Management of patients receiving implantable cardiac defibrillator shocks: Recommendations for acute and long-term patient management

Impact of Combined Modulation of Two Potassium Ion Currents on Spiral Waves and Turbulent States in the Heart

In the realm of cardiac research, the control of spiral waves and turbulent states has been a persistent focus for scholars. Among various avenues of investigation, the modulation of ion currents represents a crucial direction. It has been proved that the methods involving combined control of currents are superior to singular approaches. While previous studies have proposed some combination strategies, further reinforcement and supplementation are required, particularly in the context of controlling arrhythmias through the combined regulation of two potassium ion currents. This study employs the Luo-Rudy phase I cardiac model, modulating the maximum conductance of the time-dependent potassium current and the time-independent potassium current, to investigate the effects of this combined modulation on spiral waves and turbulent states. Numerical simulation results indicate that, compared to modulating a single current, combining reductions in the conductance of two potassium ion currents can rapidly control spiral waves and turbulent states in a short duration. This implies that employing blockers for both potassium ion currents concurrently represents a more efficient control strategy. The control outcomes of this study represent a novel and effective combination for antiarrhythmic interventions, offering potential avenues for new antiarrhythmic drug targets.

Selecting the appropriate patients for coronary artery bypass grafting in ischemic cardiomyopathy-importance of myocardial viability

Patients who undergo coronary artery bypass graft (CABG) surgery in ischemic cardiomyopathy have a survival advantage over medical therapy at 10 years. The survival advantage of CABG over medical therapy is due to its ability to reduce future myocardial infarction, and by conferring electrical stability. The presence of myocardial viability does not provide a differential survival advantage for CABG over medical therapy. Presence of angina and inducible ischemia are also less predictive of outcome. Moreover, CABG is associated with significant early mortality. Hence, careful patient selection is more important for reducing the early mortality and improving the long-term outcome than relying on results of myocardial viability. Younger patients with good exercise tolerance benefit the most, while patients who are frail and patients with renal dysfunction and dysfunctional right ventricle seem to have very high operative mortality. Elderly patients, because of poor life expectancy, do not benefit from CABG, but the age cutoff is not clear. Patients also need to have revascularizable targets, but this decision is often based on experience of the surgical team and heart team discussion. These recommendations are irrespective of the myocardial viability tests. Optimal medical treatment remains the cornerstone for management of ischemic cardiomyopathy.

Management of hemodynamically stable wide QRS complex tachycardia in patients with implantable cardioverter defibrillators

Management of hemodynamically stable, incessant wide QRS complex tachycardia (WCT) in patients who already have an implantable cardioverter defibrillator (ICD) is challenging. First-line treatment is performed by medical staff who have no knowledge on programmed ICD therapy settings and there is always some concern for unexpected ICD shock. In these patients, a structured approach is necessary from presentation to therapy. The present review provides a systematic approach in four distinct phases to guide any physician involved in the management of these patients: PHASE I: assessment of hemodynamic status and use of the magnet to temporarily suspend ICD therapies, especially shocks; identification of possible arrhythmia triggers; risk stratification in case of electrical storm (ES).

PHASE II

The preparation phase includes reversal of potential arrhythmia "triggers", mild patient sedation, and patient monitoring for therapy delivery. Based on resource availability and competences, the most adequate therapeutic approach is chosen. This choice depends on whether a device specialist is readily available or not. In the case of ES in a "high-risk" patient an accelerated patient management protocol is advocated, which considers urgent ventricular tachycardia transcatheter ablation with or without mechanical cardiocirculatory support.

PHASE III

Therapeutic phase is based on the use of intravenous anti-arrhythmic drugs mostly indicated in this clinical context are presented. Device interrogation is very important in this phase when sustained monomorphic VT diagnosis is confirmed, then ICD ATP algorithms, based on underlying VT cycle length, are proposed. In high-risk patients with intractable ES, intensive patient management considers MCS and transcatheter ablation.

PHASE IV

The patient is hospitalized for further diagnostics and management aimed at preventing arrhythmia recurrences.

Patients with an implantable cardioverter defibrillator at risk of poorer psychological health during 24 months of follow-up (results from the Danish national DEFIB-WOMEN study)

OBJECTIVE

Identify implantable cardioverter defibrillator (ICD) patients at risk of distress (i.e., depression, anxiety, and ICD concerns) and associated risk factors.

METHOD

First-time ICD patients (n = 1503) from the Danish national DEFIB-WOMEN study completed questionnaires at baseline, 3, 6, 12 and 24 months.

