Congestive heart failure implantation of intracardiac defibrillator

Editor(s)-In-Chief: James Chang, M.D., Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School [mailto:jchang@caregroup.org] and C. Michael Gibson, M.S., M.D. [mailto:mgibson@perfuse.org], Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School;

Overview

 * 50% of heart failure patients die of sudden cardiac death.
 * ICDs are indicated for patients with previous myocardial infarction and LVEF <30%, sustained ventricular tachycardia, inducible ventricular tachycardia.
 * Morbidity/mortality benefit of ICD placement vs. anti-arrhythmic drug therapy is controversial.

Indications for an Intracardiac Defibrillator
1. The left ventricular ejection fraction (LVEF) is ≤ 35%

and

2. NYHA class II/III

OR

1. The left ventricular ejection fraction (LVEF) is ≤ 30%

and

2. There is a prior history of myocardial infarction (MI)

Background

 * ICDs prevent sudden death in appropriately selected patients with heart failure and left ventricular systolic dysfunction irrespective of etiology.


 * Implantation of an ICD for primary prevention of sudden death should be considered for patients with LVEF ≤ 35% who are in NYHA functional class II or III.


 * ICD implantation is not appropriate or beneficial for patients in NYHA class IV (severely debilitated). In post-MI patients, implantation of an ICD should be performed no earlier than 40 days post-MI in patients with persistent moderate or severe left ventricular systolic dysfunction: LVEF ≤ 30% for asymptomatic (NYHA class I) patients or LVEF ≤ 35% for symptomatic (NYHA class II or III) patients.


 * ICD implantation has NOT been demonstrated to prolong life in patients who are severely symptomatic or otherwise profoundly debilitated (NYHA class IV).

==ACC/AHA Guidelines- Implantable Cardioverter Defibrillator Recommendation == {{cquote|

Class I
1. An implantable cardioverter deﬁbrillator is recommended as secondary prevention to prolong survival in patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction (LVEF) who have a history of cardiac arrest, ventricular ﬁbrillation, or hemodynamically destabilizing ventricular tachycardia. (Level of Evidence: A)

2. Implantable cardioverter deﬁbrillator therapy is recommended for primary prevention of sudden cardiac death to reduce total mortality in patients with non-ischemic dilated cardiomyopathy or ischemic heart disease at least 40 days post-myocardial infarction, a left ventricular ejection fraction (LVEF) less than or equal to 35%, and NYHA functional class II or III symptoms while receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: A)}}

Vote on and Suggest Revisions to the Current Guidelines

 * The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

 * The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult


 * 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation