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• W2138677905 abstract "HomeCirculation: Arrhythmia and ElectrophysiologyVol. 3, No. 2Safety First Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBSafety FirstProtecting the Heart, Then the Head Gregory Webster and Charles I. Berul Gregory WebsterGregory Webster From the Department of Cardiology (G.W.), Children’s Hospital Boston, Harvard Medical School, Boston, Mass; and the Division of Cardiology (C.I.B.), Children’s National Medical Center, Department of Pediatrics, George Washington University School of Medicine, Washington, DC. Search for more papers by this author and Charles I. BerulCharles I. Berul From the Department of Cardiology (G.W.), Children’s Hospital Boston, Harvard Medical School, Boston, Mass; and the Division of Cardiology (C.I.B.), Children’s National Medical Center, Department of Pediatrics, George Washington University School of Medicine, Washington, DC. Search for more papers by this author Originally published1 Apr 2010https://doi.org/10.1161/CIRCEP.110.947317Circulation: Arrhythmia and Electrophysiology. 2010;3:118–119Implantable cardioverter-defibrillators (ICDs) have become standard therapy for life-threatening ventricular arrhythmias. The clinical research on mortality outcomes has been compelling.1,2 Successful secondary prevention strategies have been augmented with data in support of primary prevention implantation, and ICD prevalence has risen accordingly. With more devices in place and a broader range of patients receiving devices, interest in the neuropsychiatric consequences of devices and quality-of-life (QoL) outcomes of ICD recipients has grown.Article see p 170Although the causes and mitigating factors associated with neuropsychiatric disorders in patients with ICDs are complex, there are 2 primary, nonconflicting hypotheses that can clarify and simplify the discussion. One hypothesis suggests that the presence of the device itself may have a long-term impact on patients. The implication of life-threatening disease, the experience of shocks (both appropriate and inappropriate), the risk of device failure or manufacturer’s recall, and other psychological concerns may change mood and QoL. The second hypothesis is that episodes of cardiac fibrillation and low output with insufficient cerebral perfusion may have cognitive and psychiatric consequences. These episodes occur at discrete times: during clinical presentation and evaluation, during implantation, and with subsequent appropriate shocks.The first hypothesis implies that the patient’s underlying medical condition and experience with their device, along with their awareness of its indications and consequences, has an impact on neuropsychiatric outcomes. Early work suggested that there was deterioration in QoL that recovered about a year after ICD implantation.3 More recent studies, however, showed that ICD implantation may not diminish or may even improve QoL and that patients who received a significant number of shocks after implantation had a poorer QoL than those who did not receive subsequent shocks.4,5 Other work suggested that even the effects of shocks may be highly attenuated by the patient’s preimplantation psychological makeup.6 In short, QoL after ICD implantation is multifactorial. Sears7 suggests that the cardiologist’s role in this setting is to provide the “4 A’s”: asking, advising, assisting, and arranging for intervention through a multidisciplinary care team.The second hypothesis implies that ventricular tachycardia or fibrillation events (VT/VF) and subsequent hypoperfusion or cerebral ischemia may have implications on neuropsychiatric outcomes, especially cognition. The most striking complications of these events are exceedingly rare (death, stroke, prolonged resuscitation).8 However, acute changes in brain chemistry and activity have raised questions about long-term neurological effects. De Vries et al9 noted changes in cerebral oxygen uptake during defibrillation threshold (DFT) testing. Dworschak et al10 noted an increase in serum levels of brain injury markers (neuronal specific enolase and S100) after DFT testing. Several authors have noted changes in cerebral perfusion and electroencephalograms during ventricular arrhythmias and DFT testing, although their conclusions on long-term neurological results are mixed.11–13The current study by Hallas et al in this month’s Journal is a prospective evaluation of patients before implantation of an ICD and then at 3 additional time