RESULTS

Of patients with low scores on distress, only 4%-7.2% experienced an increase in distress during 24 months of follow-up (FU), while 30.5%-52.5% with increased levels were likely to maintain increased levels at FU. Higher education, higher age, female sex, and good physical functioning at baseline were associated with less depression, anxiety and ICD concerns at FU. Previous psychological problems, smoking, Type D personality, NYHA class III-IV - all assessed at baseline - and shocks during FU were associated with depression, anxiety and ICD concerns.

CONCLUSIONS

Generally, patients' psychological health improved, but patients with increased baseline scores were more likely to have increased scores at FU. We need to be vigilant if patients report elevated distress, particularly if they have depression at baseline, as depression seems more persistent. Given the impact of depression on health-related quality of life and prognosis, they should be screened and monitored closely.

Development of a patient and clinician co-led education program to promote living well with an implantable cardioverter defibrillator: Insights from a pilot project

Objective

To evaluate a pilot education program designed to improve patients' experience of living well with an implantable cardioverter-defibrillator (ICD).

Methods

Patient Partners with previously implanted ICD and clinicians collaboratively performed monthly education sessions for potential and recent ICD recipients. Curriculum development was informed by current evidence of ICD patients' unique educational needs; delivery format transitioned to a virtual platform following the onset of COVID-19. Participants' experience was evaluated using a tailored questionnaire to explore preliminary insights.

Results

126 participants (median age: 62 years; women: 30%) attended 24 sessions. In-person participants (n = 62, 49.2%) reported sessions as helpful (n = 56, 94%) with regards to format and Patient Partner interactions. Virtual participants 64 (50.8%) completed an electronic survey (n = 27, 45%); reporting sufficient information for most topics with the exception of potential psychological effects of ICD implantation. Patient Partners as collaborative session leaders was perceived to be very helpful (n = 22, 82%) or somewhat helpful (n = 5, 18%).

Conclusion

This novel educational partnership met the learning needs of patients at the vulnerable time of new cardiac device implantation of both in-person and virtual formats.

Innovation

The inclusion of Patient Partners in co-led cardiac education informs novel approach to care that may improve patients' experiences of living well with complex technology.

Outcomes of early catheter ablation for ventricular tachycardia in adult patients with structural heart disease and implantable cardioverter-defibrillator: An updated systematic review and meta-analysis of randomized trials

Aims

Catheter ablation (CA) for ventricular tachycardia (VT) can improve outcomes in patients with ischemic cardiomyopathy. Data on patients with non-ischemic cardiomyopathy are scarce. The purpose of this systematic review and meta-analysis is to compare early CA for VT to deferred or no ablation in patients with ischemic or non-ischemic cardiomyopathy.

Methods and results

Studies were selected according to the following PICOS criteria: patients with structural heart disease and an implantable cardioverter-defibrillator (ICD) for VT, regardless of the antiarrhythmic drug treatment; intervention–early CA; comparison–no or deferred CA; outcomes–any appropriate ICD therapy, appropriate ICD shocks, all-cause mortality, VT storm, cardiovascular mortality, cardiovascular hospitalizations, complications, quality of life; published randomized trials with follow-up ≥12 months. Random-effect meta-analysis was performed. Outcomes were assessed using aggregate study-level data and reported as odds ratio (OR) or mean difference with 95% confidence intervals (CIs). Stratification by left ventricular ejection fraction (LVEF) was also done. Eight trials (n = 1,076) met the criteria. Early ablation was associated with reduced incidence of ICD therapy (OR 0.53, 95% CI 0.33–0.83, p = 0.005), shocks (OR 0.52, 95% CI 0.35–0.77, p = 0.001), VT storm (OR 0.58, 95% CI 0.39–0.85, p = 0.006), and cardiovascular hospitalizations (OR 0.67, 95% CI 0.49–0.92, p = 0.01). All-cause and cardiovascular mortality, complications, and quality of life were not different. Stratification by LVEF showed a reduction of ICD therapy only with higher EF (high EF OR 0.40, 95% CI 0.20–0.80, p = 0.01 vs. low EF OR 0.62, 95% CI 0.34–1.12, p = 0.11), while ICD shocks (high EF OR 0.54, 95% CI 0.25–1.15, p = 0.11 vs. low EF OR 0.50, 95% CI 0.30–0.83, p = 0.008) and hospitalizations (high EF OR 0.95, 95% CI 0.58–1.58, p = 0.85 vs. low EF OR 0.58, 95% CI 0.40–0.82, p = 0.002) were reduced only in patients with lower EF.

