ICD.pptx

Implantable cardioverter defibrillator

1. ICD Dr Seebat masrur D-Card student Cardiology department SZMCH

2. Sudden Cardiac Death Ref-https://www.aerjournal.com/articles/sudden-cardiac-death-and-arrhythmias The accepted definition of SCD is death that occurs within one hour of onset of symptoms in witnessed cases, and within 24 hours of last being seen alive when it is unwitnessed. The majority of deaths are unwitnessed, with VF being the final underlying mechanism. The majority of patients are found in asystole or pulseless electrical activity (PEA) and heart block is increasingly noted as an aetiology . An estimated 180,000–300,000 sudden cardiac deaths (SCD) occur in the US annually. Worldwide, sudden and unexpected cardiac death is the most common cause of death,accounting for 17 million deaths every year with SCD accounting for 25 % of these.

3. An ICD is an electronic device implanted in the body to protect against dangerous ventricular rates. It is designed to defibrillate the heart by delivering high voltage shocks or to stop malignant tachycardias by antitachycardia pacing(short burst of rapid pacing sequence).Contemporary ICDs also contain a classic pacemaker for bradycardia pacing.

4. Pioneers of ICDs-M&M

5. Evolution of ICDs 1947- First Human internal Defibrillation 1956-First human external Defibrillation 1969-First external canine prototype tested 1970-First Implantable prototype 1975-First Implantable Defibin Canines 1980-First human implant @ Johns Hopkins 1985-ICD market released 1995-Pectoral ICD systems 2001-ICD & Resynchronization therapy

6. Evolution With time the devices have grown smaller, more efficient.

7. Components of ICD 1.Pulse Generator-Battery, Capacitors & Voltage -Circuitry -Connector Blocks 2.Lead System 3.ICD Programmer

8. Implantable Cardioverter Defibrillator

9. Types of ICD

10. Principles of Operation Bradycardia Pacing- Antitachycardia pacing Detection -Relies on rate sensing. When the rate of the sensed R waves falls into the rate defined tachycardia zone, the detection algorithm is initiated and the counter is augmented. Therapy - Antitachycardia Pacing, Cardioversion, Defibrillation. Electrogram Storage - All episodes are stored. Advanced features include rate-adaptive dual-chamber pacing, atrial therapies and cardiac resynchronization therapy.

11. Uses of ICDs Primary Prevention Prior Myocardial Infarction(at least 40 days ago) and LVEF ≤ 35% Cardiomyopathy, NYHA II to III with LVEF < 35% Syncope who have structural heart disease and inducible VT/VF Long QT, Torsades on RX, Brugada , ARVD, HCM Secondary Prevention Prior episode of resuscitated VT/VF or sustained hemodynamically unstable VT Episodes of spontaneous sustained VT in the presence of Heart Disease(valvular, ischemic, hypertrophic, dilated or infiltrative cardiomyopathies) and other settings( eg channelopathies)

12. Class I (general agreement of benefit with ICD therapy) Ref-Cardiology 3 rd ED Micheal H Crawford Cardiac arrest due to ventricular fibrillation or hemodynamically unstable sustained VT after evaluation to define the cause of the event and to exclude any completely reversible causes. Structural heart disease and spontaneous sustained VT, whether hemodynamically stable or unstable. Syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at electrophysiological study. LVEF less than 35% due to prior MI, at least 40 days post-MI with NYHA functional Class II or III. Nonischemic dilated cardiomyopathy (DCM) with an LVEF less than or equal to 35% and NYHA functional Class II or III. LV dysfunction due to prior MI, at least 40 days post-MI with an LVEF less than 30%, and NYHA functional Class I. Nonsustained VT due to prior MI, LVEF less than 40%, and inducible VF or sustained VT at electrophysiological study

13. Class II (ICD therapy reasonable or may be considered) Ref- Ref-Cardiology 3 rd ED Micheal H Crawford Unexplained syncope, significant LV dysfunction, and nonischemic DCM. Sustained VT and normal or near-normal ventricular function. HCM with 1 or more major risk factors for SCD. Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) and 1 or more risk factors for SCD. Long-QT syndrome with syncope and/or VT while receiving beta blockers. Miscellaneous high risk conditions including Brugada syndrome, catecholaminergic polymorphic VT, Chagas’ disease, cardiac sarcoidosis, giant cell myocarditis, left ventricular noncompaction, and other familial cardiomyopathies associated with sudden death.

14. Class III (not indicated; risk of ICD therapy exceeds expected benefit)-Contraindications No reasonable expectation of survival with an acceptable functional status for at least 1 year, even if they meet ICD implantation criteria specified in the Class I and II recommendations above. Incessant VT or VF. Significant psychiatric illnesses that may be aggravated by device implantation or that may preclude systematic follow-up. NYHA Class IV drug-refractory congestive heart failure when cardiac transplantation or cardiac resynchronization therapy are not indicated

15. Types Ref-https://www.jacc.org/doi/10.1016/j.jacc.2015.11.026 An ICD is a type of cardiac therapy device. There are two basic types: A Traditional ICD -is implanted in the chest and the wires(Leads) attach to the heart. The implant procedure requires invasive surgery. A Subcutaneous ICD(S-ICD ) is another option that`s implanted under the skin at the side of the chest below the armpit. It`s attached to an electrode that runs along the breastbone. An S-ICD is larger than traditional ICD but doesn`t attach to the heart.

