Cardioverter-Defibrillator Implantation Periprocedural Care

Updated: Jul 09, 2018
  • Author: Tarek Ajam, MD, MS; Chief Editor: Richard A Lange, MD, MBA  more...
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Periprocedural Care

Periprocedural Planning

Implantable cardioverter-defibrillators (ICDs) are devices that can record the heart’s activity and treat dangerous arrhythmias with a shock. Many defibrillators work as a pacemaker as well, if the heart rate is too slow. They can deliver pacing should a ventricular arrhythmia occur to terminate it without delivering a shock. Some ICDs may also deliver cardiac resynchronization therapy (CRT) to improve cardiac function if they have multiple pacing leads.

The heart’s activity is recorded by the ICD and can be retrieved during an office visit, or during a remote home monitoring transmission. This allows the healthcare provider to review the patient's heart’s activity and to help properly treat rhythm disorders.

Generally, ICDs are recommended for patients who have survived cardiac arrest or who have experienced episodes of spontaneous, sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) (if not due to a reversible or transient cause). Also, ICDs are recommended for certain patients who are at high risk for VT or VF, such as those with congestive heart failure who have not had prior episodes of these arrhythmias.

Laboratory studies

Generally, platelet counts (preferred platelet counts: >50 × 103 per μL) and the international normalized ratio (INR) are checked to assess the risk of bleeding. However, uninterrupted warfarin use has been found to be safe, and it has become routine practice. [37]

Some clinicians will check a hemoglobin A1c level prior to implantation to ensure diabetic patients' condition is well controlled to reduce the risk of infection.

Anesthesia

Implantation of an ICD usually involves a combination of local anesthesia and conscious sedation. Conscious sedation may be administered in the form of intravenous (IV) midazolam and fentanyl. On infrequent occasions, general anesthesia may be obligatory in an extremely uncooperative or high-risk patient. Typically, the procedure takes 30 to 90 minutes to complete.

Implantation

The procedure involves an incision below the collarbone. The leads will be threaded through a vein into the heart. One lead will be placed in the right ventricle and one in the right atrium. For CRT, a third lead will be placed in the coronary sinus.

After the procedure

A chest x-ray is performed to confirm the leads are in the proper position and the lung has not been injured. Following the procedure, patients usually stay overnight in the hospital.

Subcutaneous ICD

A subcutaneous ICD (S-ICD) may be placed under the skin with no leads inside the heart. It is placed along the rib cage below the armpit or left axilla. The lead is tunneled underneath the skin. The advantages of this technique include a lower risk of infection because the lead is not directly in the blood stream. However, the device itself is larger compared to the transvenous device, and it is not able to provide pacing for slow heart rates, CRT, or antitachycardia pacing.

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Equipment

Equipment used in the placement of an implantable cardioverter-defibrillator (ICD) includes the following:

  • Surgical tray
  • Fluoroscope
  • Surgical tray
  • Peelable hemostatic sheath(s)
  • External defibrillator
  • ICD pulse generator and lead(s)
  • Pacing cable(s)
  • Pacing system analyzer (PSA)

ICD systems consist of a pulse generator and pacing leads. Endocardial leads are inserted transvenously and advanced to the right ventricle, where they are implanted into the myocardial tissue. The pulse generator is placed subcutaneously or submuscularly in the chest wall.

On September 28, 2012, the US Food and Drug Administration approved the first subcutaneous ICD for ventricular tachyarrhythmias, which allowed the lead to be placed under the skin rather than through a vein into the heart. [38]

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Patient Preparation

Anesthesia

For the overwhelming majority of patients, local anesthesia with lidocaine and conscious sedation are sufficient. Local anesthetic should be infiltrated into the skin and subcutaneous tissue. The entire area can be effectively anesthetized with one or two injections with repositioning of the needle. Repeated skin penetration by the anesthetic needle should be avoided, because it increases the risk that bacteria will be introduced.

In select patient populations, consideration should be given to general anesthesia; such populations include pediatric patients, as well as patients in whom placement of a subpectoral implantable cardioverter-defibrillator (ICD) will be performed and those who will require lead tunneling.

Positioning

The patient’s hair should be secured with a surgical hat because of its proximity to the incision. The chest should be shaved with a clipper rather than with a razor to avoid skin injury, which creates a portal for bacteria entry.

The patient should be positioned supine. In rare cases, left arm extension may be necessary to allow submammary device placement. External defibrillator patches should be placed anteriorly and posteriorly.

The author prefers that the ICD insertion area be first cleaned with detergent solution and then dried and subsequently prepared with chlorhexidine-based products; this may promote more rapid healing after ICD insertion and may diminish bacterial growth. Patients should also undergo a whole-body wash (including a hair wash) with a disinfecting solution 24 hours before implantation.

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