Conclusion

Early CA for VT in patients with structural heart disease is associated with reduced incidence of ICD therapy and shocks, VT storm, and hospitalizations. There is no impact on mortality, complications, and quality of life. (The review protocol was registered with INPLASY on June 19, 2022, #202260080).

Systematic review registration

[https://inplasy.com/], identifier [202260080].

Predictors of Hospital Admissions for Ventricular Arrhythmia or Cardiac Arrest in Patients With Cardiomyopathy

Although ventricular dysfunction is associated with the occurrence of ventricular arrhythmia (VA), most patients with cardiomyopathy do not experience VA. We therefore investigated other predictors of VA in a large contemporary cohort of patients with cardiomyopathy. All patients at a large academic medical system with left ventricular ejection fraction (LVEF) ≤50% were enrolled at the time of first documented low LVEF. Predictors of hospital admission for VA were examined using multivariable Cox models. The incidence of implantable defibrillator (ICD) placement was also examined. A total of 18,003 patients were enrolled. Over a median follow-up of 3.35 years, 389 patients (2.2%) were admitted for VA (304 of 12,037 [2.5%] among patients with LVEF ≤35% vs 85 of 5,966 [1.4%] among those with LVEF 36% to 50%). Predictors of VA hospitalization included lower LVEF (hazard ratio (HR) = 1.43 per 10% decrease, p <0.001), the presence of an ICD at baseline (HR = 1.63, p = 0.010), higher blood glucose (HR = 1.02 per 10 mg/100 ml increase, p = 0.050), the presence of end-stage renal disease (HR = 3.59, p <0.001), and the presence of liver cirrhosis (HR = 1.93, p = 0.013). During follow-up, 626 patients were implanted with a new ICD. In addition to being admitted with VA, a lower LVEF and a history of coronary artery disease or heart failure were the main predictors of ICD therapy in this population. In conclusion, in addition to more severe cardiomyopathy and the presence of an implanted ICD, metabolic derangements on initial contact are independent predictors of hospital admissions for VA in patients with cardiomyopathy. Noncardiac co-morbidities play an important role in stratifying patients with cardiomyopathy for their risk of VA or cardiac arrest.

Let It Beat: How Lifestyle and Psychosocial Factors Affect the Risk of Sudden Cardiac Death-A 10-Year Follow-Up Study

(1) Background: The aim of this study was to evaluate the lifestyle and occurrence of psychosocial factors in patients with a high risk of sudden cardiac death (SCD) and to explore their effect on the occurrence of the adequate therapy of an Implantable Cardioverter Defibrillator (ICD). (2) Methods: In this retro-prospective single-centre study, a group of patients aged 18-65 years old, who underwent the first ICD implantation for primary (PP) or secondary (SP) prevention between 2010-2014, was studied. The control group consisted of pair-matched (age ± 5 years, gender) respondents without a high risk of SCD. Information was obtained using a self-reported questionnaire and hospital electronic health records. The adequacy of ICD therapy was evaluated regularly until 31 January 2020. Multivariate logistic regression models were employed to assess the risk of SCD. (3) Results: A family history of SCD, coronary artery disease, diabetes mellitus and depression significantly aggravated the odds of being at a high risk of SCD. The occurrence of an appropriate ICD therapy was significantly associated with being in the SP group, BMI, education level and TV/PC screen time. (4) Conclusions: Lifestyle and psychosocial factors have been confirmed to affect the risk of SCD. Early identification and treatment of coronary artery disease and its risk factors remain the cornerstones of preventive effort. Further research is needed to evaluate the complex nature of psychosocial determinants of cardiac health.

Testing a nurse-led, pre-implantation educational intervention for primary prevention implantable cardioverter-defibrillator candidates: a randomized feasibility trial

AIMS

Implantable cardioverter-defibrillators (ICDs) deliver therapy for life-threatening arrhythmias. Evidence suggests that ICD candidates have misconceptions regarding ICD therapy and unmet information needs. We undertook a pilot feasibility trial comparing a nurse-led educational intervention plus standard care, vs. standard pre-ICD implantation care. Secondary aims included examination of anxiety, quality of life, and shock anxiety.

