Implantable Cardioverter Defibrillator Therapy in Athletes

Decision-making regarding subcutaneous implantable cardioverter defibrillator as primary prevention in patients with low ejection fraction

BACKGROUND

Conventional transvenous implantable cardioverter-defibrillator (TV-ICD) is the standard device used for primary prevention of sudden cardiac death (SCD) in patients with reduced left ventricular ejection fraction (LVEF). Nonetheless its use is associated with lead-related complications including infection and malfunction. A subcutaneous implantable cardioverter-defibrillator (S-ICD) offers an alternative option without the need for a transvenous lead but has limitations. The decision to implant a TV-ICD or S-ICD in patients with impaired LVEF for primary prevention of SCD is controversial. Several randomised controlled trials and large observational studies have confirmed similar safety and efficacy of S-ICDs and TV-ICDs in such population.

METHODS

A literature review was conducted to compare the outcomes of subcutaneous (S-ICD) versus transvenous (TV-ICD) implantable cardioverter-defibrillators. Databases including PubMed, MEDLINE, and Cochrane were searched for relevant peer-reviewed articles. Studies were selected based on relevance and quality. Key outcomes like complication rates, efficacy, and patient survival were summarized in a comparative table.

RESULTS

Different factors that influence the choice between an TV-ICD and S-ICD for primary prevention of SCD in patients with LVEF are highlighted to guide selection of the appropriate device in different patient populations. Moreover, future perspective on the combination of SICD with leadless pacemaker, and the latest development of the extravascular implantable cardioverter defibrillator are also discussed.

CONCLUSIONS

S-ICD offers a safe and efficacious option to primary prevention in reduced ejection fraction. Future development including incorporation of leadless pacemaker will add to the arsenal of choice to protect patients from sudden cardiac death.

Standardised Exercise Prescription for Patients with Chronic Coronary Syndrome and/or Heart Failure: A Consensus Statement from the EXPERT Working Group

Whereas exercise training, as part of multidisciplinary rehabilitation, is a key component in the management of patients with chronic coronary syndrome (CCS) and/or congestive heart failure (CHF), physicians and exercise professionals disagree among themselves on the type and characteristics of the exercise to be prescribed to these patients, and the exercise prescriptions are not consistent with the international guidelines. This impacts the efficacy and quality of the intervention of rehabilitation. To overcome these barriers, a digital training and decision support system [i.e. EXercise Prescription in Everyday practice & Rehabilitative Training (EXPERT) tool], i.e. a stepwise aid to exercise prescription in patients with CCS and/or CHF, affected by concomitant risk factors and comorbidities, in the setting of multidisciplinary rehabilitation, was developed. The EXPERT working group members reviewed the literature and formulated exercise recommendations (exercise training intensity, frequency, volume, type, session and programme duration) and safety precautions for CCS and/or CHF (including heart transplantation). Also, highly prevalent comorbidities (e.g. peripheral arterial disease) or cardiac devices (e.g. pacemaker, implanted cardioverter defibrillator, left-ventricular assist device) were considered, as well as indications for the in-hospital phase (e.g. after coronary revascularisation or hospitalisation for CHF). The contributions of physical fitness, medications and adverse events during exercise testing were also considered. The EXPERT tool was developed on the basis of this evidence. In this paper, the exercise prescriptions for patients with CCS and/or CHF formulated for the EXPERT tool are presented. Finally, to demonstrate how the EXPERT tool proposes exercise prescriptions in patients with CCS and/or CHF with different combinations of CVD risk factors, three patient cases with solutions are presented.

Sport activity in patients with cardiac implantable electronic devices: evidence and perspectives

Demographic characteristics of patients with cardiac implantable electronic devices have significantly changed during the last few years, according to the ageing of the population and the consequent increase in the number of elderly individuals with indication for pacemaker implant and, on the other hand, to the increased number of young individuals implanted with an implantable cardioverter defibrillator for the primary prevention of sudden death. More and more often, both elderly and young patients ask the physician to deal with the device in their daily activities, which often include sport practice. This latter is advisable because of its recognized benefits on cardiovascular prevention, although there are many limitations for patients with a cardiac implantable electronic device. Hence, the need to balance the patient's request with the appropriate precautions emerging from existing evidence. The current article aims to provide an overview of the most recent data on this topic, derived from registries and observational studies. Over the years an attempt to standardize recommendations has been made, but robust evidence is still lacking. Substantial differences exist between countries based on their sports regulations. Official recommendations of European and American Scientific Societies are resumed. The future perspective is to obtain data to allow these patients a safer practice of sport activity also through technological advances in terms of device materials and programming improvement and the possibility of remote monitoring.