16. Ref-https://www.jacc.org/doi/10.1016/j.jacc.2015.11.026

17. Procedure

18. Complications Venous access Bleeding Pain Hemoptysis Pneumothorax Subcutaneous emphysema Thoracic duct injury Subclavian vein Thrombosis Subclavian artery puncture , fistula Pulmonary embolism Air embolism Brachial plecus injury Pocket Hematoma Skin erosion Infection Seroma

19. Complications Leads Malposition Dislodgement Perforation Exit Block without displacement Intracardiac Thrombosis Infection Hemopericardium Cardiac tamponade Post Pericardiotomy Syndrome Diaphragmatic Stimulation Lead Electrical problems Insulator Break Conductor Break Lead disconnection Loose setscrew Connection problems Inadequate defibrillation threshold undersensing

20. Complications Inappropriate delivery of therapy Inappropriate shocks most often occur due to supraventricular tachycardia (and sinus tachycardia), self-terminating VT (in committed systems), and sensing artifacts, for example myopotentials. T-wave oversensing is an uncommon cause of inappropriate shocks Failure to deliver therapy or delay of therapy ICD inactivation Ventricular tachycardia slower than the programmed detection rate SVT–VT discriminators

21. ICD-INDUCED PROARRHYTHMIAS

22. POSTOPERATIVE EVALUATION AND CARE Ward Care -staff members are familiar with the basic programmed parameters. Emergency Care -During an emergency, however, care of the patient must be based on basic and advanced cardiac life support protocols, and standard emergency treatment is not delayed. Device Monitoring Operation Site -A final assessment of the implant site, pacing thresholds, EGM amplitude and programmed parameters may be done by a physician or other allied health professional prior to patient discharge. Noninvasive Electrophysiology Study -A NIPS is performed using the device and programmer to initiate and terminate arrhythmias. Patient Education -Physical activity, wound care, pain management, and what to do should an ICD shock occur.

23. Movement restriction

24. Outpatient follow-up and ICD device checks There are two types of clinical follow-up for patients: 1.Chronic surveillance every 3–6 months to assess and document routine device operation and clinical progress. First follow up within a month. 2.A cute unexpected evaluations prompted by patient concerns, symptoms, shocks, unsuccessful therapy or presumed failure to deliver expected therapy. When the ICD battery starts to show signs of depletion, evaluations need to be more frequent. Sound or audible alarms may be programmed to alert the patient when the battery voltage becomes critically low. The patient should be instructed to notify their physician if an alert sounds.

25. Living with an ICD Take the following precautions when you have an ICD implanted. Always carry an ID card that states you have an ICD. If you travel by air, tell security screeners that you have an ICD before going through the metal detector . Anti-theft systems or electronic article surveillance (EAS) used in department stores may interact with an ICD. Stay away from large magnetic fields such as power generation sites . If an MRI has been advised for you, contact your doctor. Newer ICDs are compatible with MRI scanners with some restrictions.

26. Living with an ICD Don't use diathermy. This is the use of heat in physical therapy to treat muscles. Don't use a heating pad directly over your ICD. Don't have transcutaneous electrical nerve stimulation (TENS) therapy. Stay away from high-voltage and radar machinery . If you are scheduled for surgery, let the surgeon know well ahead of the operation that you have an ICD. Also talk with your cardiologist before the procedure to find out if you need any special safety measures.  Always see your doctor when you feel ill after an activity, or when you have questions about beginning a new activity.

27. Thank you

28. How you prepare

29. General Instruction The doctor’s office should be notified if any of the following signs are observed, especially if they increase after the first days: 1. Any redness, heat, swelling or any kind of yellow, green or brown drainage from the site. 2. A soreness around the pulse generator or a bruise that does not go away. 3. A temperature of or above 100°F (38°C) or chills. The patient should check his or her temperature at home twice daily at the same time for 2 weeks and write it down on a piece of paper.

30. Patients Instruction at time of Discharge Prior to discharge, a final check is performed to verify proper functioning of the ICD system so as to: • ensure that the device is activated; • perform final device programming; • document lead position by chest X-ray and measure pacing threshold and R-wave amplitude to rule out early lead dislodgment; • provide patient and family education; • plan outpatient follow-up: 7 days and 1 month after implantation.

31. Contraindications Contraindications The ICD is contraindicated if there is a transient reversible cause, such as Myocardial infarction Electrolyte Imbalance Incessant ventricular tachycardia or fibrillation is also considered a contraindication(as incessant arrhythmias will cause frequent device therapy and rapid battery drainage) Psychiatric illnesses