Deactivation of implantable cardioverter defibrillators (ICD) at the end of life

There is disagreement between medical professionals about the ethics of ICD (Implantable Cardioverter Defibrillator) deactivation in end of life cases. Deactivation is requested to prevent a patient from feeling ICD-induced shocks (shocks that attempt to restore normal heart beat) at the end of the patient’s life. Some are morally opposed to it while others argue that it is a patient’s right to deactivate it and have a dignified death. Such a disagreement leads to varying approaches that healthcare professionals take when patients want to deactivate their ICDs. Variation inevitably means that some patients will be forced to feel the end-of-life shocks brought on by the ICD. Such shocks, on the surface, depart from the traditional notion of a peaceful and dignified death. Because of the prevalence of heart disease around the world, resolving this ethical dilemma will benefit thousands, if not millions. Without a discussion regarding a potential ethical right to ICD deactivation, millions may be forced to feel end of life shocks.This paper compares the ICD deactivation to active killing, withdrawing treatment, and refusing treatment. Once ICD deactivation is properly labeled in one of these categories, other concerns such as autonomy, pain, and future education are discussed in an effort to resolve the disagreement between medical professionals on this subject and determine if there is an ethical right to deactivation. ICD deactivation fits best under the “withdrawing treatment” category and has similarities with DNRs (Do Not Resuscitate orders). It can also be distinguished from direct killing by looking at the patient’s intentions under the ordinary/extraordinary care distinction. Therefore, it is an ethical right for people to be allowed to deactivate their ICDs at the end of their lives. Autonomy is hindered when one experiences the pains associated with ICDs at the end of life. Autonomy is of paramount importance in ethics and must always be honored. Deactivating ICDs honors this moral norm, while refusing to deactivate trumps this norm. Medical professionals must always respect patients’ wishes and take the necessary actions to give them a peaceful death by deactivating their ICD.

Background: End-of-life implantable cardioverter defibrillator deactivation discussions should commence before device implantation and be ongoing, yet many implantable cardioverter defibrillators remain active in patients’ last days. Aim: To examine associations among implantable cardioverter defibrillator knowledge, patient characteristics and attitudes to implantable cardioverter defibrillator deactivation. Design: Cross-sectional survey using the Experiences, Attitudes and Knowledge of End-of-Life Issues in Implantable Cardioverter Defibrillator Patients Questionnaire. Participants were classified as insufficient or sufficient implantable cardioverter defibrillator knowledge and the two groups were compared. Setting/participants: Implantable cardioverter defibrillator recipients (n = 270, mean age 61 ± 14 years; 73% male) were recruited from cardiology and implantable cardioverter defibrillator clinics attached to two tertiary hospitals in Melbourne, Australia, and two in Kentucky, the United States. Results: Participants with insufficient implantable cardioverter defibrillator knowledge (n = 77, 29%) were significantly older (mean age 66 vs 60 years, p = 0.001), less likely to be Caucasian (77% vs 87%, p = 0.047), less likely to have received implantable cardioverter defibrillator shocks (26% vs 40%, p = 0.031), and more likely to have indications of mild cognitive impairment (Montreal Cognitive Assessment score <24: 44% vs 16%, p < 0.001). Insufficient implantable cardioverter defibrillator knowledge was associated with attitudes suggesting unwillingness to discuss implantable cardioverter defibrillator deactivation, even during the last days towards end of life (p < 0.05). Conclusion: Implantable cardioverter defibrillator recipients, especially those who are older or have mild cognitive impairment, often have limited knowledge about implantable cardioverter defibrillator deactivation. This study identified several potential teachable moments throughout the patients’ treatment trajectory. An interdisciplinary approach is required to ensure that discussions about implantable cardioverter defibrillator deactivation issues are initiated at appropriate time points, with family members ideally also included.

