Implantable Cardioverter–Defibrillators and Complications
http://www.100md.com
《新英格兰医药杂志》
To the Editor: In the review article on implantable cardioverter–defibrillators by DiMarco (Nov. 6 issue),1 indications and clinical trials were comprehensively covered. However, in the section on complications, the deactivation of an implantable cardioverter–defibrillator as a solution for undesired shocks (appropriate or inappropriate) was not mentioned. Since it is ethically and legally permissible for a patient to request the withdrawal of any medical treatment,2,3 this issue should be addressed in a review article on implantable cardioverter–defibrillator therapy. Patients with implantable cardioverter–defibrillators may find their quality of life decreased4,5 and therefore may elect to receive no further intervention from such a device.
If physicians are not educated about the ethics and permissibility of deactivation, a patient might continue to receive an unwanted medical intervention. As more people receive this potentially lifesaving therapy, we need to have open discussions with our patients about situations in which the implantable cardioverter–defibrillator may infringe on a patient's values and goals for care. This process can begin with adequate education of physicians about the ethics of withholding and withdrawing medical therapy.
Christian T. Sinclair, M.D.
Hospice and Palliative CareCenter
Winston-Salem, NC 27103
christian.sinclair@hospicecarecenter.org
References
DiMarco JP. Implantable cardioverter-defibrillators. N Engl J Med 2003;349:1836-1847.
American College of Physicians. Ethics manual: fourth edition. Ann Intern Med 1998;128:576-594.
Mueller PS, Hook CC, Hayes DL. Ethical analysis of withdrawal of pacemaker or implantable cardioverter-defibrillator support at the end of life. Mayo Clin Proc 2003;78:959-963.
Schron EB, Exner DV, Yao Q, et al. Quality of life in the Antiarrhythmics Versus Implantable Defibrillators trial: impact of therapy and influence of adverse symptoms and defibrillator shocks. Circulation 2002;105:589-594.
Irvine J, Dorian P, Baker B, et al. Quality of life in the Canadian Implantable Defibrillator Study (CIDS). Am Heart J 2002;144:282-289.
To the Editor: In DiMarco's excellent review of implantable cardioverter–defibrillators, the safe perioperative management in the case of a patient with an implantable cardioverter–defibrillator, a subject that remains poorly understood in the medical community, was not specifically discussed. Electrocautery and other devices used in the operating room can adversely affect the implantable cardioverter–defibrillator.1,2
The American College of Cardiology (ACC) has addressed the issue of the perioperative care of patients with implantable cardioverter–defibrillators who are undergoing noncardiac surgery.3 Preoperatively, the implantable cardioverter–defibrillator should be comprehensively evaluated. The tachycardia-therapy option should be turned off by programming immediately before the operation, and the device should be reinterrogated, with restoration of therapy for tachycardia, immediately after the operation. Any source of electromagnetic interference may cause the implantable cardioverter–defibrillator to diagnose ventricular tachycardia or fibrillation erroneously, with the resultant delivery of inappropriate electrical therapy and possible harm to the patient.4
We wish to emphasize that guidelines for the perioperative care of patients with implantable cardioverter–defibrillators have been published by the ACC, and we hope to educate as many perioperative caregivers as possible about the existence of these guidelines.
Jesse H. Marymount III, M.D.
Evanston Northwestern Healthcare
Evanston, IL 60201
Marc A. Rozner, Ph.D., M.D.
University of Texas M.D. Anderson Cancer Center
Houston, TX 77030
mrozner@mdanderson.org
References
Philbin DM, Marieb MA, Aithal KH, Schoenfeld MH. Inappropriate shocks delivered by an ICD as a result of sensed potentials from a transcutaneous electronic nerve stimulation unit. Pacing Clin Electrophysiol 1998;21:2010-2011.
Casavant D, Haffajee C, Stevens S, Pacetti P. Aborted implantable cardioverter defibrillator shock during facial electrosurgery. Pacing Clin Electrophysiol 1998;21:1325-1326.
Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery. Bethesda, Md.: American College of Cardiology, 2002. (Accessed January 22, 2004, at http://www.acc.org/clinical/guidelines/perio/update/periupdate_index.htm.)
Hasdemir C, Shah N, Rao AP, et al. Analysis of troponin I levels after spontaneous implantable cardioverter defibrillator shocks. J Cardiovasc Electrophysiol 2002;13:144-150.
The author replies: The letters from Drs. Marymount and Rozner and from Dr. Sinclair emphasize two aspects of implantable-defibrillator therapy that I mentioned only briefly in my review article. Both their letters, although one relates to issues of technical management and the other to ethical matters, emphasize that all physicians, not just electrophysiologists and cardiologists, need to have a basic familiarity with these devices.
At the University of Virginia, my colleagues and I conduct training sessions on cardiac devices for clinicians in our operating rooms, procedures areas, and intensive care units. A team of nurse clinical specialists supported by cardiology and electrophysiology fellows and attending physicians is available for assistance. When our patients are seen at outside hospitals that do not have the required expertise on site, representatives of the device manufacturers may be called to provide assistance. Provision of this service, which is critical to long-term care for patients, is built into the cost of the device by most, but not all, manufacturers of implantable cardioverter–defibrillators. I would encourage all hospitals to establish specific protocols for the care of their patients with defibrillators.
Dr. Sinclair's comments are also important. In patients who receive defibrillators for totally appropriate indications, terminal illnesses may subsequently develop during which active defibrillator therapy would not be desired. Although death in these circumstances is often associated with asystole that is not responsive to pacing or electromechanical dissociation, ventricular tachyarrhythmias may also occur, and the delivery of shocks might cause unnecessary discomfort and distress. I agree that the patient or his or her representatives, or both, should participate fully in decisions about when to inactivate any function of an implanted defibrillator and should be free to choose to have undesired therapy functions turned off.
