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The subcutaneous implantable cardioverter-defibrillator (S-ICD) is the latest option among devices clinically available for the prevention of sudden cardiac death, with experience from previous trials and postmarketing studies supporting the feasibility and safety of this kind of system. The extracardiac positioning of the S-ICD obviates the need for transvenous leads, which translates into lower incidence rates of lead-related complications and systemic infections. This review will highlight the results of pertinent studies related to the perioperative management of S-ICDs and review potential approaches to minimizing the risk of complications such as hematoma at the pulse generator location, unsuccessful defibrillation due to suboptimal S-ICD lead and generator positioning, and postoperative pain. An extensive literature search using PubMed was conducted to identify relevant articles.

The subcutaneous implantable cardioverter defibrillator (S-ICD) has become a valid alternative to the traditional transvenous implantable cardioverter defibrillator (ICD) in patients who do not require antitachycardia/antibradycardia pacing or cardiac resynchronization therapy.1 The absence of intravascular or intracardiac components removes several complications of transvenous systems that make it particularly favorable in younger patients. Limiting factors in children have been the relatively large size of the pulse generator, concerns of device erosion, and a mandatory distance between sensing electrodes.

Introduction: Implantable cardioverter defibrillators (ICD) reduce the risk of sudden cardiac death among patients with persistently low (≤35%) left ventricular ejection fraction (LVEF) at least 40 days following acute myocardial infarction (AMI). There are limited data about clinical factors associated with ICD placement following AMI. Hypothesis: We hypothesized that increasing age and number of comorbidities would decrease the odds of ICD placement post-AMI among patients with low (≤35%) LVEF, while revascularization for AMI would increase odds of ICD use. Methods: We used ICD-9 and 10 codes to identify all Veterans hospitalized for AMI from 2004-2017 and excluded Veterans with prior ICD and those who died during AMI hospitalization. We used a validated natural language processing algorithm to determine LVEF from echocardiograms performed 40-365 days post-AMI and identified patients with LVEF ≤35%. Using multivariable logistic regression, we examined the association of demographics, comorbidities, revascularization status for AMI, and prescription of guideline-directed medical therapy (GDMT) with the primary outcome of ICD placement 41-365 days post-AMI. Results: Of 10,447 Veterans eligible for an ICD, 1,966 (18.8%) received an ICD. Of 1,966 patients who received an ICD 7.1% died within 1-year, compared with 26.8% of patients who did not receive an ICD. In multivariable analysis, younger age, fewer comorbidities, revascularization during AMI hospitalization, and use of GDMT were associated with increased odds of receiving an ICD (Table). Eligible Black patients were less likely (OR 0.78, 95% CI 0.67-0.90) to receive an ICD than White patients. Conclusions: Many factors affect ICD placement among patients with reduced LVEF post-AMI. In particular, Black patients were less likely to receive ICDs than White patients. Future qualitative work could provide a deeper understanding of how patient and clinician factors influence decisions around ICD use.

Persistent left superior vena cava can create technical challenges during implantation of pacing devices; which, in the majority of cases, are implanted on the left side. We present a chest x-ray of a patient with a left-sided biventricular implantable cardioverter defibrillator placement through a persistent left SVC.

Characteristics of hospitalizations including healthcare utilization for adult patients with congenital heart disease (ACHD) at the time of implantable cardioverter defibrillator (ICD) placement has not been well studied.We analyzed data from the 2002-2014 United States National Inpatient Sample (NIS). ICD implantation, CHD, complications, and indications for admissions were determined based on diagnostic codes among adults. Propensity score matching was performed, based on age, sex and in-hospital mortality index with a 10:1 ratio between adults without CHD and those with CHD, to determine relative healthcare utilization attributable to CHD.ACHD accounted for 136,509 ± 3488 admissions of which 1451 ± 121 admissions (1.1 ± 0.06%) were associated with an ICD placement. ICD placement occurred most frequently among patients with TOF, VSD, and transposition complexes usually in the context of a dysrhythmia. Compared to those without CHD, ACHD patients had higher adjusted total hospital charges ($147,002 ± 5516 vs $132,455 ± 2182; p 0.001), length of stay (6.2 ± 0.5 vs 5.2 ± 0.1 days; p 0.001), lower readmission score (5.5 ± 0.5 vs 9.7 ± 0.1; p = 0.04) and a higher complication rate (13.4% vs 8.3%; p 0.001). Dysrhythmias were more frequently the primary diagnosis for admission in the ACHD cohort (63% vs 38%; p 0.001).Compared to a matched non-CHD population, ACHD patients had greater healthcare utilization and had more frequent complications. The reasons underlying this difference bear investigation to improve care quality.

