, depending on the recognized rhythm and the pre-programmed rhythm detection algorithm. It comes in three systems, a single lead or single chamber device, a dual lead or a dual-chamber device, and one that is coupled with cardiac resynchronization therapy (CRT-D) that is essentially a bi-ventricular device with leads in the right atrium (RA), Right ventricle (RV) and coronary sinus (CS) lead. Due to its proximity, CS lead is also called the LV lead. In 2012, the US Food and Drug Administration (FDA) approved the sub-cutaneous device (S-ICD) which used sub-cutaneous leads rather than intra-cardiac leads. Recently, wearable defibrillators (WCD) have also been introduced for short-term usage.

Complications divide into short-term and long-term. Short term complications (2 to 3%) are usually immediate and relate to the procedure; they are[6][7]: Access complications like bleeding, thrombosis of subclavian/ axillary vein, and inadvertent puncture of lung tissue causing pneumothorax or hemothorax Pocket complications like pain, pocket hematoma, and even Twiddler syndrome which is the twisting and misplacement of the device, usually due to pressure exerted by expanding hematoma, that causes device malfunction usually by disrupting the lead and generator connections Device-related infection (1 to 2%), including endocarditis, have also been reported Serious complications (less than 1%) like pulseless electrical activity (PEA) and death can also occur during DFT Long term complications (up to 4%) include[7][8]: Device-related pain Anxiety Lead fracture Inappropriate shock delivery Phantom shock (which means that the patient perceives as receiving shock therapy, but device interrogation does not reveal any such shock or event) Device erosion through the skin Device Infection - more so in cases of replacement or generator change, than new device implantation[8] Immunologic rejection - rare

With advances in cardiovascular healthcare and new strategies and therapies in the management of coronary heart disease and heart failure, the overall life expectancy of patients has increased and has led to an ever-growing population of patients with LV systolic dysfunction and an increased risk of sudden cardiac death. This has opened up avenues for device therapy not only to save but also to improve life. The National Cardiovascular Data Registry (NCDR) also has setup device registry which helps physicians and hospitals to pool their data, share their experiences and help each other out which, not only, is translating into better outcomes for these patients but also reassuring patients that there is hope, and there are health professionals for them, working for them. There remains a taboo, a psychological component with these devices, the fear of not returning to their previous lives, and the fear of getting shocked during treatment. However, this could be readily overcome by adequate support and proper patient counseling by the physicians, electrophysiologists, cardiac rehab staff, and the heart failure staff that are involved in the management of such patients. Effective communication and timely referral are essential amongst physicians, cardiologists, electrophysiologists as well as rehab and cardiac staff and patient caretakers as these patients require a lot of medical and psychosocial support to return to and maintain an adequate quality of life. All in all, these devices have become a valuable tool for the heart failure team.