points, using a repeated-measures design. The authors enrolled 67 patients and performed follow-up analysis on 52 available subjects, focusing primarily on cognition. Approximately 30% of patients at each follow-up time point had significant cognitive impairment. Interestingly, the patients with cognitive impairment were not the same at each time point, creating a fluctuating population of the impaired. As the authors point out, impairment that varies with time has been described previously in patients after undergoing cardiac bypass.14,15 The results in the present study differ somewhat from those findings, but they highlight an important similarity in that the timing and severity of cognitive impairment is not yet predictable in any individual patient.Unlike other authors, Hallas et al do not attempt to directly link ICDs and QoL, except by comparing their testing data with population normative data. Instead, they demonstrate cognitive decline in some patients with ICDs and note that this decline does not appear to impair QoL. In this study, depression and anxiety were both linked with the mental health subscale of the SF-36. The authors point out that this may represent a direct effect of depression and anxiety or may be related to subjective perceptions of impairment in patients with mood disorders and not strictly related to QoL testing. This article adds further data to an already highly fragmented discussion about QoL and ICD recipients. We still have farther to go to determine which patients are at risk for a decline in QoL. A robust model that predicts which patients will benefit most from psychiatric intervention still remains elusive.The authors discuss in detail the hypothesis that DFT testing and VT/VF cause significant reductions in cerebral oxygen flow. During their study, the subjects had 4 occasions in which they may have had VT or VF: first, during clinical presentation as candidates for ICD therapy; second, during electrophysiology study before implantation; third, during implantation and DFT testing; and fourth, in those patients who received shock therapy during the next year (24%). The authors considered both DFT frequency and postoperative shock status. They were unable to find any correlation between these variables and neuropsychological outcomes. Currently, some implanters choose to test DFT during most or all implantations, with single-shock or multiple-shock stepwise analysis; others choose not to test DFTs at all during the implantation procedure. There is a broad middle ground of practice and a wide range of clinical management for sedation and anesthesia during ICD implantation and DFT testing. Evidence has not appeared yet in support of one best protocol. Although patient safety and adequate device functioning should remain paramount, determining the effects of DFT testing on measures of neurocognitive outcome will be important to help guide optimization of implantation protocols.In summary, the authors of this novel and intriguing prospective clinical study uncovered a changing incidence of postprocedural cognitive dysfunction and noted some association between patients with mood disorders and lower QoL scales. Notably, they did not find an association between frequency of DFTs or postoperative shocks and neuropsychiatric outcomes. However, the data in this study, and others, continue to suggest that there are clinically important neuropsychological risks of ICDs. The causes for these impairments are still unclear. It remains difficult to predict in advance which patients are at risk for subsequent changes in mood, cognition, and QoL. In addition, this study, like many others, does not take into account other patients who currently receive ICDs and merit special attention, such as children and those patients with preexisting cognitive delay.16As the authors of the present study suggest, psychological adjustment and cognitive abilities have important effects on patient’s long-term clinical care. Further research is needed to predict the emotional and mental health of individual patients with ICDs in a clinically useful fashion. Although ICD therapy has been shown to protect the heart from sudden cardiac death, the current study highlights the importance of also protecting the head.