Guidelines suggest that patients who receive implantable cardioverter-defibrillators (ICDs) for primary prevention should be expected to live more than one year after placement. However, tools for validating this prognosis are not sufficiently predictive. We sought to identify definitive predictors of one-year survival after ICD placement. By reviewing medical records and the Social Security Death Index, we analyzed baseline characteristics and survival outcomes of 3,164 patients who underwent ICD placement at our institution from January 2006 through March 2014. Survival outcome could be confirmed for 2,346 patients (74%). Of these, 184 (7.8%) died within one year of ICD placement. We noted significant differences in numerous variables between those who lived and died. However, multivariable analysis revealed only 5 independent predictors of earlier death: worse New York Heart Association functional class (hazard ratio [HR]=1.87 per class [95% CI, 1.22–2.87]; P Despite significant univariate differences between the ICD recipients who did and did not live beyond one year, we found only moderate predictors of survival. Better tools are needed to predict outcomes when considering ICD placement for primary prevention.

The purpose of this study was to analyze course of defibrillation threshold (DFT) with growth.Data on regular DFT testing after extracardiac implantable cardioverter-defibrillator (ICD) placement in infants and small children is still limited.An extracardiac ICD was placed in 23 pediatric patients (median age 6.1 years; median body weight 21 kg, median length 120 cm). The defibrillator lead was tunneled pleurally, and the device was placed as "active can" in the right upper abdomen or in a horizontal position between the diaphragm and the pericardium, respectively. DFT was verified intraoperatively, 3 months later, and every 12 months thereafter. The aim was to achieve DFT 15 J allowing ICD programming with a double safety margin above DFT.In all 23 patients, an intraoperative DFT 15 J could be accomplished. Serial DFT testing showed an increase from a median DFT of 10 J intraoperatively to 15 J after 1 year. During mean follow-up of 2.0 years, a significant correlation between DFT and body length, but not body weight, was observed. In 4 of 23 (17%) patients, surgical revision was required because of a DFT increase20 J during regular DFT testing. No complications regarding DFT testing were noted.After extracardiac ICD placement in infants and small children, DFT increase related to body length was evident during mid-term follow-up. Routine serial DFT testing was a safe procedure and identified a significant DFT increase in 4 of 23 patients. Serial DFT testing during follow-up in these patients is recommended.

In infants and children, the small size of the systemic veins precludes safe and durable transvenous placement of automatic internal cardiac defibrillator (ICD). In such cases, an alternative method of implanting an automatic ICD is via thoracotomy. This report describes the technique used at Onassis Cardiac Surgery Center for the epicardial placement of an ICD system with a transvenous ICD coil placed in the posterior pericardium via a left thoracotomy, producing a stable location and excellent coil-to-can vector for successful defibrillation. To the best of our knowledge, this is the first case in Greece.

The feasibility and safety of same-day discharge after transvenous implantable cardioverter-defibrillator implantation is well-established. However, subcutaneous ICDs (S-ICDs) are now increasingly being implanted, and the feasibility, safety, and potential cost savings associated with same-day discharge after S-ICD placement has not been widely investigated. In a small cohort of patients (n = 24) who underwent S-ICD implantation at our institution, 54% were successfully discharged on the same day as their implant procedure. Procedure-related complications were not apparent in this sampling and the reduction in health care costs was high, suggesting this protocol has immense benefit in today's health care environment. As such, same-day discharge of S-ICD patients is appropriate to consider and should receive further attention.

