Indications of ICD in 2010

1. Indications of ICD in 2010 Dr Mervat Aboulmaaty Professor of Cardiology Ain Shams University DAF 1st EP course 2010

2. SCD Burden

3. SCD Risk

4. ICDImplantable Cardiovertor Defibrillator

5. 1980:Large Devices, Limited Battery Life, Abdominal Implant, Epicardial Leads • First human implants • Thoracotomy, multiple incisions • Primary implanter= cardiac surgeon • General anesthesia • Long hospital stays • Complications from major surgery • Perioperative mortality up to 9% • Nonprogrammable therapy • High-energy shock only • Device longevity  1.5 years • Fewer than 1,000 implants/year

6. Today:Small Devices, Long Battery Life, Pectoral Implant, Endocardial Leads • First-line therapy for VT/VF patients • Treatment of atrial arrhythmias • Cardiac resynchronization therapy for HF • Transvenous, single incision • Local anesthesia; conscious sedation • Short hospital stays and few complications • Perioperative mortality < 1% • Programmable therapy options • Single- or dual-chamber therapy • Battery longevity up to 9 years* • More than 100,000 implants/year *Battery longevity information in slide notes.

7. Therapies Provided by Today’sDual-Chamber ICDs Atrium & Ventricle • Bradycardia sensing & Pacing • Atrium • AT/AF tachyarrhythmia detection • Antitachycardia pacing • Cardioversion • Ventricle • VT/ VF detection • Antitachycardia pacing • Cardioversion • Defibrillation

8. CRT-DMultisite ICD

9. Indications for ICDs • Primary • Prevent a SCD eventbeforeitoccurs • Definepatients at risk • Secondary • Prevent SCD eventafter an initialeventsurvival • Excludetransientor reversible causesfor VF

12. MADIT 1996 (196 patients) MADIT II 2002 (1232 patients) MADIT-CRT 2005 (1820 patients) Clinical Question: Can prophylactic ICD therapy improve survival in high risk HF patients when compared to medical therapy alone? Endpoint:All-cause mortality. Key Finding: Use of ICDs resulted in a 54% reduction in the mortality rate in the ICD group as compared to the conventional medical therapy group (p value: 0.009) Clinical Question: Can heart attack survivors with impaired heart function (EF≤30%), and no other risk stratification, benefit from ICD therapy versus conventional therapy alone? Endpoint:All-cause mortality. Key Finding: Use of ICDs resulted in a 31% reduction in the risk of death in heart attack survivors (p value: 0.016). As a result , patients no longer have to undergo invasive electrophysiological testing to receive the ICD therapy Clinical Question: Does early intervention with CRT-D slow the progression of HF in high-risk patients* with mild HF* when compared to ICD-only therapy? Endpoint: All-cause mortality OR first HF event. Key finding: CRT-D therapy is associated with a significant 34% reduction in death or first HF event when compared to ICD therapy alone (p value: 0.001) * Mild HF”:NYHA Class I and II ; High-risk”:EF ≤30%; QRS ≥130ms

13. Reductions in Mortality with ICD Therapy 75% 76% 61% 55% 54% 31% % Mortality Reduction w/ ICD Rx ICD mortality reductions in primary prevention trialsare equal to or greaterthan those in secondaryprevention trials. 1 2 3, 4 27 months 39 months 20 months 59% 56% 33% % Mortality Reduction w/ ICD Rx 31% 28% 20% 1 Moss AJ. N Engl J Med. 1996;335:1933-40. 2 Buxton AE. N Engl J Med. 1999;341:1882-90. 3 Moss AJ. N Engl J Med. 2002;346:877-83 4 Moss AJ. Presented before ACC 51st Annual Scientific Sessions, Late Breaking Clinical Trials, March 19, 2002. 5 The AVID Investigators. N Engl J Med. 1997;337:1576-83. 6 Kuck K. Circ. 2000;102:748-54. 7 Connolly S. Circ. 2000:101:1297-1302. 6 7 5 3 Years 3 Years 3 Years

15. Class I • Documented survivors of SCD due to VF • 40days post MI + LVEF≤ 35 + NYHA II/III • 40 days post MI + LVEF≤ 30 + NYHA I • Non ischemic cardiomyopathy + LVEF≤ 35 + NYHA II/III • Non sustained VT post MI + sustained VT/VF by EPS+ LVEF ≤ 40 • Structural heart disease + sustained VT • Syncope + unstable VT/VF by EPS

16. Class IIA • LQTS + syncope/VT (on β blockers) • Unexplained syncope + DCM + significant LV dysfunction • Sustained VT + normal LV • CPVT + syncope/VT (on β blockers) • High risk ARVD • High risk HCM • Brugada syndrome + syncope/VT

18. Indications for ICD in HF patients

19. Guidelines of ICD in a Pocket

20. Indications for ICD implantationClass IIIICD is NOT indicated IN • Syncope of undetermined cause no VT induced NO structural HD • Incessant VT VF • VT/VF resulting from arrhythmias amenable for ablation as WPW Fasicular VT • VT due to reversible disorder • Significant psychological disorder • Terminal illness life expectancy <6months

21. 55 yr old, first hour of Acute MI

22. Conclusions • ICDs are reliable devices that have the potential to add quality years of life for appropriate candidates. • There are scientifically-derived guidelines for their prescription that are limited by the scope of the clinical trials and observational data. • Cardiologists should recommend ICD devices to their individual patients based on the current guidelines.

23. ICD Programming

24. How ICD works?

25. I C D I N T E R R O G A T I O N

26. I C D I N T E R R O G A T I O N Burst 1 Sinus VT

27. I C D I N T E R R O G A T I O N Acc. VT VT Burst

28. I C D I N T E R R O G A T I O N Cont. Sinus Acc.VT DC

29. Thank you