METHODS AND RESULTS

Implantable cardioverter-defibrillator candidates were consented and randomized to standard pre-ICD implantation care vs. standard care plus a nurse-led educational intervention. The primary feasibility outcomes included: recruitment rate, consent rate, randomization rate, proportion of participants able to complete all questionnaires, time to deliver intervention, and intervention topics completion. At baseline, demographic and Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety scores were collected. Four weeks post-ICD implantation, participants completed the PROMIS, Florida Patient Acceptance Survey (FPAS), and Florida Shock Anxiety Scale (FSAS). Twenty patients consented (10 per group). Feasibility targets were achieved for all but two outcomes: consent rate was 87% vs. 95% target, and completion of data collection measures was 85% vs. 90% target. Consent rate was lower than expected as one patient declined, and two could not be approached. Completion rate was lower than expected as two patients were lost to follow-up, and one did not receive an ICD during the study period, leading to incomplete post-implantation survey collections.

CONCLUSION

The results demonstrate the feasibility of conducting a trial comparing a nurse-led pre-implantation educational intervention to standard care in an outpatient setting. Further study to evaluate the effectiveness of this intervention on patient-reported outcomes is warranted.

Sinergy between drugs and devices in the fight against sudden cardiac death and heart failure

The impact of sudden cardiac death (SCD) in heart failure (HF) patients is important and prevention of SCD is a reasonable and clinically justified endpoint if associated with a reduction in all-cause mortality. According to literature, in HF with reduced ejection fraction, only three classes of agents were found effective in reducing SCD and all-cause mortality: beta-blockers, mineralcorticoid receptor antagonists and, more recently, angiotensin-receptor neprilysin-inhibitors. In the PARADIGM trial that tested sacubitril/valsartan vs. enalapril, the 20% relative risk reduction in cardiovascular deaths obtained with sacubitril/valsartan was attributable to reductions in the incidence of both SCD and death due to HF worsening and this effect can be added to the known positive effect of implantable cardioverter-defibrillators in appropriately selected patients. In order to maximize the implementation of all the available treatments, patients with HF should be included in virtuous networks with a dialogue between all the physician involved, with commitment by all these physicians for appropriate decision-making on application of pharmacological and device treatments according to available evidence, as well as commitment for drug titration before and after device implant, taking advantage from remote monitoring, and with the safety of back up device therapy when indicated. There are potential synergistic effects of drug therapy, with all the therapies acting on neuro-hormonal and sympathetic activation, but specifically with sacubitril/valsartan, and device therapy, in particular cardiac resynchronization therapy, with added incremental benefits on positive cardiac remodelling, prevention of HF progression, and prevention of ventricular tachyarrhythmias.

The Psychology of Total Joint Arthroplasty

Patient dissatisfaction after total joint arthroplasty can be as high as 20%. There are many factors that lead to dissatisfaction including unmet expectations, persistent pain, and technical errors. There is increasing evidence that psychological factors play a role in a patient's ability to manage with the surgical stress of total joint arthroplasty. These factors play an important role in dissatisfaction after surgery. In addition, there are several studies that demonstrate certain psychological factors such as resiliency can affect patient outcomes. This symposium explores the impact of these psychological factors on total joint arthroplasty with a specific focus on identification and modification of these factors.

Deactivation of implantable defibrillators at end of life - Can we do better?

INTRODUCTION

Dying patients with implantable defibrillators (ICD) have a risk of receiving unnecessary shocks before death. The aim of this study was to investigate if deactivation of shock therapy at end-of-life has increased since publication of new guidelines in 2010 on ICD management.

METHOD AND RESULTS

This is a study of two groups of ICD patients who died in hospitals before and after publication of new guidelines. Group 1 consists of 89 patients who died between 2003 and 2010. Group 2 consists of 252 patients, the total number of ICD patients in Sweden who died in hospital during 2014. Data was obtained from the Swedish ICD and Pacemaker Registry, Swedish Tax Agency and patient medical notes. Two-thirds died in wards other than Cardiology. Fifty-four percent in group 1 had a Do-Not-Resuscitate-order (DNR) compared to 73% in group 2. Shock deactivation was present in 52% in group 1 and 67% in group 2. The difference in shock deactivation between group 1 and 2 was only significant (p = 0.014) for DNR-patients treated in Cardiology. A significant difference (p = 0.036) was found in deactivation within group 2 between DNR-patients in Cardiology vs. DNR-patients in Non-Cardiology wards.

CONCLUSION

Two-thirds of ICD patients die in wards other than Cardiology. Since publication of guidelines on ICD management there is a general increase in shock deactivation for DNR-patients, but only significant for patients in Cardiology. This implicate that actions have to be taken for patients treated in Non-Cardiology wards to bridge the gap between guidelines recommendations and clinical practice.

Electrical storm - still an extremely poor prognosis. Do these acute states of life-threatening arrhythmias require a multidirectional approach from the start?