Deactivation of Implantable Cardioverter Defibrillators in Terminal Illness and End of Life Care

Implantable cardioverter defibrillators (ICDs) may be burdensome in end-stage heart failure. At the end of life, as many as one-fifth to one-third of patients experience an ICD shock. Critical care nurses should be aware of the potential burden of these shocks at the end of life as well as the ethics and organizational policies surrounding ICD deactivation. This literature review examines the issues surrounding ICD therapy at the end of life. Based on this author's findings, recommendations for discussing and implementing ICD deactivation are offered. Health care organizations should have clear policies addressing ICD deactivation to provide for seamless integration of palliative care services throughout the course of heart failure. These policies should empower nurses to activate resources in a timely manner and should clearly outline processes for ICD deactivation.

Disorders of the cardiac muscle or cardiomyopathies are a broad, yet collectively common, group of conditions. Despite the heterogeneous etiologies, mode of death from these conditions is remarkably similar - progressive decline in cardiac function leading to intractable heart failure (HF) and sustained ventricular arrhythmias resulting in sudden cardiac death (SCD). Nearly 50% of patients die within 5 years of a HF diagnosis.1 Indeed, in the United States, HF alone is thought to cause 55,000 deaths per year2 and further contribute to 1 in 9 deaths overall.1 However, while advanced HF and the risk of SCD were once thought to be untreatable, technological advances has seen the emergence of device therapies as viable treatment options. Specifically, implantable cardioverter-defibrillator (ICD) therapy for treatment of ventricular arrhythmias, cardiac resynchronization therapy (CRT) for restoring cardiac synchrony and mechanical efficiency, and ventricular assist device (VAD) therapy to temporarily or permanently replace the function of the failing heart, have all emerged as highly efficacious therapies. The expanding use of device therapies, however, poses many challenges. First, while the indications for these devices are well summarized in clinical guidelines,3,4 considerable hurdles remain in ensuring eligible patients receive these therapies.5 By the same token, establishing the safety and effectiveness of these therapies in populations that are found in clinical practice, yet commonly excluded from trials, such as the elderly6 and uncommon forms of cardiomyopathies,7 is a high priority. Second, rapid dissemination of technologies frequently results in disparities in care. Indeed, age, gender, and racial disparities, in both receipt of these devices and outcomes following implantation, have been well documented. Whether these disparities have persisted, and the potential causative mechanisms underlying these disparities, however, are uncertain.8,9 Third, these devices are not without significant untoward effects; understanding …

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More older adults are living with an implantable cardioverter defibrillator (ICD). Deactivation rates for those approaching end-of-life are low, risking undue distress and an undignified death. This scoping review aimed to determine the availability and content of hospital guidance documents regarding ICD deactivation towards end-of-life. Guidelines' databases from two Australian states (Victoria and South Australia) were systematically searched between September 2022 to February 2023, to identify all documents that specified guidance for ICD deactivation at end-of-life. Relevant documents were analysed using a pre-specified data extraction tool. Following screening of 59,662 documents from 94 health services providing acute, aged or palliative care, 11 were included. Most were from public (10, 91%), metropolitan (eight, 73%) health services. Guidance on timing of ICD deactivation discussions was limited; only two (18%) documents advised discussion at time of insertion, one (9%) at generator change and six (55%) during advance care planning discussions. Recommended criteria for ICD deactivation varied: people with a terminal illness (two, 18%), with an active do not resuscitate order (five, 45%), receiving end-of-life care (11, 100%), or at the person's request (seven, 64%). Nine (82%) recommended consent dialogue that deactivation does not cause/hasten death (eight, 73%) or deactivate pacing (eight, 73%), aims to promote a peaceful death (eight, 73%) and that reactivation is possible (eight, 73%). There is a paucity of local health service guidance to support clinicians navigating ICD deactivation at end-of-life.

