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Clinical Crossroads | Clinician's Corner

A 59-Year-Old Man Considering Implantation of a Cardiac Defibrillator

Peter J. Zimetbaum, MD, Discussant
JAMA. 2007;297(17):1909-1916. doi:10.1001/jama.297.17.1909.
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Nearly 450 000 individuals experience sudden cardiac death yearly in the United States. A history of prior myocardial infarction with resultant left ventricular dysfunction identifies a group at particularly high risk of sudden arrhythmic death. Implantable cardioverter-defibrillators have proven highly effective at reducing this risk and are now increasingly implanted in patients with this risk profile. The case of Mr M, a 59-year-old man with a history of myocardial infarction, low ejection fraction, and mild congestive heart failure, who is considering implantable cardioverter-defibrillator placement, illustrates the issues in having a device implanted as a prophylactic measure as well as increasing concerns due to device recalls and malfunction. A thorough discussion of the benefits and risks associated with this therapy is necessary for patients and physicians to make appropriate decisions with regard to the primary prevention of sudden death.

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Figure 1. Examples of Electrogram Recordings of Ventricular Arrhythmias With Implantable Cardioverter-Defibrillator (ICD) Therapy
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Recordings downloaded from the log of an ICD in 2 separate patients. A, Recording demonstrates an episode of ventricular fibrillation (VF) sensed by the ICD and treated with a defibrillation. VS indicates sensing of ventricular event; VP, delivery of pacing pulse. B, Recording demonstrates an episode of ventricular tachycardia treated with rapid ventricular pacing (antitachycardia pacing). TF indicates detection of heart rate consistent with ventricular tachycardia; TP, delivery of pacing pulse; VS, sensing of ventricular event; FS, sensing of fibrillation event. Letters in the abbreviations read vertically in panel B.

Figure 2. Dual-Chamber Implantable Cardioverter-Defibrillator (ICD) System
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