Implantable Cardioverter-Defibrillator: A Practical Manual
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This book serves as an introductory text to those who are relatively new to this technology. In its manual form, it outlines the pertinent components of ICD functions and the basic differences among the various models. It provides practical points in ICD implantation, and in its programming and trouble-shooting. Product Details Table of Contents.
Table of Contents Foreword. Historical Perspective. Indications for ICD Therapy. Device Operation. Implantation Procedure. Patient Management. New Features. Average Review. Write a Review.
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Implantable Cardioverter-Defibrillator: A Practical Manual / Edition 1
An Atlas of Insect Diseases. Diseases of insects are important factors reducing the number of insects in natural populations. They are density dependent and they act especially under conditions of outbreaks and close contact of susceptible hosts. Brouwer meets Husserl: On the Phenomenology of Choice. Can a line be analysed mathematically such a way that it does not fall apart Can a line be analysed mathematically such a way that it does not fall apart into a set of discrete points?
Are there objects of pure mathematics that can change through time? Brouwer argued that the two Design of Tools for Deformation Processes. Although the problem of tool design - involving both the selection of suitable geometry and Economic Analysis of Institutions and Systems. In the late s, the field of comparative economics and NATO faced a similar problem ES is a multidisciplinary syndrome requiring a multidisciplinary approach involving technical aspects such as ICD reprogramming, advanced intensive care in patients experiencing low-output state and multiorgan failure, interventional procedures such as radiofrequency RF CA and advanced HF management.
Careful risk stratification and the early recognition of prognostic unfavorable signs are of pivotal importance in achieving success. In patients who present with multiple clustered ICD shocks, the first step should always be to perform a device interrogation to exclude inappropriate shocks ie, atrial fibrillation with fast ventricular response and device reprogramming to reduce shocks in favor of ATP, which is painless. This can be reached both by increasing detection rate and duration. All potentially reversible causes of arrhythmias ie, electrolyte imbalances, acute ischemia, proarrhythmic drug effects, hyperthyroidism, infections, and decompensated HF should also be ruled out or treated.
A practical flowchart for initial patient care and risk stratification is presented in Figure 1.
Irish Heart ICD - Irish Heart
The introduction of pharmacologic therapy with AADs can be effective in suppressing VAs and reducing the need for ICD-based therapies in patients with ES, even if a clear mortality benefit as compared with standard medical therapy has never been proved. A significant increase in sympathetic tone characterizes ES and is responsible for VA onset and maintenance, making the suppression of adrenergic tone pivotal.
Benzodiazepines alone or in addition to short-acting analgesics such as remifentanil should be the first choice as they can suppress sympathetic hyperactivity and provide analgesia without negative inotropic effects. However, it should be used cautiously since it can result in severe hypotension and bradycardia. Amiodarone is generally the AAD of choice for use in uncomplicated cardiac patients; it has been validated in numerous clinical trials and can be safely administered in the absence of contraindications like hyperthyroidism or QT prolongation.
Rarely, thrombophlebitis can result in systemic infection including bacteremia and device infections, which further complicate the clinical course in patients with ES.
Procainamide is a class IC agent that may be helpful to acutely terminate VAs. During ischemic VT, the altered membrane potential and pH reduction increase the drug-binding rate, so lidocaine is mostly recommended for VA suppression in the setting of acute ischemia. The role of CA in VT management is becoming increasingly relevant, having repeatedly shown its superiority to medical therapy in reducing the arrhythmic burden and thus improving the prognosis and quality of life for patients with structural heart disease who present with VT.
After a median follow-up of 1. We recently reported on the long-term outcomes of a large series of patients presenting with ES undergoing CA. Often, more than one CA procedure is needed to achieve good long-term VT control, especially in patients presenting with ES. In our experience, an average of 1. Repeated procedures were generally longer, had more inducible and less mappable VTs, involved more epicardial access, and had higher complication rates 8.
Femoral artery hemostasis can be achieved with either manual compression or vascular closure devices, with recent studies suggesting improved outcomes with the use of active closure systems. The prevalence, therapeutic options, and appropriate implications of ES in ARVC patients are still not completely understood. Thus, when hemodynamic support is required in these individuals, the use of an RV support device or ECMO system can be considered. Performing RF CA in patients with ES is challenging, as advanced HF, unstable VTs, and non-cardiac comorbidities may all contribute to a low-output state, increasing the risk of intraprocedural hemodynamic collapse and, consequently, periprocedural mortality.
Moreover, we proposed a scoring system the PAINESD score that accounts for such characteristics to identify high-risk patients in whom prophylactic mechanical support may improve outcomes Figure 2.
Cardiac rhythm management devices
In these cases, devices providing biventricular support, including ECMO, should be considered. Figure 2: A and B: A scoring system to identify patients undergoing CA at high risk of hemodynamic decompensation who may benefit from prophylactic mechanical circulatory support, as proposed by Santangeli et al. Patients with ES refractory to standard medical treatment and CA may benefit from bailout treatments like epidural anesthesia or cardiac sympathetic denervation CSD.