Electrical storm (ES) is a state of electrical instability of the heart manifesting as multiple and potentially lethal recurring ventricular arrhythmias such as ventricular tachycardia or ventricular fibrillation. This definition is not related to the condition of each patient, who can present from asymptomatic to unconscious and in deep cardiogenic shock. Most patients affected by ES have heart failure (HF) of ischaemic origin. Ischaemia, exacerbation of HF, low ejection fraction, previous ventricular arrhythmias, infection or electrolyte disturbances together with other factors, or a few factors combined, may result in ES. The prognosis of ES survivors is very poor, with 1-year mortality exceeding 40%, which should draw attention to this group of patients as one of extremely high risk. The number of patients with cardioverter-defibrillators is increasing and so is the number of patients suffering from ES. Therefore, each patient should be supported with tailored therapy, and not only restricted to pharmacotherapy or ablation procedures. This paper was written to analyse the most frequent causes of ES and prompt the most appropriate clinical pathways and possibilities, underlining the need for a comprehensive invasive approach to diagnosis, treatment and circulatory stabilization in addition to adequate pharmacotherapy. This approach might help to reduce the mortality rate in this group of patients and improve the prognosis.

The effects of gender on electrical therapies for the heart: procedural considerations, results and complications: A report from the XII Congress of the Italian Association on Arrhythmology and Cardiostimulation (AIAC)

Use of cardiac implantable devices and catheter ablation is steadily increasing in Western countries following the positive results of clinical trials. Despite the advances in scientific knowledge, tools development, and techniques improvement we still have some grey area in the field of electrical therapies for the heart. In particular, several reports highlighted differences both in medical behaviour and procedural outcomes between female and male candidates. Women are referred later for catheter ablation of supraventricular arrhythmias, especially atrial fibrillation, leading to suboptimal results. On the opposite females present greater response to cardiac resynchronization, while the benefit of implantable defibrillator in primary prevention seems to be less pronounced. Differences on aetiology, clinical profile, and development of myocardial scarring are the more plausible causes. This review will discuss all these aspects together with gender-related differences in terms of acute/late complications. We will also provide useful hints on plausible mechanisms and practical procedural aspects.

Physicians' knowledge of implantable defibrillator treatment: are we good enough?

Aims

When admitted to hospitals, patients with an implantable cardioverter defibrillator (ICD) are treated in a variety of departments. Physicians need to have basic ICD knowledge in order to provide the best possible care from implantation to the end of life. The aim of this study was to assess the levels of knowledge concerning ICD treatment among physicians active in Cardiology, Internal Medicine, and Geriatrics.

Methods and results

This cross-sectional comparative study, after stratified sampling, distributed 432 surveys in 18 hospitals with a response rate of 99.5%. As many as 349 (83%) physicians had experience with ICD patients; 288 (68%) rated their ICD knowledge to be low. According to predefined criteria, 175 (41%) physicians' scores reflected sufficient knowledge. There was a significant difference in the level of knowledge between specialities. Sufficient knowledge was reached by 56 (30%) of the physicians in Internal Medicine and 20 (19%) of them in Geriatrics, whereas in Cardiology 99 (71%) reached sufficient knowledge.

Conclusion

There is lack of basic knowledge in ICD treatment and clinical management among physicians. The majority of the respondents had prior experience in treating ICD patients. Over two-thirds of the physicians rated their knowledge to be low, while test scores revealed sufficient knowledge in only 41% of the physicians surveyed. The lack of ICD knowledge is most prominent in Internal Medicine and Geriatrics, but it also extends to physicians in Cardiology departments. With an increasing number of ICD patients, it is of great importance to fill this knowledge gap as soon as possible.

A Decade of Information on the Use of Cardiac Implantable Electronic Devices and Interventional Electrophysiological Procedures in the European Society of Cardiology Countries: 2017 Report from the European Heart Rhythm Association

Aims

The aim of this analysis was to provide comprehensive information on invasive cardiac arrhythmia therapies in the European Society of Cardiology (ESC) area over the past 10 years.

Methods and results

The European Heart Rhythm Association (EHRA) has collected data on invasive arrhythmia therapies since 2008. This year 53 of the 56 ESC member countries provided data for the EHRA White Book. Here we present updated data on procedure rates together with information on demographics, economy, vital statistics, local healthcare systems and training activities. Considerable heterogeneity in the access to invasive arrhythmia therapies still exists across the five geographical ESC regions. In 2016, the device implantation rates per million population were 3-6 times higher in the Western region than in the non-European and Eastern ESC member countries. Catheter ablation activity was highest in the Western countries followed by the Northern and Southern areas. In the non-European countries, atrial fibrillation ablation rate was more than tenfold lower than in the European countries. On the other hand, the growth rate over the past ten years was highest in the non-European and Eastern countries. In some Eastern European countries with relative low gross domestic product the procedure rates exceeded the average values.

