Dr. Kush ICD ppt.pptx

Dr. Kush ICD ppt.pptx

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  The Electrical Management of CardiacRhythm Disorders History of ICD By Dr. Kush Kumar Bhagat
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  The Genesis of ICDs ●The idea of the ICD came to Dr. Michel Mirowski when his friend died of SCD ● Concept: could a defibrillator be implanted in the body? ● Technological challenges ○ Could an implantable device deliver sufficient energy? ○ Could leads be developed to carry that much energy? ○ How would the device detect arrhythmias? ○ How could defibrillation become “automated”?
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  Dr. Michel Mirowski ● Dr.Harry Heller died of SCD in 1966 ● His friend, Dr. Michel Mirowski, knew that he might have lived had he received defibrillation immediately ● Technological and even ethical hurdles ○ Was it ethical to even test such a device on humans? ● By 1969, Dr. Mirowski was working on the first experimental models of what would later become the ICD ● But it would be almost 20 years before the device was commercially available!
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  Timeline ● Sinai Hospitalof Baltimore recruited Dr. Mirowski and offered him opportunity to work on ICD idea ● At Sinai, Mirowski teamed up with Martin Mower in the research lab ● In 1969, experimental model ● First transvenous defibrillation (1969) ● Canine implants (1970s) ● First human implant: 1980 (Johns Hopkins, Baltimore)
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  Technological Challenges ● Capacitortechnology allowed small battery to store and deliver large amount of energy ● Transvenous defibrillation leads could carry defibrillation energy to the inside of the heart ● Circuitry could sense cardiac rhythms and interpret potentially dangerous ventricular tachyarrhythmias ● Device could be downsized enough to implant in the body
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  Early Devices ● 1980-1985clinical trial of first ICDs ● 1985 FDA approved first ICD for human use ● Those first devices were 10 times the size of modern ICDs! ● Their large size mandated an abdominal implant ● Thoracotomy required to implant leads
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  Road to ICDs
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  ICD Evolution ● Cardioversion(lower-energy shocks) and “tiered therapy” ● Programmability (1988) ○ First ICDs were custom-built since cutoff rates were set at the factory! ● Biphasic waveforms ● Multiple zones (VT/VF) ● Transvenous ICD leads ● Radically downsized generators (pectoral implants) ● Full-featured integrated pacemakers
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  ICD Header (ConnectingPort)
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  Defibrillation Leads
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  Single-Coil Defib Leads ● Pacingrequires one or more electrodes on the lead to pace sense ● Shocking requires one or more “coils” on the lead to defibrillate ● A single-coil lead has one coil on the lead and forms the electrical circuit by using the ICD can as the other pole to complete the circuit ● Improve Extractability.
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  Modern Defibrillation Leads ●Integrated bipolar and true bipolar leads ○ Refers to sensing cardiac signals ○ Integrated bipolar uses distal shocking coil to sense cardiac signals ○ True bipolar has dedicated distal sensing electrode ● Single-coil and dual-coil designs ● Very thin, comparable to some pacing leads! ● Choice of lead fixation mechanisms ○ Active fixation (helix, corkscrew) ○ Passive fixation (fins, tines) ● Steroid elution
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  Progress: The Implant Procedure THEN ●Open-chest ● Took several hours ● General anesthesia ● Several days hospital stay ● Large device ● Abdominal implant ● No or very limited programmability
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  Progress: Device Functionality THEN •Very few Programmable options • Short Service Life • Only ONE Therapy (Defib) • No Pacing Capability( If Pacing needed, a second device might be required • Could only be monitored in- Clinic NOW • Lots of Programmability including Advanced Features • Long Service Life up to 15 years • Tiered Therapy, Even ATP Before Charging • Full Pacing Capability including some Dual Chamber rate response pacing with advanced features • Remote Patient Monitoring
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  Device Acceptance ● Thefirst ICDs were considered a device of last resort ○ Patients had to be drug-refractory and survived at least two episodes of SCD ● Early concepts pitted drugs against devices as if they were mutually exclusive ● Devices became acceptable as first-line therapy for certain types of secondary-prevention patients ● Today, we know devices can provide additive benefits to drug therapy and that combination therapy (drugs plus devices) is ideal for most patients ● Recent studies have shown the mortality benefits of primary prevention therapy
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  The Future ofICDs ● Smaller, flatter devices, physiocurve (improved capacitor technology) ● Longer-lived devices (improved battery technology) ● Remote patient monitoring ( e.g., Medtronic Carelink Remote Monitoring) ● FDA approved full body 1.5 T & 3 T MRI devices ● Wireless patient monitoring(while doing device Interrogation in clinic) ● Special algorithms (to Reduce In-appropriate shocks) ● Single Lead VDD ICD ● More automatic features(smart shock technologies) ● Audible Alert in case of ERI etc. ● Built-in monitors( Bluetooth enabled devices) ● Single Chamber ICD able to Identify Atrial Arryhtmia
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  S-ICD • Subcutaneous Implantable Cardioverterdefibrillator • Beneficial for the Patient with no venous access who were unsuitable for transvenous ICD. • There is no risk of vascular Injury or pneumothorax This Photo by Unknown Author is licensed under CC BY-NC-ND
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  THANK YOU