Left atrial (LA) volume and function (LA ejection fraction, LAEF) have demonstrated prognostic value in various cardiovascular diseases. We investigated the incremental value of LA volume and LAEF as measured by cardiovascular magnetic resonance imaging (CMR) for prediction of appropriate implantable cardioverter defibrillator (ICD) shock or all-cause mortality, in patients with ICD. We conducted a retrospective, multi-centre observational cohort study of patients who underwent CMR prior to primary or secondary prevention ICD implantation. A single, blinded reader measured maximum LA volume index (maxLAVi), minimum LA volume index (minLAVi), and LAEF. The primary outcome was a composite of independently adjudicated appropriate ICD shock or all-cause death. A total of 392 patients were enrolled. During a median follow-up time of 61months, 140 (35.7%) experienced an appropriate ICD shock or died. Higher maxLAVi and minLAVi, and lower LAEF were associated with greater risk of appropriate ICD shock or death in univariate analysis. However, in multivariable analysis, LAEF (HR 0.92 per 10% higher, 95% CI 0.81-1.04, p = 0.17) and maxLAVi (HR 1.02 per 10ml/m2 higher, 95% CI 0.93-1.12, p = 0.72) were not independent predictors of the primary outcome. In conclusion, LA volume and function measured by CMR were univariate but not independent predictors of appropriate ICD shocks or mortality. These findings do not support the routine assessment of LA volume and function to refine risk stratification to guide ICD implant. Larger studies with longer follow-up are required to further delineate the clinical implications of LA size and function.

the PROVE trial was designed to determine if antitachycardia pacing (ATP) is clinically beneficial for primary prevention in patients who have implantable cardioverter defibrillators (ICDs) or cardiac resynchronization therapy defibrillators (CRT-Ds). use of ICDs and CRT-Ds reduces mortality in patients with ventricular dysfunction and mild to moderate heart failure. However, in studies of the primary prevention population, shock-only ICDs are predominantly used, without ATP programming for less painful termination of ventricular tachycardia (VT). we conducted a prospective, nonrandomized, multicenter study using market-released ICDs and CRT-Ds. Patients received devices programmed to deliver ATP for VT cycle lengths of 270-330 ms. Follow-up evaluation was performed at 3, 6, and 12 months. The incidence of VT and the rate of successful termination by ATP were analyzed. of 830 patients in the study population (men, 73%; mean age, 67.3 ± 12 years), 32% received single-chamber ICDs, 44% dual-chamber ICDs, and 24% CRT-Ds. ATP was attempted for 112 VT episodes in 71 patients, and 103 (92%) of the VT episodes were successfully terminated. Three VT episodes were accelerated by ATP and required termination by ICD shock; 6 episodes terminated spontaneously or by ICD shock. VT is common in patients without a history of this arrhythmia who have received ICDs or CRT-Ds for primary prevention indications. Programming ICDs for ATP therapy at the time of implantation could potentially terminate most VT episodes and reduce the number of painful shocks for these patients.

To evaluate whether the revascularization of a coronary chronic total occlusion in an infarct-related artery (IRACTO) may be associated with lower recurrence of ventricular arrhythmias (VA) among patients with a secondary prevention implantable cardioverter defibrillator (ICD). IRACTO is increasingly recognized as an independent predictor of VA. It is unknown whether IRACTO revascularization can reduce the burden of VA. Multicenter observational cohort study that included consecutive patients with prior myocardial infarction and secondary prevention ICD. The primary endpoint was any appropriate ICD therapy. Among the 460 patients included, 269 (58%) had at least one IRACTO at the coronary angiogram performed before ICD implantation; of these, 20 (7%) had their IRACTO successfully revascularized (IRACTO-R) afterwards. During a median follow-up of 48 months, 229 patients (49%) had at least one appropriate ICD therapy. Patients with IRACTO not revascularized (IRACTO-NR) had the highest incidence of ICD therapies (65%) while patients with IRACTO-R had the lowest (10%, p < .001). In the entire cohort, IRACTO-NR was an independent predictor of appropriate ICD therapies (HR 2.85, p < .001) and appropriate ICD shocks (HR 2.94, p < .001). Among patients with IRACTO at baseline, IRACTO-R was independently associated with a marked reduction of appropriate ICD therapies (HR 0.12, p = .002) and appropriate ICD shocks (HR 0.21, p = .03). In patients with prior myocardial infarction and secondary prevention ICD, IRACTO revascularization was independently associated with a markedly lower incidence of appropriate ICD therapies and shocks. These results should be corroborated by larger prospective studies.