Conclusion

It was encouraging to note that during the past decade the growth in invasive arrhythmia therapies was greatest in the areas historically with relatively low activity. Nevertheless, there is substantial disparity and continued efforts are needed to improve harmonization of cardiac arrhythmia therapies in the ESC area.

A time local subset feature selection for prediction of sudden cardiac death from ECG signal

Prediction of sudden cardiac death continues to gain universal attention as a promising approach to saving millions of lives threatened by sudden cardiac death (SCD). This study attempts to promote the literature from mere feature extraction analysis to developing strategies for manipulating the extracted features to target improvement of classification accuracy. To this end, a novel approach to local feature subset selection is applied using meticulous methodologies developed in previous studies of this team for extracting features from non-linear, time-frequency, and classical processes. We are therefore enabled to select features that differ from one another in each 1-min interval before the incident. Using the proposed algorithm, SCD can be predicted 12 min before the onset; thus, more propitious results are achieved. Additionally, through defining a utility function and employing statistical analysis, the alarm threshold has effectively been determined as 83%. Having selected the best combination of features, the two classes are classified using the multilayer perceptron (MLP) classifier. The most effective features would subsequently be discussed considering their prevalence in the rank-based selection. The results indicate the significant capacity of the proposed method for predicting SCD as well as selecting the appropriate processing method at any time before the incident. Graphical abstract ᅟ.

Ventricular Arrhythmias

Ventricular tachycardia (VT) is the most common form of wide complex tachycardia and is associated with a high mortality rate. Electrocardiographic analysis remains paramount in diagnosis and helps to direct therapy. Antiarrhythmic agents, although effective in reducing arrhythmia burden, have never demonstrated a mortality benefit. The implantable cardioverter-defibrillator aids not only in the acute termination of ventricular arrhythmia, but provides a wealth of information for the long-term management of patients with VT. Contemporary treatment options such as catheter ablation are increasingly used and effective, but often remain imperfect, with recurrent VT being not uncommon.

Long-term outcome of catheter ablation and other form of therapy for electrical storm in patients with implantable cardioverter-defibrillators

PURPOSE

Radiofrequency catheter ablation (RFCA) for electrical storm (ES) has become a widely used therapeutic method. Its effectiveness in comparison to other forms of ES treatment is however uncertain.

METHODS

This single-centre retrospective study investigated the long-term clinical outcome after RFCA for ES and compared long-time effects of ablation to other forms of treatment. The study population consisted of 70 consecutive patients hospitalised between January 2010 and June 2015 due to ES. Patients were recruited for the study if the following criteria were fulfilled: first ES caused by ventricular tachycardia (VT) or ventricular fibrillation (VF), implanted cardioverter defibrillator or cardiac resynchronisation therapy device and left ventricular ejection fraction < 50%. The follow-up data on VT/ES recurrence was obtained from pacemaker/implanted cardioverter defibrillator memory. Data on all-cause mortality was collected during outpatient visits or by telephone contact.

RESULTS

Of the 70 patients enrolled, 28 (40%) were treated with RFCA (group A) and 42 (60%) received other forms of treatment for ES (group B). During a mean (±SD) 864 (629) days of follow-up, death occurred in 4 (14.3%) patients in the ablation group and in 16 (38.1%) patients treated with other methods [p = 0.03]. There was no significant between-group difference in VT/VF and ES recurrence. Statistical analysis revealed that the presence of cardiac resynchronisation therapy device during ES, stroke and/or transient ischaemic attack and lower baseline hematocrit level were the multivariate predictors of all-cause mortality.

CONCLUSIONS

In patients treated with RFCA for ES, all-cause mortality was significantly lower compared to the group treated with other methods.

Patient-centred care of patients with ventricular arrhythmias and risk of sudden cardiac death: What do the 2015 European Society of Cardiology guidelines add?

Nurses and allied professionals are at the forefront of care delivery in patients with arrythmogenic risk and have a responsibility to deliver care that is focused on their individual needs. The 2015 European Society of Cardiology guideline on prevention of ventricular arrhythmia and sudden cardiac death heralds a step-change in patient and family focus and interdisciplinary involvement. This development reflects a recognition within the European Society of Cardiology that chronic care of patients with cardiovascular conditions can be improved by involving all stakeholders, making use of multidisciplinary interventions, and placing the patient at the centre of the care process. In this article, taskforce contributors discuss the latest evidence and highlight some of the most pertinent issues for nurses involved in patient-centred care of patients and families with ventricular arrhythmias and/or risk of sudden death.