Management considerations are discussed for HCM patients with massive LV hypertrophy including consideration for primary prevention implantable cardioverter defibrillator placement, and increased risk of progressive heart failure symptoms secondary to obstruction, relieved with myectomy. With treatment these individuals with the most extreme HCM phenotype can achieve extended longevity with low mortality risks.

Young patients have high rates of implantable cardioverter-defibrillator (ICD) lead fractures and are at risk for venous occlusion or tricuspid regurgitation with transvenous lead placement. Epicardial ICDs have the potential to circumvent complications associated with transvenous ICDs, but the literature on young patients remains limited.The purpose of this study was to evaluate the results of a minimally invasive epicardial ICD lead placement approach in young patients.A retrospective, institutional review board-approved electronic medical record review of all patients undergoing epicardial ICD placement at our institution from January 2011 to December 2015 was performed.A total of 46 patients (20 female [43%]; mean age 10.3 years, range 0.7-18.2 years; mean weight 41 ± 21 kg) were identified; 24 (52%) were ≤10 years old. A minithoracotomy was used in 28 patients (61%). All had acceptable defibrillation, right ventricular sensing, and stimulation thresholds. Median follow-up was 2.0 ± 1.3 years (range 0.02-4.5 years). Eight surgical complications occurred in 7 patients (15%), and 8 device-related complications occurred in 6 patients (13%). Fifty-eight appropriate shocks were delivered in 7 patients (15%). Four patients received inappropriate shocks in relation to lead fractures/microfractures. One patient in this cohort who had long QT syndrome type 8 died of a hypoglycemic seizure.Minimally invasive epicardial ICD placement provides an effective, alternative method for implanting an ICD system, particularly in very young patients (6 years of age) or patients who are concerned about cosmetic appearance. This technique is an acceptable alternative to traditional transvenous ICD placement.

Diaphragmatic hernias are an uncommon occurrence in the pediatric population; however, they can cause significant morbidity and mortality if the diagnosis is missed or delayed. This case discusses the radiographic and clinical exam findings of a one-year-old patient with this pathology.

We report a case of sudden cardiac arrest in the setting of ventricular fibrillation in a previously healthy 19-year-old male. Chest imaging demonstrated severe pectus excavatum with Pectus Severity Index of 22.7. Extensive workup was unrevealing for other cardiopulmonary etiologies, including conduction and structural abnormalities. The patient was scheduled for a Ravitch procedure and was discharged on a wearable defibrillator vest for temporary protection against ventricular arrhythmias. Later, the patient underwent subcutaneous implantable cardioverter defibrillator placement. Sudden cardiac arrest as an initial presentation of pectus excavatum is a rare entity scarcely discussed in medical literature. In this patient-centered focused review, we explore this unique case and offer our management approach amid the lack of concrete guidelines.

We report the successful minimally invasive placement of a pericardial implantable cardioverter-defibrillator (ICD) in a 16-kg child. A transvenous ICD dual coil was advanced through a small subxiphoid incision and screwed into the oblique sinus pericardium under fluoroscopic guidance. An additional sense-pace lead was sutured onto the right ventricular apex, and the generator was placed in the upper abdominal wall through the same incision. Threshold testing demonstrated successful defibrillation at 15 J. After implantation, the patient had two episodes of appropriate shock for ventricular fibrillation. The ICD system continues to show stable impedance at 6 months of follow-up.

Brandon C. Varr, MD, Shirin Zarafshar, MD, Terra Coakley, MAT, Michaela Liedtke, MD, Richard A. Lafayette, MD, Sally Arai, MD, Stanley L. Schrier, MD, Ronald M. Witteles, MD From the Division of Cardiology, Columbia University Medical Center, New York, New York, Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford University School of Medicine, Stanford, California, Division of Hematology, Division of Nephrology; and Division of Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, California.