Unusual case of late dislodgment of a superior vena cava coil

Although guidelines recommend driving restrictions for 3 to 6 months after appropriate implantable cardioverter-defibrillator (ICD) shocks, contemporary data to support these recommendations are lacking. To define the time course of subsequent shocks after an initial ICD discharge. Retrospective analysis of a nationwide cohort of 14 230 ICD recipients enrolled in a remote monitoring program. Participants underwent ICD implantation from October 1, 2008, to December 31, 2013, and experienced at least 1 shock. The risk of driving after an ICD shock was estimated using the risk for harm (RH) formula, and an annual RH of less than 5 events per 100 000 ICD recipients was deemed safe. The likelihood of loss of consciousness associated with an ICD shock was estimated using a cautious value of 32% and an estimate of 14% based on contemporary data. Data were extracted and analyzed from December 17, 2014, to October 31, 2015. Time course of subsequent shocks after an initial ICD discharge. Of 73 503 ICD recipients who underwent remote monitoring, 14 230 (19.4%) experienced at least 1 ICD shock and were included in this analysis (10 870 men [76.4%]; 3360 women [23.6%]; median age at device implantation, 68 years; interquartile range [IQR], 60-76 years). The cumulative incidence of receiving a second shock was 14.5% (IQR, 13.9%-15.1%) at 1 month and 28.7% (IQR, 27.9%-29.5%) at 6 months. The time from implantation to initial shock had an inverse association with the likelihood of receiving a second shock (lowest quartile of time at 6 months, 31.6% [95% CI, 30.2%-33.2]; highest quartile of time at 6 months, 25.3% [95% CI, 23.8%-26.9%]). The number of ICD therapy zones was also significantly associated with the incidence of a second shock (1 therapy zone, 20.8% [95% CI, 19.4%-22.3%] at 3 months to 51.5% [95% CI, 48.5%-53.7%] at 3 years; 3 therapy zones, 26.9% [95% CI, 24.8%-29.0%] at 3 months to 57.3% [95% CI, 54.1%-60.5%] at 3 years). When a likelihood of loss of consciousness of 32% associated with an ICD shock was used, the RH while driving fell below the accepted threshold at 4 to 6 months after an initial shock. However, when a contemporary estimate for loss of consciousness associated with an ICD shock of 14% was used, the RH fell below the threshold at 1 month after an initial shock. In this large cohort of ICD recipients, the incidence of a second shock after an initial ICD discharge was lower than previously reported and depended on several programmed ICD variables. These data, with future research to derive contemporary estimates of the likelihood of fatality resulting from an ICD shock while driving, should support the development of evidence-based guidelines for driving restrictions in ICD recipients.

