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The automatic implantable cardioverter-defibrillator. Long-term clinical experience and outcome at a hospital without
Insights
The automatic cardioverter-defibrillator (ACD) is effective for treating ventricular tachycardia/fibrillation. Implantation is feasible and practical at community hospitals with expert cardiac electrophysiology teams.
Area of Science:
- Cardiology
- Medical Devices
Background:
- Refractory sustained ventricular tachycardia/fibrillation poses significant mortality risks.
- The automatic cardioverter-defibrillator (ACD) offers a therapeutic option for these patients.
- Community hospital implantation of ACDs requires evaluation for feasibility and efficacy.
Purpose of the Study:
- To assess the feasibility, learning curve, and efficacy of automatic cardioverter-defibrillator implantation.
- To evaluate long-term clinical outcomes in patients with refractory ventricular tachycardia/fibrillation.
- To determine the safety and practicality of ACD implantation in a community hospital setting without open-heart surgery facilities.
Main Methods:
- A retrospective review of 111 patients who underwent ACD implantation between November 1982 and April 1989.
- Analysis of operative mortality, postoperative complications, and long-term survival.
- Assessment of device discharge events and associated symptoms during follow-up.
Main Results:
- Operative mortality decreased from 10.9% to 5.4% over the study period.
- Postoperative complications occurred in 14% of patients, predominantly in the early experience.
- At a mean follow-up of 22 months, 76% of discharged patients were alive, with low actuarial incidence of sudden death (1.2% at 1 year).
Conclusions:
- The automatic cardioverter-defibrillator is an effective therapy for refractory ventricular tachycardia/fibrillation.
- Device implantation is feasible and practical in community hospitals with experienced cardiac electrophysiology teams.
- A learning curve for implantation exists, with improved outcomes over time.
Abstract:
From November 1982 through April 1989, 111 patients with refractory sustained ventricular tachycardia/fibrillation had the automatic cardioverter-defibrillator implanted at our institution, the first community hospital involved in implantation of such a device. We have reviewed our long-term clinical experience to assess the feasibility, learning curve, and efficacy of device implantation in a facility with cardiac electrophysiology expertise but without open-heart surgery facilities. All patients were considered inoperable or at high risk for other concomitant surgery. Eighty-six patients (77%) underwent uneventful implantation. Nine patients (8%) died prior to hospital discharge. Operative mortality declined from 10.9% to 5.4% during the first half (55 patients; November 1982 through September 1986) and second half (56 patients; October 1986 through April 1989) of the experience. Other postoperative complications occurred in 16 patients (14%), 12 of whom experienced complications during the first half of the experience. At 22 +/- 20 (mean +/- SD) months' follow-up, 78 (76%) of 102 patients discharged were alive, and 24 patients (24%) had died. Fifty patients (49%) had experienced at least one automatic cardioverter-defibrillator discharge associated with hypotensive symptoms. The actuarial incidence of sudden death at 1, 2, and 3 years was 1.2%, 5.5%, and 6.2%, respectively. We concluded that the automatic implantable cardioverter-defibrillator is an effective therapy for refractory ventricular tachycardia/fibrillation and that device implantation at community hospitals with an experienced cardiac electrophysiology team is both feasible and practical.