Automated Implantable Cardioverter Defibrillator (AICD) Topic Review

An automated implantable cardioverter defibrillator (ICD or AICD) is a permanent device in which a lead (wire) inserts into the right ventricle and monitors the heart rhythm.

It is implanted similar to a single-chamber pacemaker and the generator lies in the upper chest area. Venous access is through the subclavian vein. Subcutaneous ICDs without leads have been available since 2012. Therapies are delivered in the form of anti-tachycardia pacing (ATP) or shocks to convert to sinus rhythm from sustained ventricular tachycardia or ventricular fibrillation, both of which are life-threatening rhythms.

Enlarge 

For primary prevention of sudden cardiac death, ICDs are indicated:

• Patients with a prior myocardial infarction and a left ventricular ejection fraction of < 30% (MI must have been at least 40 days prior in order to allow time for recovery of LV systolic function).
• Patients with systolic heart failure (New York Heart Association functional class II or III) and an ejection fraction < 35%. Optimal medical therapy must be present and at least 3 months must have elapsed in case the systolic function recovers to an ejection fraction > 35% in patients with  non-ischemic cardiomyopathy or ischemic cardiomyopathy who underwent bypass surgery. [Al-Khatib S, et al. Circulation. 2018;138:e272-e391;18a].

For secondary prevention of sudden cardiac death, ICDs are indicated:

• Patients with documented cardiac arrest from sustained ventricular tachycardia or ventricular fibrillation or documented hemodynamically stable sustained ventricular tachycardia even if the left ventricular ejection fraction is > 35%, as long as no reversible cause is identified. The above must not be within 48 hours of an acute coronary syndrome. The 2017 American Heart Association/American College of Cardiology/Heart Rhythm Society Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death recommends ICDs for this population if “meaningful survival greater than 1 year is expected”. [Al-Khatib S, et al. Circulation. 2018;138:e272-e391;17a].

ICDs are also indicated in hypertrophic obstructive cardiomyopathy (HOCM) if any of the criteria below are present:

• Syncope
• Interventricular septal thickness of 30 mm or greater
• Documented ventricular tachycardia and/or cardiac arrest
• Family history of sudden cardiac death
• Left ventricular systolic dysfunction in the setting of wall thinning (also known as “burnt out” left ventricle)

References:

• Al-Khatib SM, et al. Circulation. 2018;doi:10.1161/CIR.0000000000000549.