Patients with implantable cardioverter defibrillators (ICDs) can require antiarrhythmic drugs to manage arrhythmias and prevent device shocks. We sought to determine the prevalence, clinical correlates, and institutional variation in the use of antiarrhythmic drugs over time after ICD implantation. From the ICD Registry (2006 to 2011), we analyzed the trends in the use of antiarrhythmic agents prescribed at hospital discharge for patients undergoing first-time ICD placement. The patient, provider, and facility level variables associated with antiarrhythmic use were determined using multivariate logistic regression models. A median odds ratio was calculated to assess the hospital-level variation in the use of antiarrhythmic drugs. Of the cohort (n = 500,995), 15% had received an antiarrhythmic drug at discharge. The use of class III agents increased modestly (13.9% to 14.9%, p0.01). Amiodarone was the most commonly prescribed drug (82%) followed by sotalol (10%). Among the subgroups, the greatest increase in prescribing was for patients who had received a secondary prevention ICD (26% in 2006% and 30% in 2011, p0.01) or with a history of ventricular tachycardia (23% to 27%, p0.01). The median odds ratio for antiarrhythmic prescription was 1.45, indicating that 2 randomly selected hospitals would have had a 45% difference in the odds of treating identical patients with an antiarrhythmic drug. In conclusion, antiarrhythmic drug use, particularly class III antiarrhythmic drugs, is common among ICD recipients at hospital discharge and varies by hospital, suggesting an influence from local treatment patterns. The observed hospital variation suggests a role for augmentation of clinical guidelines regarding the use of antiarrhythmic drugs for patients undergoing implantation of an ICD.

Background: In the current age of ever-increasing healthcare costs, it is of utmost importance to adopt strategies that reduce hospital stay and cost, while still maintaining patient safety. In this study we review our approach of same-day discharge following implantable cardioverter defibrillator (ICD) placement for primary prevention of sudden cardiac death (SCD). Methods: We conducted a retrospective chart review of 415 consecutive patients who underwent ICD implantation for prevention of SCD between 2007 and 2010. Patients were divided into an outpatient group (Group A) and an inpatient group (Group B). We evaluated the patients’ demographics, comorbidities, and the rate of short-term surgical complications on or before the 2-week follow-up appointment. Results: Of 252 patients included in Group A, 198 (78.6%) were successfully discharged on the same day (Group A1). At the 2-week wound check appointment, four patients (2%) had minor surgical site bleeding, one patient had a hematoma, and one patient developed fever and swelling around the implantation site. Of the Group A patients, 54 (21.4%) were not discharged on the same day (Group A2). A total of 53 patients were included in Group B, four (7.5%) developed a hematoma at the 2-week follow-up wound check visit. Conclusions: Procedure-related complications after ICD placement are rare. Same-day discharge is safe and feasible following ICD placement for primary prevention of SCD and hence a reduction in healthcare costs can be achieved by decreasing the length of hospital stay. (PACE 2013; 00:1‐7)

Aims In 2012, the first totally Subcutaneous Implantable Cardioverter-Defibrillator (S-ICD) was approved by the Food and Drug Administration (FDA) in the United States. A possible benefit of this device is that it does not involve placing leads 'in' or 'on' the heart, potentially reducing complications. Methods amd results Ninety-one S-ICD and 182 single chamber TV-ICD implants were performed between 10/22/2012 and 9/22/2015. During this period of time, 91 patients with S-ICD were matched to TV-ICD patients using single centre NCDR ICD Registry Data based on dialysis status, gender, and age. Intra- and post-operative complications and deaths were examined within the first 180 days following implantation. Patients with S-ICDs had higher creatinine (2.3 ± 2.5 vs. 1.1 ± 0.7, P < 0.001) and were more likely to be on chronic dialysis (20.9% vs. 5.5%, P

Repaired congenital heart disease has become more prevalent in women of childbearing age. We report an unusual case of a 24-year-old multigravida with a repaired tetralogy of Fallot, severe dilated cardiomyopathy, and implantable cardioverter defibrillator placement who was managed successfully by a cesarean section three times. This case underscores the impact of such events on maternal and fetal safety and the importance of a multidisciplinary approach in the management of pregnant patients with complex congenital and medical problems.