Sudden Death and Ventricular Arrhythmias in Athletes: Screening, De-Training and the Role of Catheter Ablation

Athletes enjoy excellent health outcomes including greater longevity relative to non-athletic counterparts. Paradoxically, however, endurance athletic conditioning is associated with an increase in some arrhythmias. This review discusses the potential mechanisms for this paradox and strategies enabling early identification of potentially serious pathologies. Screening remains contentious due to the challenges of identifying relatively rare entities amongst a healthy cohort. The imperfect diagnostic accuracy of all current tests means that screening strategies have potential for harm through incorrect diagnoses as well as the potential for identification of important sub-clinical pathologies. Management of athletes at risk of ventricular arrhythmias and sudden cardiac death is similarly complex. There is much yet to learn about the specific patterns of ventricular arrhythmias in athletes, and the separation of benign from potentially life-threatening remains imperfect. There are some promising advances, however, such as specialised imaging modalities combined with improved electrophysiological diagnostics and therapeutics. Some unique clinical patterns are emerging to advance our understanding and management of athletes with ventricular arrhythmias, requiring specialised skillsets for evaluation and management.

[Is it possible to practice sports with an implantable cardioverter-defibrillator?]

Why? The potential risks of sport for an ICD recipient include appropriate and inappropriate shocks, device damage and worsening of the underlying cardiopathy. These risks should be compared to the physical and psychological benefits of exercise. Where? Due to different medico-legal contexts and considering the results of recent studies, the new US guidelines are more permissive than the European guidelines regarding sport practice in ICD recipients. Who? The underlying context (structural or electrical cardiopathy, psychological impact) should be assessed before any decision is taken. What sport? The intensity and duration of the exercise, the environment, the type of sport (bodily contact sports or compromising the costoclavicular area) and the potential consequences for the patient or the spectators of a possible loss of consciousness must to be anticipated. How? The patient's information on the consequences of the ICD on his subsequent physical activity must be delivered before the device implantation. In addition, the type and programming of the ICD must be personalized according to the sport. When? The patient should wait at least 6 weeks after ICD implantation to return to leisure sport and after an exercise test has been performed. After a ventricular arrhythmia, the patient must wait 3 months before returning to sport.

Inherited primary arrhythmia disorders: cardiac channelopathies and sports activity

Sudden cardiac death (SCD) in an apparently healthy individual is a tragedy. It is important to identify the cause of death and to prevent SCD in potentially at-risk family members. Inherited primary arrhythmia disorders are associated with exercise-related SCD. Despite the well-known benefits of exercise, exercise restriction has been a historical mainstay of therapy for these conditions. However, since familiarity with inherited arrhythmia conditions has increased and patients are often children and young adults, it is necessary to reassess the treatment guidelines regarding exercise constraints. The aim of this review is to analyze the risk of exercise-induced SCD in patients with inherited cardiac conditions and explore the challenges faced when advising patients about exercise limitations. We searched for publications on cardiac channelopathies in PubMed with the following medical subject headings (MeSH): "long QT syndrome"; "short QT syndrome"; "Brugada syndrome"; and "catecholaminergic polymorphic ventricular tachycardia". The abstracts of these articles were scanned, and articles of relevance, along with pertinent references, were read in full. The analysis was restricted to reports published in English. The findings of this analysis suggest that exercise with low-to-moderate cardiovascular demand may be possible under regular clinical follow-up in inherited primary arrhythmia disorders. Recent data show that patients with inherited primary arrhythmia disorders are at low risk for events once a comprehensive treatment program has been established. Recreational activity is likely safe for these individuals, with personalized management based on individual patient preferences and priorities.