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.DisclosuresNone.FootnotesCorrespondence to Charles I. Berul, MD, Chief, Division of Cardiology, Children’s National Medical Center, 111 Michigan Ave, NW; Washington, DC 20010. E-mail [email protected] References 1 Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC Jr, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Blanc JJ, Budaj A, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL, American College of Cardiology/American Heart Association Task Force, European Society of Cardiology Committee for Practice Guidelines, European Heart Rhythm Association, Heart Rhythm Society. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006; 114: e385–e484.LinkGoogle Scholar2 Epstein AE, Dimarco JP, Ellenbogen KA, Estes NA III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, American College of Cardiology, American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, Society of Thoracic Surgery. ACC/AHA/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities. Heart Rhythm. 2008; 5: e1–e62.CrossrefGoogle Scholar3 May CD, Smith PR, Murdock CJ, Davis MJ. The impact of the implantable cardioverter defibrillator on quality-of-life. Pacing Clin Electrophysiol. 1995; 18: 1411–1418.CrossrefMedlineGoogle Scholar4 Mark DB, Anstrom KJ, Sun JL, Clapp-Channing NE, Tsiatis AA, Davidson-Ray L, Lee KL, Bardy GH, Sudden Cardiac Death in Heart Failure Trial I. Quality of life with defibrillator therapy or amiodarone in heart failure. N Engl J Med. 2008; 359: 999–1008.CrossrefMedlineGoogle Scholar5 Irvine J, Dorian P, Baker B, O'Brien BJ, Roberts R, Gent M, Newman D, Connolly SJ. Quality of life in the Canadian Implantable Defibrillator Study (CIDS). Am Heart J. 2002; 144: 282–289.CrossrefMedlineGoogle Scholar6 Sears SF, Lewis TS, Kuhl EA, Conti JB. Predictors of quality of life in patients with implantable cardioverter defibrillators. Psychosomatics. 2005; 46: 451–457.CrossrefMedlineGoogle Scholar7 Sears SF Jr, Conti JB. Quality of life and psychological functioning of ICD patients. Heart. 2002; 87: 488–493.CrossrefMedlineGoogle Scholar8 Birnie D, Tung S, Simpson C, Crystal E, Exner D, Ayala Paredes FA, Krahn A, Parkash R, Khaykin Y, Philippon F, Guerra P, Kimber S, Cameron D, Healey JS. Complications associated with defibrillation threshold testing: the Canadian experience. Heart Rhythm. 2008; 5: 387–390.CrossrefMedlineGoogle Scholar9 de Vries JW, Bakker PF, Visser GH, Diephuis JC, van Huffelen AC. Changes in cerebral oxygen uptake and cerebral electrical activity during defibrillation threshold testing. Anesth Analg. 1998; 87: 16–20.CrossrefMedlineGoogle Scholar10 Dworschak M, Franz M, Czerny M, Gorlitzer M, Blaschek M, Grubhofer G, Haider W. Release of neuron-specific enolase and S100 after implantation of cardioverters/defibrillators. Crit Care Med. 2003; 31: 2085–2089.CrossrefMedlineGoogle Scholar11 Adams DC, Heyer EJ, Emerson RG, Spotnitz HM, Delphin E, Turner C, Berman MF. Implantable cardioverter-defibrillator: evaluation of clinical neurologic outcome and electroencephalographic changes during implantation. J Thorac Cardiovasc Surg. 1995; 109: 565–573.CrossrefMedlineGoogle Scholar12 Murkin JM, Baird DL, Martzke JS, Yee R. Cognitive dysfunction after ventricular fibrillation during implantable cardioverter/defibrillator procedures is related to duration of the reperfusion interval. Anesth Analg. 1997; 84: 1186–1192.CrossrefMedlineGoogle Scholar13 Dorman BH, Conroy JM, Baker JD III, Kratz JM, Leman RB. Cerebral monitoring during implantation of automatic internal cardiac defibrillators. South Med J. 1993; 86: 533–536.CrossrefMedlineGoogle Scholar14 Selnes OA, Goldsborough MA, Borowicz LM, McKhann GM. Neurobehavioural sequelae of cardiopulmonary bypass. Lancet. 1999; 353: 1601–1606.CrossrefMedlineGoogle Scholar15 Thornton EW, Groom C, Fabri BM, Fox MA, Hallas C, Jackson M. Quality of life outcomes after coronary artery bypass graft surgery: relationship to neuropsychologic deficit. J Thorac Cardiovasc Surg. 2005; 130: 1022–1027.CrossrefMedlineGoogle Scholar16 DeMaso DR, Lauretti A, Spieth L, van der Feen JR, Jay KS, Gauvreau K, Walsh EP, Berul CI. Psychosocial factors and quality of life in children and adolescents with implantable cardioverter-defibrillators. Am J Cardiol. 2004; 93: 582–587.CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails April 2010Vol 3, Issue 2 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCEP.110.947317PMID: 20407104 Originally publishedApril 1, 2010 Keywordsimplantable cardioverter-defibrillatoroutcomesquality of lifeEditorialsPDF download Advertisement SubjectsArrhythmiasCatheter Ablation and Implantable Cardioverter-Defibrillator" @default.
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