Although implantation of an endocardial implantable cardioverter defibrillator (ICD) is meant to protect against ventricular arrhythmias, in some cases it can be paradoxically pro-arrhythmic. Recognition of this device complication, while rare, is important because it is potentially reversible and can be treated by managing the device, in lieu of, or in addition to, antiarrhythmics and catheter ablation of ventricular tachycardia (VT). This case describes VT caused by right ventricular pacing after ICD implantation.

Myocarditis comprises 5 to 11% of sudden cardiac death (SCD) in individuals less than 40 years of age. Fulminant myocarditis is defined as acute heart failure or life threatening arrhythmias in the setting of myocarditis. We describe a case report about a patient with ventricular fibrillation (VF)

Background Patient sex and age may influence rates of death after receiving an implantable cardioverter‐defibrillator for primary prevention. Differences in outcomes other than mortality and whether these differences vary by heart failure symptoms, etiology, and left ventricular ejection fraction are not well characterized. Methods and Results We studied 2954 patients with left ventricular ejection fraction ≤0.35 undergoing first‐time implantable cardioverter‐defibrillator for primary prevention within the Cardiovascular Research Network; 769 patients (26%) were women, and 2827 (62%) were aged >65 years. In a median follow‐up of 2.4 years, outcome rates per 1000 patient‐years were 109 for death, 438 for hospitalization, and 111 for heart failure hospitalizations. Procedure‐related complications occurred in 8.36%. In multivariable models, women had significantly lower risks of death (hazard ratio 0.67, 95% CI 0.56 to 0.80) and heart failure hospitalization (hazard ratio 0.82, 95% CI 0.68 to 0.98) and higher risks for complications (hazard ratio 1.38, 95% CI 1.01 to 1.90) than men; patients aged >65 years had higher risks of death (hazard ratio 1.55, 95% CI 1.30 to 1.86) and heart failure hospitalization (hazard ratio 1.25, 95% CI 1.05 to 1.49) than younger patients. Age and sex differences were generally consistent in strata according to symptoms, etiology, and severity of left ventricular systolic dysfunction, except the higher risk of complications in women, which differed by New York Heart Association classification ( P =0.03 for sex–New York Heart Association interaction), and the risk of heart failure hospitalization in older patients, which differed by etiology of heart failure ( P =0.05 for age–etiology interaction). Conclusions The burden of adverse outcomes after receipt of an implantable cardioverter‐defibrillator for primary prevention is substantial and varies according to patient age and sex. These differences in outcome generally do not vary according to baseline heart failure characteristics.

Objectives This study was designed to compare the cost-effectiveness of implantable cardioverter-defibrillator (ICD) placement with and without risk stratification with microvolt T-wave alternans (MTWA) testing in the MADIT-II (Second Multicenter Automatic Defibrillator Implantation Trial) eligible population. Background Implantable cardioverter-defibrillators have been shown to prevent mortality in the MADIT-II population. Microvolt T-wave alternans testing has been shown to be effective in risk stratifying MADIT-II–eligible patients. Methods On the basis of published data, cost-effectiveness of three therapeutic strategies in MADIT-II–eligible patients was assessed using a Markov model: 1) ICD placement in all; 2) ICD placement in patients testing MTWA non-negative;, and 3) medical management. Outcomes of expected cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness were determined for patient lifetime. Results Under base-case assumptions, providing ICDs only to those who test MTWA non-negative produced a gain of 1.14 QALYs at an incremental cost of $55,700 when compared to medical therapy, resulting in an incremental cost-effectiveness ratio (ICER) of $48,700/QALY. When compared with a MTWA risk-stratification strategy, placing ICDs in all patients resulted in an ICER of $88,700/QALY. Most (83%) of the potential benefit was achieved by implanting ICDs in the 67% of patients who tested MTWA non-negative. Results were most sensitive to the effectiveness of MTWA as a risk-stratification tool, MTWA negative screen rate, cost and efficacy of ICD therapy, and patient risk for arrhythmic death. Conclusions Risk stratification with MTWA testing in MADIT-II–eligible patients improves the cost-effectiveness of ICDs. Implanting defibrillators in all MADIT-II–eligible patients, however, is not cost-effective, with one-third of patients deriving little additional benefit at great expense.