Athletes with Implantable Cardioverter Defibrillators

Athletes with an implantable cardioverter defibrillator (ICD) represent a diverse group of individuals who may be at an increased risk of sudden cardiac death when engaging in vigorous physical activity. Therefore, they are excluded by the current guidelines from participating in most competitive sports except those classified as low intensity, such as bowling and golf. The lack of substantial data on the natural history of the cardiac diseases affecting these athletes as well as the unknown efficacy of ICDs in terminating life-threatening arrhythmias occurring during intense exercise has resulted in the restrictive nature of these now decade old guidelines.

Exercise and competitive sports in patients with an implantable cardioverter-defibrillator

Implantable cardioverter-defibrillators (ICDs) prevent sudden arrhythmic death in patients with different arrhythmogenic cardiac diseases. Because intense physical activity may trigger ventricular arrhythmias and may favour inappropriate shock delivery that impacts quality of life, current international recommendations only give clearance for moderate leisure-time physical activity to patients with an ICD. Hence, athletes are deemed non-eligible to compete with their ICD. The rationale for the current restriction from competitive sports is discussed in this review, as well as new insights that may alter these recommendations for certain sports participants in the foreseeable future. This review provides guidance for the choice of a durable lead and device system, careful programming tailored to the characteristics of the patient's physiological and pathological heart rhythms, instalment of preventive bradycardic medication, and guided rehabilitation with psychological counselling, allowing a maximum of benefit and a minimum of harm for physically active ICD patients.

Syncope in the athlete

Syncope in the athlete requires a complete evaluation, as this may be the only warning prior to an episode of sudden cardiac death. This should include a detailed history which includes specific details of the event as well as bystander descriptions when possible. Following the history should be a careful physical examination and subsequent diagnostic testing based on the individual's needs. The purpose of the evaluation is to determine if structural or electrical heart disease is present that may lead to sudden death. If absent, the patient, family and staff can be reassured that it is safe to resume athletic activity. Careful attention to the athlete with syncope may both prevent potential disasters in some, while at the same time enjoyment of intense physical activity in others.

Attitudes towards implantable cardioverter-defibrillator therapy: a national survey in Danish health-care professionals

AIMS

The aim of this study was to examine health-care professionals attitudes towards implantable cardioverter-defibrillator (ICD) therapy and issues discussed with patients.

METHODS AND RESULTS

Survey of 209 health-care professionals providing specialized treatment and care of ICD patients at the five implanting centres in Denmark. Questions pertained to gender, age, years of experience within the field, knowledge of the ongoing critical debate on ICD therapy, and personal experience with ICD treatment, and/or sudden cardiac arrest within family and/or friends. Of all participants, 185 (88.5%) completed the survey. Physicians spent less time informing patients about ICD treatment prior to implantation (mean min = 17.7 ± 11.2 vs. 28.6 ± 19.4; P < 0.001). They were more likely to discuss clinical issues but less likely to discuss psychosocial issues with patients compared with non-physicians. Physicians were less likely to believe that their personal attitude towards ICD treatment has no influence on how they deal professionally with patients (27.8 vs. 43.6%; P = 0.04). Physicians and non-physicians were equally positive towards ICD therapy as primary prophylaxis in ischaemic cardiomyopathy (87.6 vs. 82.1%; P = 0.40) but not in non-ischaemic cardiomyopathy (57.3 vs. 83.9%; P < 0.001). Physicians were more positive towards ICD therapy as secondary prophylaxis (98.9 vs. 84.2%; P = 0.001) compared with non-physicians.

CONCLUSIONS

Physicians focus on clinical rather than psychosocial issues when discussing ICD treatment with candidate patients. At the same time, physicians are more aware that their attitude towards ICD treatment may influence how they deal professionally with patients compared with non-physicians.

Atrial and ventricular lead insulation defects with resulting inappropriate shocks and end-of-life of the ICD pulse generator in a young bodybuilder with congenital long-QT-syndrome

We report on a 19-year-old male with a congenital Long-QT syndrome who was admitted to our hospital because of insulation defects of both atrial and ventricular ICD leads resulting in inappropriate delivered shocks and a non-responding pulse generator during telemetrical evaluation. The insulation defects led to multiple arc marks within the ICD pocket and there was a short circuit between denuded leads and the electrically active pulse generator. The high current flow generated sufficient heat to damage several circuits of the generator. A new ICD system was implanted successfully and the postoperative course has been remained uneventful for almost 6 years.