Cardiac Device Therapy Cardiac Electrophysiology

Abrar H. Shah M.D.

“Helping You to a Healthy Heart”

Disclosures Speaker declared research support from: Biotronik Medtronic Speakers bureau: Boehringer Ingelheim

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Cardiac Device Therapy 

Pacemaker



Implantable Cardioverter Defibrillator



Bi-Ventricular Pacemaker



Implantable Loop Recorder

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Permanent Pacemaker

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Indication for Pacemaker 

Symptomatic Bradycardia.



Sinus Node Dysfunction – Sinus Node Pauses (> 3 sec) – Chronotropic Incompetance – Bradycardia as a result of needed medical therapy



AV Block – Mobitz II – Complete Heart Block – Pause of > 5 sec in patient with atrial fibrillation.



Alternating bundle-branch block

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Lyme Disease 

A-V Block resolves spontaneously.

Lyme Disease is Borrelia Burgdorderi

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A-V Block 

Sarcoid



Amyloid



Neuromuscular Disorder – Myotonic muscular dystrophy – Kearns-Sayre Syndrome – Erb dystrophy

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Bifascicular Block

-Syncope -HV > 100 msec -Intermittent Type II or third degree AV Block “Helping You to a Healthy Heart”

Third International Study on Syncope of Uncertain Etiology (ISSUE-3): 

77 patients were at least 40 years old and had a clinical history that suggested NMS



ILR monitoring, demonstrated at least three seconds of asystole associated with clinical syncope or an asystolic nonsyncopal episode of at least six seconds.



The pacemaker-on group showed a 57% reduction in relative risk of fainting within two years of randomization (p=0.039).

Circulation. 2012;125:2566-2571 “Helping You to a Healthy Heart”

Implantable Cardioverter Defibrillator For Primary and Secondary Prevention of Sudden Cardiac Death

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Magnitude of SCA in the US

Stroke3

Lung Cancer2

SCA claims more lives each year than these other diseases combined

SCA 4

Breast Cancer2 AIDS1

1 2 3 4

U.S. Census Bureau, Statistical Abstract of the United States: 2001. American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001. 2002 Heart and Stroke Statistical Update, American Heart Association. Circulation. 2001;104:2158-2163. “Helping You to a Healthy Heart”

Underlying Arrhythmia of Sudden Cardiac Arrest Primary VF 8% Torsades de Pointes 13%

VT 62%

Adapted from Bayés de Luna A. Am Heart J. 1989;117:151-159. “Helping You to a Healthy Heart”

Bradycardia 17%

Etiology of SCA

5% Other*

15% Cardiomyopathy

80% Coronary Artery Disease

Adapted from Heikki et al. N Engl J Med, Vol. 345, No. 20, 2001. * ion-channel abnormalities, valvular or congenital heart disease, other causes

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Evolution of ICD Therapy: 1980 to Present 1980

1985

1993

1996

2002-4

• First Human Implant

• FDA Approval of ICDs

• Smaller Devices

MADIT

• MADIT II • SCD-HeFT • COMPANION 100,000

1999

1989

90,000

• MUSTT

• Transvenous Leads

80,000 70,000 60,000 50,000

1997/98 • DC ICDs • AT Therapies • AVID • CASH • CIDS

40,000 30,000 20,000 10,000 0

1980

1985

1990

Number of Worldwide ICD Implants Per Year * Under clinical investigation in the US

1995

2000 E “Helping You to a Healthy Heart”

Therapies Provided By ICDs

Ventricle

Atrium & Ventricle

 Antitachycardia pacing

 Bradycardia sensing

 Cardioversion

 Bradycardia pacing

 Defibrillation

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Primary Prevention Trials

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Primary Prevention Trials: Benefit of ICD therapy. MADIT

MADIT II Moss et al, NEJM 1996

Moss et al, NEJM 2002

MUSTT

Buxton et al, NEJM 1999

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SCD HeFT Sudden Cardiac DeathHeart Failure Trial

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Indication for ICD for Primary Prevention in Patients With Cardiomyopathy Nonischemic

Ischemic

Ischemic

Ischemic

CMP (9 months)

CMP

CMP

CMP & NSVT

EF < 35%

EF < 30% *

EF 31-35% *

EF < 40%

Class I

Yes

If + EPS

Class II

Yes

Yes

Yes

If + EPS

Class III

Yes

Yes

Yes

If + EPS

Only if CRT

Only if CRT

Class IV Only if CRT SCD-HeFT + COMPANION

MADIT II + COMPANION

SCD-HeFT + COMPANION

Contraindication: Life expectancy < 1 yr. * No MI in 40 days or revascularization in 3 months for ischemic CMP.

MUSTT: NSVT at least 4 days after Cardiac event “Helping You to a Healthy Heart”

Continuum of Risk of Sudden Cardiac Death

Myerburg R et al. Circulation 1998, 97:1514-1521 “Helping You to a Healthy Heart”

Secondary Prevention Trials

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Reductions in Mortality with ICDs Secondary Prevention Trials

% Mortality Reduction

60% 50% 37%

40% 31% 30%

20% 20 % 10% 0%

AVID1

CASH2

CIDS3

3 years

2 years

3 years

1

The AVID Investigators. N Engl J Med. 1997;337:1576-1583. 2 Kuck K. ACC98 News Online. April, 1998. Press release.

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3

Connolly S. ACC98 News Online. April, 1998. Press release.

ICD in Hereditary Arrhythmia Patients 

Long QT syndrome



ARVD



Brugada Syndrome



Hypertrophic Cardiomyopathy



Short QT syndrome



Catecholenergic Polymorphic Ventricular Tachycardia

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Number Needed to Treat To Save A Life NNTx years = 100 / (% Mortality in Control Group – % Mortality in Treatment Group)

50

Drug Therapy

45 40 35

26

30

ICD Therapy

25

20

28

simvastatin

20 11

15 10

3

metoprolol

9

captopril

4

5 0 MUSTT (5 Yr)

MADIT (2.4 Yr)

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MADIT II (3 Yr)

AVID (3 Yr)

SAVE (3.5 Yr)

Merit-HF (1 Yr)

4S (6 Yr)

Cardiac Resynchronization on Morbidity and Mortality in Heart Failure: Care-HF trial

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Death and Hospitalization for Major Cardiovascular Event

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Reduction in all cause Mortality with BiV Pacemaker

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MADIT CRT

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A. Moss: N Engl J Med 2009; 361:1329-1338

Conclusions 

“Calculations based on hazard ratios suggest that, for every nine devices implanted, one death and three hospitalizations for major cardiovascular events are prevented.”

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Indication for Biventricular Pacemaker 

Class I-IV heart failure despite medical therapy.



QRS > 120 msec (LBBB)



LV ejection fraction < 35%

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Implantable Loop Recorder

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Early application of an ILR allows effective specific therapy in patients with recurrent suspected NMS

Eur Heart J (2006) 27 (9): 1085-1092. “Helping You to a Healthy Heart”

Syncopal recurrence of the total population undergoing ILR implantation (Phase I) and of the two subgroups of patients who received ILR-based specific therapy

Brignole M et al. Eur Heart J 2006;27:1085-1092

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