High defibrillation thresholds (DFTs) occasionally are encountered during placement of implantable cardioverter defibrillators (ICDs). There are multiple strategies to lower DFTs in such patients, including reassessment of right ventricular lead position, alteration of the shock waveform, and implantation of subcutaneous arrays. This article describes a novel technique of implanting a high-voltage lead in the azygos vein. This procedure may serve as an adjunctive approach to reduce DFTs. The anatomic location of the azygos vein posterior to the heart provides a suitable shocking vector between the right ventricular electrode, a high-voltage lead placed in the azygos vein, and the ICD can. (J Cardiovasc Electrophysiol, Vol. 15, pp. 780-783, July 2004)

Background: Patients with left ventricular ejection fraction (LVEF) ≤ 35% are eligible for implantable cardioverter-defibrillator (ICD) placement for the primary prevention of sudden cardiac death (SCD). This recommendation results in continuously growing waiting lists of patients who have been qualified for and are awaiting the procedure. Whiled reduced LVEF is a feature shared by all the patients in this group, the risk of malignant ventricular arrhythmias varies widely. It therefore seems important from the clinical point of view to improve the waiting lists by identifying patients at the lowest risk of SCD, who can safely wait for the procedure, while higher-risk patients undergo the procedure before them. Aim: To verify the utility of microvolt T-wave alternans (MTWA) testing, which is characterised by high negative predictive value (NPV), in scheduling ICD implantation in these patients. Methods: The study included 152 patients with LVEF ≤ 35%, qualified for ICD implantation for the primary prevention of SCD, and managed in accordance with the current recommendations. Patients with a history of malignant ventricular arrhythmias were excluded. Each patient underwent MTWA testing during chronic treatment (including beta-blockers) and was followed-up. Results: During 14 ± 8 months of follow-up, the primary outcome, which included SCD, non-fatal sustained ventricular arrhythmia, or appropriate high-voltage ICD discharge, was observed in 16 patients. The one-year event rate was 13.1% (5.8–19.8%) in non-negative MTWA patients and 0% in those who had negative MTWA result (p = 0.027). The NPV of the MTWA test was 100% (95% CI 92.73– 00%). Conclusions: In the group of patients with left ventricular systolic dysfunction, excluding patients with a history of malignant ventricular arrhythmia, the NPV of MTWA was 100% over 12 months of observation. MTWA may therefore be considered useful in determining the order of ICD implantation procedures in this group of patients by identifying patients at a relatively low risk of malignant ventricular arrhythmias, who can be relatively safely rescheduled for ICD implantation at a later time. Future studies should concentrate on this issue.

There is a paucity of research on the use of CS during ICD or pacemaker implantation. Pacemaker patients generally require small amounts of i.v. sedation, in conjunction with local anesthetic agents, to relieve incisional discomfort. Because of innovations in ICD technology, little difference now exists between ICD and pacemaker placement. Studies have reported on the use of deep sedation during ICD implantations, but only one study addressed CS in ICD placement. Whether deep levels of sedation are necessary for DFT testing is not apparent from these studies. Two studies report giving sedation at a level consistent with deep sedation, yet partial loss of protective reflexes was not reported in one of the studies. Further research is needed to explore the use of sedation in ICD implantation. It may be that deep sedation for patient comfort is necessary only during DFT testing or for tunneling of leads to an abdominal generator site, and that CS is more than appropriate for the implant portion of the procedure. Research may disclose that agents such as midazolam and, to some extent propofol, provide an amnesic effect that may mitigate the need for deep sedation during DFT testing or lead tunneling. Another benefit of agents and analgesics such as Fentanyl, is the relatively short duration of sedation, which minimizes recovery time. Patients recover quicker than with general anesthesia and can be discharged the same day in some procedures (e.g., generator replacement). Cost-benefit studies also are needed to compare the cost of anesthesiologist-delivered sedation with that of nurse-administered sedation. A comparison study could explore complication rates, patient comfort, and costs for the two sedation delivery methods.