As stated above, sympathetic hyperactivity plays a critical role in VA onset and maintenance. Arrhythmia suppression may therefore be achieved by modulating neuraxial efferents to the heart. Widespread ICD use has considerably improved the life expectancy of patients with structural heart disease at risk of sudden death, but it has also created new challenges for affected patients, those individuals who are close to them, and for involved healthcare professionals, particularly when ICD carriers approach the end of their life.
This may be due to progressive worsening of the underlying heart disease ie, advanced heart failure that cannot be improved by additional treatment or the development of another terminal condition such as cancer. In this setting, ICD operation may be more of a burden than a benefit. Relatives should always be involved with respect to confidentiality to provide support to the patient and help discuss care goals. Several opportunities to discuss ICD deactivation and the ability to contribute meaningfully to a shared decision should be given to the patient because this topic is sensitive and difficult.
The relative risks and benefits of continued ICD therapies should be continually reviewed, and ongoing discussions should be had with all critically ill patients. ES is a life-threatening condition that requires a multimodal approach including optimal ICD reprogramming, pharmacologic therapy, interventional approaches aimed at modifying the arrhythmic substrate such as the use of RF CA, or techniques to suppress the sympathetic trigger such as cardiac sympathetic denervation. Currently, RF CA appears to be the most valuable strategy to acutely suppress arrhythmias and improve long-term arrhythmia-free survival; therefore, it should be considered in all patients presenting with ES, reserving alternative approaches like surgical cryoablation or transcoronary ethanol ablation to selected cases refractory to or unsuitable for CA.
Articles Articles October. Introduction Electrical storm ES is a life-threatening condition characterized by recurrent ventricular arrhythmias VAs requiring urgent medical care.
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Incidence and predictors The true incidence of ES in ICD carriers is difficult to estimate due to its heterogeneous definition especially in older studies and its relation to the underlying heart disease and reasons for ICD implantation. Figure 1: Risk stratification and management of patients presenting with ES. Pharmacologic therapy The introduction of pharmacologic therapy with AADs can be effective in suppressing VAs and reducing the need for ICD-based therapies in patients with ES, even if a clear mortality benefit as compared with standard medical therapy has never been proved.
Palliative care Widespread ICD use has considerably improved the life expectancy of patients with structural heart disease at risk of sudden death, but it has also created new challenges for affected patients, those individuals who are close to them, and for involved healthcare professionals, particularly when ICD carriers approach the end of their life. Heart Rhythm. Implantable cardioverter-defibrillator therapy in Brugada syndrome: a year single-center experience. J Am Coll Cardiol. Electrical storm in patients with transvenous implantable cardioverter-defibrillators: Incidence, management and prognostic implications.
Electrical storm presages nonsudden death the antiarrhythmics versus implantable defibrillators AVID trial. Clusters of ventricular tachycardias signify impaired survival in patients with idiopathic dilated cardiomyopathy and implantable cardioverter defibrillators. Role of electrical storm as a mortality and morbidity risk factor and its clinical predictors: a meta-analysis. Clinical predictors and prognostic significance of electrical storm in patients with implantable cardioverter defibrillators.
Eur Heart J. Strategic programming of detection and therapy parameters in implantable cardioverter-defibrillators reduces shocks in primary prevention patients: results from the PREPARE Primary Prevention Parameters Evaluation study. Reduction in inappropriate therapy and mortality through ICD programming.
N Engl J Med. Electrical storm in patients with an implantable defibrillator: incidence, features, and preventive therapy: insights from a randomized trial.
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Management of ventricular tachycardia in the setting of a dedicated unit for the treatment of complex ventricular arrhythmias: long-term outcome after ablation. Effectiveness of extracorporeal life support for patients with cardiogenic shock due to intractable arrhythmic storm. Crit Care Med. Comparative effectiveness of antiarrhythmic drugs and catheter ablation for the prevention of recurrent ventricular tachycardia in patients with implantable cardioverter-defibrillators: A systematic review and meta-analysis of randomized controlled trials.
Treating electrical storm: sympathetic blockade versus advanced cardiac life support-guided therapy. Beta 1-and beta 2-adrenergic-receptor subpopulations in nonfailing and failing human ventricular myocardium: coupling of both receptor subtypes to muscle contraction and selective beta 1-receptor down-regulation in heart failure. Circ Res.
Beta2-adrenergic receptor antagonists protect against ventricular fibrillation: in vivo and in vitro evidence for enhanced sensitivity to beta2-adrenergic stimulation in animals susceptible to sudden death. Remifentanil-midazolam sedation provides hemodynamic stability and comfort during epicardial ablation of ventricular tachycardia.
J Cardiovasc Electrophysiol. Effects of remifentanil on the contractility of failing human heart muscle. J Cardiothorac Vasc Anesth. Electrical storm and termination with propofol therapy: a case report. Int J Cardiol. Heart rate variability dynamics during low-dose propofol and dexmedetomidine anesthesia. Ann Biomed Eng.