Diagnosis and management of subcutaneous implantable cardioverter-defibrillator infections based on process mapping

The Subcutaneous Implantable Cardioverter-Defibrillator: A Patient Perspective

The subcutaneous implantable cardioverter-defibrillator (S-ICD) is a new technology for the management of ICD patients. But what is the patients' perspective? Previous studies on the transvenous ICD (TV-ICD) showed that device implantation is related not only to anxiety and depression because of the fear of ICD shocks, but also to many biopsychosocial factors like body image changes, perceived reduction of socialization and limitation in professional and sports activities. Anxiety and distress are more evident in younger women because of aesthetic reasons. The scar size and the position of the S-ICD can help these patients and positively influence their social relationships. Moreover, the position of the S-ICD reduces possible complications from catheters due to stress injury and can improve patients' professional life by avoiding some work activity limitations. An S-ICD can be also a good option for athletes in avoiding subclavian crash and reducing inappropriate shocks. However, some questions remain unsolved because an S-ICD is not suitable for patients with indications for pacing, cardiac resynchronization therapy or anti-tachycardia pacing. In conclusion, the use of an S-ICD can assist physicians in reducing the negative impact of implantation on the well-being of some groups of patients by helping them to avoid depression and anxiety as well as improving their noncompliance with their medical treatment.

Opportunities and drawbacks of the subcutaneous defibrillator across different clinical settings

INTRODUCTION

The subcutaneous implantable cardioverter-defibrillator (S-ICD) is an established therapy for the prevention of sudden cardiac death (SCD) and an alternative to a transvenous implantable cardioverter-defibrillator system in selected patients. Beyond randomized clinical trials, many observational studies have described the clinical performance of S-ICD across different subgroups of patients.

AREAS COVERED

Our review aimed to describe the opportunities and drawbacks of the S-ICD, focusing on their use in special populations and across different clinical settings.

EXPERT OPINION

The choice to implant S-ICD should be based on the patient's tailored approach, which takes into account the adequate S-ICD screening at rest or during stress, the infective risk, the ventricular arrhythmia susceptibility, the progressive nature of the underlying disease, the work or sports activity, and the risk of lead-related complications.

Cardiac Implantable Electronic Devices Infection Assessment, Diagnosis and Management: A Review of the Literature

The use of increasingly complex cardiac implantable electronic devices (CIEDs) has increased exponentially in recent years. One of the most serious complications in terms of mortality, morbidity and financial burden is represented by infections involving these devices. They may affect only the generator pocket or be generalised with lead-related endocarditis. Modifiable and non-modifiable risk factors have been identified and they can be associated with patient or procedure characteristics or with the type of CIED. Pocket and systemic infections require a precise evaluation and a specialised treatment which in most cases involves the removal of all the components of the device and a personalised antimicrobial therapy. CIED retention is usually limited to cases where infection is unlikely or is limited to the skin incision site. Optimal re-implantation timing depends on the type of infection and on the results of microbiological tests. Preventive strategies, in the end, include antibiotic prophylaxis before CIED implantation, the possibility to use antibacterial envelopes and the prevention of hematomas. The aim of this review is to investigate the pathogenesis, stratification, diagnostic tools and management of CIED infections.

Effects and Complications of Subcutaneous Implantable Cardioverter-Defibrillator in the Prevention of Sudden Cardiac Death: A Narrative Review

An implantable cardioverter-defibrillator (ICD) is one of those devices that is a big boom for the prevention of sudden deaths due to heart failure. This particular device has been in use for just a couple of years, but its impact in the domain has brought about a considerable change in the way a specific issue of the cardiovascular system is tackled. Although subcutaneous or hypodermic implantable cardioverter-defibrillator (S-ICD) is considered to be a better alternative as far as transvenous implantable cardioverter-defibrillator (TV-ICD) is concerned, the former, being a newer introduction in the market, needs to be assessed in depth to clearly understand its effects and complications. Various types of research have been conducted on the efficacy of this device, and in most of the studies, the supremacy of this device is clearly evident when compared with other devices that are used for the same purpose. Better innovations in subcutaneous or hypodermic implantable cardioverter-defibrillators would enable them to be manufactured in a more efficient and cost-effective way so that a huge lot of people are benefited from this device. This review article is a whole peep into the various studies done in this domain, thereby providing adequate scientific insights about subcutaneous or hypodermic implantable cardioverter-defibrillators in a very simple and comprehensive manner.