Trait anxiety is a dispositional factor that predisposes individuals to respond to perceived threats with more frequent and intense elevations in emotional states associated with arousal of the autonomic nervous system, which is thought to lead to the development of anxiety disorders. Trait anxiety has demonstrated promise in the empirical literature as a potential predictor of long term outcomes in ICD recipients. The present study adds novel information to this body of literature by studying the relation of trait anxiety to clinical diagnoses of anxiety disorders based on the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID). Two hundred and seven recipients of ICDs within the past five years were evaluated using the SCID to establish past and current anxiety disorder diagnoses. Self-report questionnaires were administered to assess device-related appraisals and functional impairment. Participants were 70% (n=144/207) male, 63% (n=130/207) married and 29% currently working (60/207) with a mean age of 63.0 (±12.3) years. Ninety-seven (47%) shocked and 110 (53%) non-shocked ICD recipients were interviewed. ICD recipients high in trait anxiety (n = 59/207, 29%) had significantly higher rates of current episodes of obsessive compulsive disorder (χ 2 = 9.05; p2 = 6.38; p2 = 9.05; p ICD recipients high in trait anxiety (n = 59, 29%) reported greater device-related distress ( t = 5.65;pt =2.39;pt = -3.98;pt = 2.39; pt = 5.69; pt = -4.09; p Women (n=63/207; 30%) reported greater mean levels of trait anxiety ( t = -2.10; pt = -2.41; pt = 2.86; pt = 4.78; pt = 3.04; pt = 3.82; pt = 3.94; p The results from the current study suggest that assessment of trait anxiety may help clinicians identify individuals at risk for poor adjustment following ICD placement, even before implantation. Early identification of risk for maladjustment via pre-implant predictors might allow ICD recipients to enjoy the full benefits associated with these devices - longer and better quality of life.

The insulation of implantable cardioverter-defibrillator (ICD) sensing leads can fracture, causing device malfunction. Before March 1989, 32 patients received silicon CPI K54 sensing leads. Of these, four (12.5%) experienced discharges while in sinus rhythm. Subsequent ICD interrogation revealed that abdominal muscular contraction triggered discharges in two patients, but no abnormal sensing could be elicited in the other two patients. These patients subsequently were found to have sensing lead fractures. All sensing leads appeared intact radiographically but at reoperation were found to have insulation fractures 2-4 cm from the pin. The mechanism of fracture appears to be related to chronic intermittent lead compression between the anterior abdominal wall musculature and the ICD generator. Since March 1989, 134 patients have undergone ICD implantation with improved CPI 4312 sensing leads; none of these patients has experienced sensing lead fractures. The insulation of these leads is 2.5 times thicker than the K54 (1.0 mm vs. 0.4 mm). Patients with K54 sensing leads are at an increased risk for sensing lead insulation fracture and merit close surveillance. More importantly, sensing lead fractures must be considered in patients who present with inappropriate ICD discharges.

Previous studies documented racial and gender disparities in implantable cardioverter-defibrillator (ICD) placement. The authors examined whether racial and gender disparities in ICD placement are due to underutilization or overutilization. Among 1,054 adults hospitalized from 2001 to 2004 with ventricular arrhythmias in a large academic hospital, the study found that 17% of patients had clinical indicators concordant with ICD placement criteria. Among those, Blacks were less likely than Whites to receive an ICD (adjusted odds ratio [OR] = 0.24; 95% CI = 0.08-0.71). Among the 83% who were discordant with ICD placement criteria, Blacks (adjusted OR = 0.30; 95% CI = 0.18-0.52) and Hispanics (adjusted OR = 0.24, 95% CI = 0.10-0.57) were less likely than Whites, and women less likely than men, to receive an ICD (adjusted OR = 0.48; 95% CI = 0.34-0.67). In this cohort, these differences appear related to overutilization among men and Whites who are discordant with ICD placement criteria in addition to underutilization among Blacks concordant with placement criteria.