John P. DiMarco, M.D., Ph.D.
University of Virginia Health System
Charlottesville, VA 22908-0158
jdimarco@virginia.edu
If physicians are not educated about the ethics and permissibility of deactivation, a patient might continue to receive an unwanted medical intervention. As more people receive this potentially lifesaving therapy, we need to have open discussions with our patients about situations in which the implantable cardioverter–defibrillator may infringe on a patient's values and goals for care. This process can begin with adequate education of physicians about the ethics of withholding and withdrawing medical therapy.
Christian T. Sinclair, M.D.
Hospice and Palliative CareCenter
Winston-Salem, NC 27103
christian.sinclair@hospicecarecenter.org
References
DiMarco JP. Implantable cardioverter-defibrillators. N Engl J Med 2003;349:1836-1847.
American College of Physicians. Ethics manual: fourth edition. Ann Intern Med 1998;128:576-594.
Mueller PS, Hook CC, Hayes DL. Ethical analysis of withdrawal of pacemaker or implantable cardioverter-defibrillator support at the end of life. Mayo Clin Proc 2003;78:959-963.
Schron EB, Exner DV, Yao Q, et al. Quality of life in the Antiarrhythmics Versus Implantable Defibrillators trial: impact of therapy and influence of adverse symptoms and defibrillator shocks. Circulation 2002;105:589-594.
Irvine J, Dorian P, Baker B, et al. Quality of life in the Canadian Implantable Defibrillator Study (CIDS). Am Heart J 2002;144:282-289.
To the Editor: In DiMarco's excellent review of implantable cardioverter–defibrillators, the safe perioperative management in the case of a patient with an implantable cardioverter–defibrillator, a subject that remains poorly understood in the medical community, was not specifically discussed. Electrocautery and other devices used in the operating room can adversely affect the implantable cardioverter–defibrillator.1,2
The American College of Cardiology (ACC) has addressed the issue of the perioperative care of patients with implantable cardioverter–defibrillators who are undergoing noncardiac surgery.3 Preoperatively, the implantable cardioverter–defibrillator should be comprehensively evaluated. The tachycardia-therapy option should be turned off by programming immediately before the operation, and the device should be reinterrogated, with restoration of therapy for tachycardia, immediately after the operation. Any source of electromagnetic interference may cause the implantable cardioverter–defibrillator to diagnose ventricular tachycardia or fibrillation erroneously, with the resultant delivery of inappropriate electrical therapy and possible harm to the patient.4
We wish to emphasize that guidelines for the perioperative care of patients with implantable cardioverter–defibrillators have been published by the ACC, and we hope to educate as many perioperative caregivers as possible about the existence of these guidelines.
Jesse H. Marymount III, M.D.
Evanston Northwestern Healthcare
Evanston, IL 60201
Marc A. Rozner, Ph.D., M.D.
University of Texas M.D. Anderson Cancer Center
Houston, TX 77030
mrozner@mdanderson.org
References
Philbin DM, Marieb MA, Aithal KH, Schoenfeld MH. Inappropriate shocks delivered by an ICD as a result of sensed potentials from a transcutaneous electronic nerve stimulation unit. Pacing Clin Electrophysiol 1998;21:2010-2011.
Casavant D, Haffajee C, Stevens S, Pacetti P. Aborted implantable cardioverter defibrillator shock during facial electrosurgery. Pacing Clin Electrophysiol 1998;21:1325-1326.
Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery. Bethesda, Md.: American College of Cardiology, 2002. (Accessed January 22, 2004, at http://www.acc.org/clinical/guidelines/perio/update/periupdate_index.htm.)
Hasdemir C, Shah N, Rao AP, et al. Analysis of troponin I levels after spontaneous implantable cardioverter defibrillator shocks. J Cardiovasc Electrophysiol 2002;13:144-150.
The author replies: The letters from Drs. Marymount and Rozner and from Dr. Sinclair emphasize two aspects of implantable-defibrillator therapy that I mentioned only briefly in my review article. Both their letters, although one relates to issues of technical management and the other to ethical matters, emphasize that all physicians, not just electrophysiologists and cardiologists, need to have a basic familiarity with these devices.
At the University of Virginia, my colleagues and I conduct training sessions on cardiac devices for clinicians in our operating rooms, procedures areas, and intensive care units. A team of nurse clinical specialists supported by cardiology and electrophysiology fellows and attending physicians is available for assistance. When our patients are seen at outside hospitals that do not have the required expertise on site, representatives of the device manufacturers may be called to provide assistance. Provision of this service, which is critical to long-term care for patients, is built into the cost of the device by most, but not all, manufacturers of implantable cardioverter–defibrillators. I would encourage all hospitals to establish specific protocols for the care of their patients with defibrillators.
Dr. Sinclair's comments are also important. In patients who receive defibrillators for totally appropriate indications, terminal illnesses may subsequently develop during which active defibrillator therapy would not be desired. Although death in these circumstances is often associated with asystole that is not responsive to pacing or electromechanical dissociation, ventricular tachyarrhythmias may also occur, and the delivery of shocks might cause unnecessary discomfort and distress. I agree that the patient or his or her representatives, or both, should participate fully in decisions about when to inactivate any function of an implanted defibrillator and should be free to choose to have undesired therapy functions turned off.
John P. DiMarco, M.D., Ph.D.
University of Virginia Health System
Charlottesville, VA 22908-0158
jdimarco@virginia.edu