Implantable cardioverter defibrillator management: an update

Implantable cardioverter defibrillator (ICD) is the cornerstone of primary and secondary prevention of sudden cardiac death. In 35 years of technologic improvement and clinical trials, there has been a continuous increase in implantation rate. Purpose of this review is to point out and discuss every aspect related to actual ICD management, investigating implantation procedure and predischarge care, office and remote monitoring follow-up, diagnostic evaluations, management of patients with suspected therapies or malfunctions, heart failure, surgery, radiotherapy and endoscopic procedures. Also, ICD backface such as infections and other complications will be discussed. Finally, we will focus on interesting future perspectives for this setting of patients.

Left Ventricular Ejection Fraction Predicts Severity of Posttraumatic Stress Disorder in Patients With Implantable Cardioverter-Defibrillators

BACKGROUND

Implantable cardioverter-defibrillators (ICD) have provided effective therapy for fatal arrhythmia. However, ICD patients are known to develop psychological problems, such as posttraumatic stress disorder (PTSD), if they have experienced potentially fatal arrhythmia and ICD shocks. Little is known about the factors influencing PTSD in ICD patients.

HYPOTHESIS

Echocardiographic cardiac-function parameters might relate to psychological problems, especially PTSD, in ICD patients.

METHODS

A total of 128 outpatients with ICD implantation completed the Impact of Event Scale Revised (IES-R) questionnaire as a measurement of PTSD. Demographic and clinical characteristic data were collected from medical records.

RESULTS

The mean age of the ICD patients was 59 ± 16 years; 103 were male; and the mean left ventricular ejection fraction (LVEF) by echocardiography was 52.4% ± 18.3%. In the ICD patients, female sex and impaired LVEF were related to lower IES-R scores or led to PTSD (P = 0.01 and P = 0.03, respectively). Impaired LVEF also worsened 2 symptoms of PTSD, intrusion (P = 0.02) and hyperarousal (P = 0.03). In patients with LVEF <35%, there was a significant negative correlation between LVEF level and IES-R score (P = 0.045).

CONCLUSIONS

This study showed that LVEF was related to the severity of PTSD, especially in the ICD patients with LVEF of <35%. We should pay more attention to ICD patients with severely impaired left ventricular function to prevent psychological problems.

ED evaluation and management of implantable cardiac defibrillator electrical shocks

Patients with implantable cardiac defibrillators not infrequently present to the emergency department after experiencing an implantable cardiac defibrillator shock. This review considers the management of such patients in the emergency department, including appropriate, inappropriate, and phantom shocks as well as electrical storm.

Potential role of antitachycardia pacing alerts for the reduction of emergency presentations following shocks in patients with implantable cardioverter-defibrillators: implications for the implementation of remote monitoring

AIMS

Despite increased use of remote monitoring (RM) to follow up implantable cardioverter-defibrillator (ICD) recipients, many patients still receive ICD shocks in the community and present to the emergency department. Our aim was to identify the best predictors of impending shock delivery that can be measured with an ICD and to identify the most appropriate activities to alert physicians to during RM follow-up.

METHODS AND RESULTS

All patients presenting to our institution for ICD shock, from November 2011 to November 2014, were enrolled in this prospective study. Patient characteristics, investigation results, and details of electrical activities from ICD interrogation were recorded at presentation. Presentations were classified as potentially avoidable if activities from a list of set criteria were apparent more than 48 h before index shock. Univariate and multivariate analyses were then used to identify predictors of potentially avoidable shocks. In total, 109 emergency presentations were recorded in 90 patients (male: 85%; 57 ± 16 years; ischaemic cardiomyopathy: 49%; LVEF: 34 ± 13%; electrical storm: 40%), of which 26 (24%) were potentially avoidable. Antitachycardia pacing (ATP) episodes were the most important predictor of impending shock. Potentially avoidable shocks were preceded by more episodes of ATP than unavoidable shocks (13 [3-67] vs. 3 [0-10]; P < 0.001). Patients followed up with RM systems configured to generate alerts following ATP delivery experienced significantly less ICD shocks (24 vs. 16%, P < 0.01).

CONCLUSION

Remote monitoring systems that generate alerts following ATP delivery could reduce emergency presentations for ICD shock by 24%, as ATP is a key predictor of impending shock delivery.