Heart rate variability (HRV) is a beat-to-beat variation in cardiac cycle length resulting from autonomic influence on the sinus node of patients in sinus rhythm. The importance of HRV as a risk stratifier has been well accepted, particularly in survivors of myocardial infarction. Large clinical trials are still needed to clarify the role of HRV in patients with non-ischemic cardiomyopathy. Given the significant association between HRV and the development of fatal arrhythmias/sudden cardiac death, HRV has been used in some clinical trials as one of the screening tests to select optimal candidates for implantable cardioverter-defibrillator placement, although its role in this area has not been fully established. Additional large prospective clinical trials are needed to further clarify the predictive value of existing or novel HRV parameters, on their own or in combination with other risk stratifiers, for assessing the risk of sudden cardiac death in a variety of clinical settings.

Mixed venous oxygen saturation (Sv0 2 ) monitoring was used to assess tissue and circulatory recovery following induced ventricular tachycardia or fibrillation in 17 patients undergoing surgery for automatic implantable cardioverter-defibrillator (AICD) placement. Return of systemic arterial pressure conventionally determines adequate recovery. The duration of circulatory arrest during defibrillator threshold (DFT) testing, measured from the moment of absent phasic pressure at the radial artery until its return, was 18 ± 18 seconds (mean ± SD, n = 118 episodes). The absolute decrease in Sv0 2 from baseline to nadir for these 118 episodes was 14% ± 6% absolute, and correlated well with the duration of circulatory arrest ( r = 0.757, P = 0.0001). The time from onset of phasic arterial blood pressure to the nadir of Sv0 2 , available for 46 episodes, was 28 ± 14 seconds, and did not correlate with the duration of arrest. The time from onset of phasic pressure to the return of SvO 2 to within 1 % (absolute) of baseline saturation, available for 84 episodes, was 52 ± 32 seconds and, in the aggregate, correlated poorly ( r = 0.401) with duration of arrest. Simultaneous recording of arterial pressure and Sv0 2 (n = 41) showed that arterial recovery (6 ± 3 seconds) occurred long before Sv0 2 recovery (48 ± 16 seconds, P = 0.0001). The authors interpret these data as showing that mixed venous oximetry, compared to arterial blood pressure, provides a more sensitive indicator of tissue recovery following periods of circulatory arrest during DFT testing of AICDs.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a disorder that predominantly affects the right side of the heart and causes ventricular arrhythmias. In many patients the disease is familial. ARVC may account for as many as 5% of unexpected sudden deaths. We report a case of ARVC diagnosed at 21 weeks gestation treated with an implantable cardiac defibrillator. The remainder of her pregnancy was uneventful and the patient underwent induction of labor at 39 weeks gestation with a passive second stage forceps-assisted delivery resulting in delivery of a normal infant. In the gravida with cardiac arrhythmias, defibrillator placement may offer a safe, life-preserving treatment and should be considered.

This report describes a case of an active-can ICD placed in the thigh. A 74-year-old man on chronic renal dialysis had no venous access from cephalic, subclavian, or jugular approaches. Using long active-fixation leads the device was placed from a femoral approach with good sensing, pacing, and defibrillation parameters.

Desminopathy is a neuromuscular disorder associated with the accumulation of the protein desmin. This article reports a case of a man with a mutation in the desmin gene suffering from cardiomyopathy and skeletal myopathy. This patient underwent implantable cardioverter defibrillator (ICD) implantation for prognostic considerations and subsequently developed a sustained ventricular tachycardia (SVT). While nonsustained VTs (NSVT) have previously been reported, this is the first time that a SVT could be seen in a patient with this disease.

Massive pneumoperitoneum developed 3 days after placement of an automatic implantable cardioverter defibrillator in a 75-year-old man. A subsequent computed tomographic examination revealed generator wires passing through the subxiphoid colon. Partial colectomy was performed, the generator was removed, and the wires were moved. The postoperative course was uneventful.