"Shift and cover technique": conservative management of complications for the rescue of S-ICD subcutaneous implantable defibrillator systems

BACKGROUND

The risk of complications has been shown to be lower with subcutaneous implantable defibrillator (S-ICD) than with conventional ICDs. Given the low frequency of complications, experience of how to manage them is limited. In this paper, we describe generator- and lead-related complications recorded in a series of S-ICD patients, and we propose our conservative approach to managing them.

METHODS

The study cohort consisted of S-ICD patients who were referred to our institution owing to generator- or lead-related complications requiring surgical intervention. With our "shift and cover" approach, the system component involved is moved from its original position to an alternative, more protected location. In the case of the generator, this involves moving it to an intermuscular pocket. In the case of infections at the parasternal scar, the electrode sleeve is moved away from its original location, stitched, and then covered with the muscular fascia.

RESULTS

Fourteen S-ICD patients were referred to our institution owing to system-related complications. Complications involved the generator in 7 cases (deep pocket infections with erosion, extrusion, or pain), the lead in 5 cases (parasternal infections at the xyphoid incision site), and both the generator and the lead in 2 cases. Complications were managed without completely removing the device and resolved in a single surgical session with no intraoperative complications. During defibrillation testing, the first shock at 65 J was effective in all patients. The shock impedance after revision was significantly lower than that measured during first implantation (59 ± 10 Ohm versus 86 ± 24 Ohm, P = 0.013). In all cases, the cosmetic result was satisfactory. No complications or recurrent infections were reported at the 12-month follow-up visit.

CONCLUSIONS

The proposed conservative approach was successful in managing S-ICD complications. The revision procedure allowed to optimize the system configuration in terms of the defibrillation vector, resulting in lower shock impedance values and better device positioning.

Process Mapping Strategies to Prevent Subcutaneous Implantable Cardioverter-Defibrillator Infections

BACKGROUND

Infection remains a major complication of cardiac implantable electronic devices (CIEDs) and can lead to significant morbidity and mortality. Implantable devices that avoid transvenous leads, such as the subcutaneous implantable cardioverter-defibrillator (S-ICD), can reduce the risk of serious infection-related complications, such as bloodstream infection and infective endocarditis. While the 2017 AHA/ACC/HRS guidelines include recommendations for S-ICD use for patients at high risk of infection, currently, there are no clinical trial data that address best practices for the prevention of S-ICD infections. Therefore, an expert panel was convened to develop consensus on these topics.

METHODS

An expert process mapping methodology was used to achieve consensus on the appropriate steps to minimize or prevent S-ICD infections. Two face-to-face meetings of high-volume S-ICD implanters and an infectious diseases specialist, with expertise on cardiovascular implantable electronic device infections, were conducted to develop consensus on useful strategies pre-, peri-, and post-implant to reduce S-ICD infection risk.

RESULTS

Expert panel consensus of recommended steps for patient preparation, S-ICD implantation, and post-operative management were developed to provide guidance in individual patient management.

CONCLUSION

Achieving expert panel consensus by process mapping methodology for S-ICD infection prevention was attainable, and the results should be helpful to clinicians in adopting interventions to minimize risks of S-ICD infection. This article is protected by copyright. All rights reserved.

Diagnosis and management of subcutaneous implantable cardioverter-defibrillator infections based on process mapping

BACKGROUND

Infection is a well-recognized complication of cardiovascular implantable electronic device (CIED) implantation, including the more recently available subcutaneous implantable cardioverter-defibrillator (S-ICD). Although the AHA/ACC/HRS guidelines include recommendations for S-ICD use, currently there are no clinical trial data that address the diagnosis and management of S-ICD infections. Therefore, an expert panel was convened to develop consensus on these topics.

METHODS

A process mapping methodology was used to achieve a primary goal - the development of consensus on the diagnosis and management of S-ICD infections. Two face-to-face meetings of panel experts were conducted to recommend useful information to clinicians in individual patient management of S-ICD infections.

RESULTS

Panel consensus of a stepwise approach in the diagnosis and management was developed to provide guidance in individual patient management.

CONCLUSION

Achieving expert panel consensus by process mapping methodology in S-ICD infection diagnosis and management was attainable, and the results should be helpful in individual patient management.