Sudden Cardiac Arrest Morhaf Ibrahim, MD, FHRS Electrophysiology

Causes of Death in USA 1999

Etiology of SCA

Prior cardiovascular event SCA Risk Factors Prior cardiovascular event Advancing age Hereditary factors African American Ethnicity 40% of all SCA occur in patients with known risk factors Zipes Circulation 1998;98:2334-2351 b: Zipes JACC 2006;48:e247-e346

Arrhythmia Cause of SCA

Underlying Arrhythmias of SCA

LVEF and SCA

Heart Failure and SCA

Severity of Heart Failure Modes of Death

Incidence of SCA vs. Annual Sudden Deaths

AIVR

Nonsustained Monomorphic VT

Nonsustained LV VT

Sustained Monomorphic VT 72-year-old woman with CHD

Nonsustained Polymorphic VT

Sustained Polymorphic VT Exercise induced in patient with no structural heart disease

Bundle Branch Reentrant VT

Spontaneous conversion to NSR (12-lead ECG) Ventricular Flutter Spontaneous conversion to NSR (12-lead ECG)

VF with Defibrillation (12-lead ECG)

Wide QRS Irregular Tachycardia: Atrial Fibrillation with antidromic conduction in patient with accessory pathway – Not VT

Treatments to Reduce SCA

AICD

Michel Mirowski

Primary Prevention Trials SCA Prevention Primary Prevention Trials Trial Risk Type Clinical Relevance MADITa (1996) EF<35% prior MI NSVT, EP+ The survival benefits of ICD therapy were demonstrated in high-risk patients who had not experienced life-threatening VT/VF MADIT IIb (2001) EF<30% The survival benefits of ICD therapy were demonstrated in high-risk patients who did not have documented arrhythmias. COMPANIONc (2002) CAD; CHF QRS >120 The survival benefits of CRT-D (defibrillation) therapy were demonstrated in heart failure patients who did not have an ICD indication SCD-HeFTd (2005) EF<35%; CAD±MI or NICM The survival benefits of ICD therapy were demonstrated in NYHA Class II or III CHF patients with an LVEF < 35% CAD = coronary artery disease; EP+ = positive for documented episode of asymptomatic, unsustained ventricular tachycardia; LVEF = Left ventricular ejection fraction; MI = myocardial infarction; NSVT = non-sustained ventricular tachyarrhythmia; NICM = non-ischemic cardiomyopathy; SCA = sudden cardiac arrest; By 2005, the mortality benefit of ICD therapy was clearly established for both primary and secondary prevention of SCA. a: Moss NEJM 1996;335:1933-1940 b: Moss NEJM 2002;346:877-883 c: Bristow NEJM 2004;350:2140-2150 d: Bardy NEJM 2005;352:225-237

Introduction to the S-ICDTM System Protection Without Touching the Heart

Subcutaneous ICD Therapy The S-ICDTM System Entirely subcutaneous Does not require leads in the heart Sophisticated algorithms provide effective detection and treatment of VT/VFa,b a: Gold J Cardiovasc. Electrophysiol. 2012, 23:359-366 b: Weiss Circulation 2013;128:944–953

Implantation of S-ICDTM System A predictable implant that relies only on anatomical landmarks

Implanted S-ICDTM Systems Device location is well accepted by patientsa Smith W, Hood M. HRS 2007 Abstract Presentation S-ICD System Comfort and Tolerability Study Heart Rhythm; 4(5) S210. b) Case studies are not necessarily representative of clinical performance. Case study performance may vary .

EFFORTLESS Registry Broad Range of Clinical Indications Patients with a broad range of cardiac conditions have received the S-ICDTM System Lambiase EFFORTLESS S-ICD Registry, HRS 2012, Boston, MA

Broad Range of Body Habitus Patients in all age groups and across a broad range of body habitus have received the S-ICDTM System S-ICD System Commercial Implant Analysis, Q3 2012 (1079 patients). Data on File. Boston Scientific, San Clemente, California

Appropriate Use of the S-ICDTM System Poole JE, Gold MR Appropriate Use of the S-ICDTM System Poole JE, Gold MR. Circ Arrhythm Electrophysiol 2013;6:1236-1245. Strong Candidates No vascular access History of recurrent TV lead infections/fractures Renal failure, diabetes, immuno-compromised Reasonable Candidates Young patients with primary electrical problems Patients with a primary prevention indication Prior VF arrest Prosthetic valves Inappropriate Candidates Patients with bradycardia pacing indications Need for CRT Recurrent monomorphic VT

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