Emergency Care of Patients with Pacemakers and Defibrillators

Devices such as pacemakers and implantable cardioverter-defibrillators (ICDs) are commonly inserted to treat unstable cardiac rhythm disturbances. Despite the benefits of these devices on mortality and morbidity rates, patients often present to the emergency department with complaints related to device insertion or malfunction. Emergency physicians must be able to rapidly identify potential life threats caused by pacemaker malfunction, ICD firing, and complications associated with implantation of the devices.

Clinical course and prognostic relevance of antitachycardia pacing-terminated ventricular tachyarrhythmias in implantable cardioverter-defibrillator patients

AIMS

In patients with an implantable cardioverter-defibrillator (ICD), ICD shocks due to ventricular tachycardia (VT) or ventricular fibrillation (VF) have been associated with an increased mortality. It is not known whether patients with antitachycardia pacing (ATP)-terminated VT/VF episodes have a similar worse outcome. The aim of this study was to evaluate the clinical course and prognostic impact of ATP-terminated episodes on mortality in ICD patients.

METHODS AND RESULTS

A total of 1398 consecutive patients of the prospective single-centre ICD-registry Ludwigshafen who underwent an ICD implantation between 1992 and 2008 for primary or secondary prevention of sudden cardiac death were analysed. Patients treated with ATP were compared with patients with appropriate ICD shocks or patients without any appropriate ATP or ICD shock. During the median follow-up time of 6 years, 749 (54%) patients experienced 17 827 episodes of VT or VF which were terminated by ATP in 74% and by shock in 26% of patients. In approximately half (n = 321/749) of those patients with VT/VF, the first episode was terminated by ATP. In a multivariate analysis adjusted for different baseline confounding parameters, the occurrence of first ATP therapy was associated with a higher mortality rate [hazard ratio (HR) 2.60, 95% confidence interval (CI) 2.02-3.35]. When excluding all patients with appropriate ICD shocks first ATP therapy remained associated with a worse prognosis (HR 1.92, 95% CI 1.38-2.67).

CONCLUSIONS

In ICD patients, about three-fourths of ventricular arrhythmias are terminated by ATP. The occurrence of ATP-terminated episode is associated with an increased mortality rate.

Sudden loss of the deep brain stimulation effect with high impedance without macroscopic fracture: a case report and review of the published literature

The number of deep brain stimulation (DBS) hardware complications has increased during the past decade. In cases of abnormally high lead impedance with no evidence of a macroscopic fracture, optimal treatment options have not yet been established. Here, we present the case of a 49-year-old woman with a 12-year history of Parkinson's disease who received bilateral subthalamic nucleus DBS in March 2006. The patient showed good control of parkinsonism until December 24, 2010, when she awoke with abrupt worsening of parkinsonian symptoms. At telemetric testing, lead impedances were found at >2,000 Ω in all four leads on the left side. Fracture of a lead or an extension wire was suspected. However, radiological screening and palpation revealed no macroscopic fracture. In June 2011, the implantable pulse generator (IPG) was changed under local anesthesia without any complications. Postoperatively, her parkinsonism immediately improved to the previous level, and the lead impedance readings by telemetry were also normalized. The disconnection of the neurostimulator connector block and the hybrid circuit board of the IPG was confirmed by destructive analysis. The present report illustrates that a staged approach that starts with simple IPG replacement can be an option for some cases of acute DBS effect loss with high impedance, when radiological findings are normal, thereby sparing the intact electrodes and extension wires.

Implantable cardioverter defibrillator deactivation: a hospice quality improvement initiative

BACKGROUND

Dying patients whose implantable cardioverter defibrillators (ICDs) continue to deliver shocks may experience significant pain, and the National Quality Forum has endorsed routine deactivation of ICDs when patients near the end of life. The overarching goal of this quality improvement project was to increase rates of ICD deactivation among hospice patients.

MEASURES

ICD deactivation rates pre- vs. post-intervention; and clinicians' knowledge and confidence regarding ICD management.

INTERVENTION

A multifaceted intervention included clinical tools, education, and standardized documentation templates in the electronic medical record.

OUTCOMES

The proportion of patients whose ICD was deactivated increased after the intervention (pre- vs. post-intervention: 39/68, 57% vs. 47/56, 84%; odds ratio 3.88; 95% confidence interval 1.54-10.37; P = 0.001). Clinicians' knowledge and confidence regarding ICD management improved (pre- vs. post-intervention median questionnaire scores: 5 vs. 9 on a scale of 0 to 10; Wilcoxon signed-rank test Z = -5.01; P < 0.001).

CONCLUSIONS/LESSONS LEARNED

A multifaceted intervention can increase rates of ICD deactivation among patients near the end of life.