Stress testing is integral to evaluate patients with heart disease. However, few data are available regarding safety of stress testing in patients with implantable cardioverter defibrillators (ICDs). Some exercise laboratories consider maximal exercise stress testing and pharmacologic stress testing with dobutamine contraindications in patients with ICDs and some laboratories inactivate ICDs prior to stress testing. PURPOSE The aim of this retrospective study was to assess the safety and feasibility of exercise and pharmacologic stress testing (PST) in patients with ICDs. METHODS Patients with ICD implantation and subsequent stress testing were included in this analysis. Chart review was performed. Primary end-points were occurrence of malignant ventricular arrhythmias (MVAs), onset of burst pacing or ICD firing, cardiopulmonary resuscitation (CPR) or death during stress testing. Secondary end-points were need for urgent coronary revascularization based on stress testing results and hospital readmissions for MVAs. RESULTS From January 1999 to December 2003, 1734 patients underwent ICD implantation or generator replacement. A total of 84 patients subsequently underwent 107 stress tests at William Beaumont Hospital, Royal Oak. Mean age was 67±12 years and 76% were men. Indications for ICD implantation were dilated cardiomyopathy (51%), sustained ventricular tachycardia (39%), sudden cardiac death (8%) and long QT syndrome (1%). 41% underwent exercise stress testing and 59% underwent PST utilizing dobutamine (21%) or dipyridamole (38%). Left ventricular ejection fraction was 32±20. 71% had fixed defects and 22% had reversible perfusion defects as determined by myocardial perfusion imaging. None of the ICDs were inactivated prior to stress testing. Heart rate at peak stress averaged 92±27 beats per minute. 83% were on beta-receptor antagonists. Although 4% of patients had self-terminating, non-sustained ventricular tachycardia at peak stress, none had sustained ventricular tachycardia precipitating burst pacing, ICD shock, CPR or death. One patient underwent urgent coronary angiography, but was found to have non-critical coronary disease. There were no hospital readmissions for MVAs. CONCLUSIONS These preliminary findings suggest that stress testing can be performed safely in patients with ICDs. MVAs requiring emergent treatment are rare occurrences during stress testing. Knowledge of programmed ventricular tachycardia and ventricular fibrillation zones may help predetermine maximal heart rates on stress testing and preclude routine inactivation of ICDs prior to testing.

Background Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, and sudden cardiac death represents an important mode of death in these patients. Data evaluating the implantable cardioverter defibrillator (ICD) in this patient population remain scarce. Purpose We aimed to describe long-term follow-up of patients with TOF and ICD through a large nationwide registry. Methods Nationwide Registry including all TOF patients with an ICD initiated in 2010. The primary outcome was the first appropriate ICD therapy. Secondary outcomes included ICD-related complications, heart transplantation, and death. Clinical events were centrally adjudicated by a blinded committee. Cox proportional hazard models were used to identify predictors of appropriate ICD therapies and ICD-related complications. Results A total of 165 patients (mean age 42.2±13.3 years, 70.1% males) were included from 40 centers, including 104 (63.0%) in secondary prevention. During a median (IQR) follow-up of 6.8 (2.5–11.4) years, 78 (47.3%) patients received at least one appropriate ICD therapy, giving an annual incidence of 10.5% (7.1% and 12.5% in primary and secondary prevention, respectively, p=0.03). Overall, 71 (43.0%) patients presented with at least one complication, including inappropriate ICD shocks in 42 (25.5%) patients and lead/generator dysfunction in 36 (21.8%) patients. Among 61 (37.0%) primary prevention patients, the annual rate of appropriate ICD therapies was 4.1%, 5.3%, 9.5%, and 13.3% in patients with respectively no, one, two, or ≥ three guideline-recommended risk factors. In our cohort, QRS fragmentation was the only independent predictor of appropriate ICD therapies (HR 4.34, 95% CI 1.42–13.23), and its integration in a model with current criteria increased the area under the curve from 0.61 to 0.72 (p=0.006). No patient with left ventricular ejection fraction (LVEF) ≤35% without at least one other risk factor had appropriate ICD therapy. Patients with congestive heart failure and/or reduced LVEF had a higher risk of non-sudden death or heart transplantation (HR=11.01, 95% CI: 2.96–40.95). Conclusions Our findings demonstrate high rates of appropriate therapies in TOF patients with an ICD, including in primary prevention. The considerable long-term burden of ICD-related complications, however, underlines the need for careful candidate selection. A combination of easy-to-use criteria might improve risk stratification beyond low LVEF. Freedom from appropriate ICD therapy Funding Acknowledgement Type of funding source: None

We read with interest the CMAJ article on deactivation of implantable cardioverterdefibrillators by Dr. Wan and colleagues.[1][1] We concur that unwanted implantable cardioverter-defibrillator shocks can lead to substantial distress in the last weeks or months of life in patients with terminal