Implantable Cardioverter-Defibrillator Management

Implantable cardioverter-defibrillator (ICD) management is a multidisciplinary long-term process for patients with primary and secondary prevention indications including ischemic and non-ischemic cardiomyopathy with reduced ejection fraction, hypertrophic cardiomyopathy, channelopathies (long QT, Brugada, CPVT), arrhythmogenic right ventricular cardiomyopathy, and survivors of sudden cardiac arrest. Modern devices include single-chamber, dual-chamber, biventricular CRT-D and subcutaneous ICDs.

Routine management involves remote monitoring (CareLink, LATITUDE, MyHeartLink) detecting arrhythmias, lead impedance changes, and battery status; in-clinic interrogation every 6-12 months; appropriate therapy review (anti-tachycardia pacing, cardioversion, defibrillation shocks); and device programming optimized to reduce inappropriate shocks. Programming strategies include high detection rates (>200 bpm), prolonged detection durations (>30 beats), and SmartShock technology to reduce inappropriate therapy from atrial fibrillation, sinus tachycardia and lead noise.

Special situations include electrical storm (≥3 sustained VT episodes in 24 hours) requiring escalation to amiodarone, beta-blockers, sedation and catheter ablation; lead failure or recall (Sprint Fidelis, Riata) requiring extraction; generator replacement at end-of-service indicator (typically 7-10 years); and end-of-life deactivation discussions in palliative care with explicit informed consent. MRI-conditional devices allow imaging with appropriate pre-MRI programming. Patient education on driving restrictions, electromagnetic interference, and shock response is essential.