Transcript ICD Therapy Post Cardiac Arrest

Implantable Defibrillator Therapy
Post Cardiac Arrest
Samir Saba, MD, FACC, FHRS
Associate Chief of Cardiology
Director, Cardiac Electrophysiology
Disclosures
Research Support:
Boston Scientific
Medtronic
St Jude Medical
Consulting:
Boston Scientific
St Jude Medical
Outline
 Guidelines
 Secondary Prevention Trials
AVID
CASH
CIDS
 Reversible Causes of Sudden cardiac Death
 AVID registry
UPMC Data
 Role of the LifeVest
Indications
UPMC Experience
 Advances in ICD Therapy
Sudden Cardiac Death in the United States
300,000
250,000
200,000
150,000
100,000
50,000
0
SCD
CVA Lung CA Breast
CA
Auto
Acc.
AIDS
Fires
Implantable Cardioverter Defibrillator
Ventricular Tachycardia
Sinus Rhythm
31 J
ICD Guidelines after SCA
“ICD therapy is indicated in patients who are survivors
of cardiac arrest due to ventricular fibrillation or
hemodynamically unstable sustained VT after
evaluation to define the cause of the event and to
exclude any completely reversible causes” (Class I
Indication; Level of Evidence: A)
ACC/AHA/HRS 2008 guidelines for Device-Based Therapy of Cardiac Rhythm
Abnormalities: executive summary. J Am Coll Cardiol. 2008 May 27;51(21):e1-62.
Cardiac Arrest Study Hamburg (CASH)
HR=0.77, P=0.08
Kuck KH et al. Circulation 2000;102:748-54.
Canadian Implantable Defibrillator Study (CIDS)
HR=0.80, P=0.14
Connolly SJ et al. Circularion 2000;1011297-1302
Antiarrhythmics Vs. Implantable Defibrillators
(AVID) Trial
HR=0.69, P=0.02
The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators.
N Engl J Med 1997;337:1576-1584.
Patient Management After
Sudden Cardiac Arrest
 Correct any reversible cause of SCA:
 Revascularization when indicated for ACS
 Correct electrolyte/metabolic abnormalities
 Discontinue medications/drugs implicated in SCA
 Zebras
 WPW
 Lightening/drowning/trauma
Anti-Arrhythmic Drugs After
Sudden Cardiac Arrest
 Use of AAD is adjunctive therapy
 AAD Not needed as a matter of routine
 Reserved for patients with high burden of ectopy or NSVT
 May be required transiently until other triggers are reversed
 The choice of AAD
 Avoid class I agents (e.g. Flecainide, Propafenone) in patients
with CAD or structural heart disease
 Avoid class III agents (e.g. Sotalol, Dofetilide) in patients with
prolonged QT interval or renal insufficiency
 In the acute and subacute phases, Amiodarone is often used
given that it is effective and hemodynamically tolerated
 Amiodarone should be avoided when possible for long term use
given its potential end-organ toxicities
Ventricular Arrhythmia Ablation After
Aborted Sudden Cardiac Arrest
 Adjunctive therapy to ICD implantation
SMASH-VT trial:
 N=128 post MI and
VT/VF
 Randomized 1:1
 ICD
 ICD+RFA
VTACH trial:
 N=110 post MI and
stable VT with EF<50%
 Randomized 1:1
 ICD
 ICD+RFA
HR=0.35, 95% CI 0.15 to 0.78, P = 0.007
HR=0.61, 95% CI 0.37 to 0.99, P = 0.045
Reversible Correctible Causes of SCA
Conceptual Concerns
Determining the exact cause of a SCA and whether
it is reversible is fraught with uncertainty:
1. Reversible causes may actually be a consequence of the
SCA and resuscitation efforts rather than a cause
2. In addition, reversible and correctable causes may not be
avoidable in future follow-up
3. The occurrence of SCA in the presence of a presumed
reversible cause may unveil a predisposition to electrical
cardiac instability
Reversible Correctible Causes of SCA
AVID Registry
VF or Unstable VT
No
Reversible
Cause?
Yes
R
No ICD
ICD
AVID Trial
AVID Registry
Reversible Correctible Causes of SCA
UPMC Data
N=646 Patients
Irreversible
(N=211)
Reversible
(N=435)
Corrected
(N=330)
Not Corrected
(N=105)
ICD
(N=87)
No ICD
(N=243)
ICD
(N=31)
No ICD
(N=74)
ICD
(N=41)
(N=170)
Death
N=31
(36%)
Death
N=114
(47%)
Death
N=12
(39%)
Death
N=42
(57%)
Death
N=15
(37%)
Death
N=107
(63%)
No ICD
Reversible Correctible Causes of SCA
UPMC Data
IRREVERSIBLE
REVERSIBLE NOT CORRECTED
In Acute Coronary Syndrome
REVERSIBLE CORRECTED
Wearable Defibrillator (LifeVest)
 Used only as a bridge to ICD
 The LifeVest is indicated when
there is an ICD indication but
patient’s condition delays or
prohibits ICD implantation
 Infection
 Neurological condition after SCA
 Patient /family decision
 Poor patient compliance
Advances in ICD Therapy
Sub-Cutaneous ICD (S-ICD)
Advantages:




No Radiation
No endocarditis
No vascular occlusions
No need for high risk
transvenous extractions
 More predictable
implantation times
Disadvantages:
 No back-up pacing
 No ATP
Advances in ICD Therapy
MRI-Conditional ICD
EKG
Pulse Ox
Start of Scan
RF Lead
Heating
Tissue
Damage
Pacing
Capture
Threshold
Change
Loss of
Pacing
Capture
Summary
 Indications for ICD implantation after aborted SCA are
well established for the secondary prevention of SCD
 Adjunctive therapies include:
 AAD
 Ablation procedures
 Gaps in knowledge exist regarding managing survivors of
SCA in the context of a reversible cause
 Recent advances in ICD technology:
 MRI-compatible ICD
 Subcutaneous ICD
 Home monitoring
 The LifeVest is only used as a bridge to ICD when ICD
therapy has to be delayed in a SCA survivor
Questions?