1. Date of download: 6/23/2016 Copyright © The American College of Cardiology. All rights reserved. From: Implantable Cardiac Defibrillator Lead Failure and Management J Am Coll Cardiol. 2016;67(11):1358-1368. doi:10.1016/j.jacc.2015.12.067 ICD Lead Design (A) DF-1 and DF-4 headers and leads. Schematic diagram of the DF-4 and earlier DF-1 connector. (B) Defibrillation lead schematic cross sections. Schematic diagram of multilumen ICD design. ICD = implantable cardioverter-defibrillator; P/S = pace/sense; RV = right ventricle; SVC = superior vena cava. Figure Legend:

2. Date of download: 6/23/2016 Copyright © The American College of Cardiology. All rights reserved. From: Implantable Cardiac Defibrillator Lead Failure and Management J Am Coll Cardiol. 2016;67(11):1358-1368. doi:10.1016/j.jacc.2015.12.067 Defibrillation Lead Configurations From Different ICD Manufacturers Schematic diagram of ICD leads from various manufacturers. This diagram shows the various components of different ICD multilumen leads. ICD = implantable cardioverter-defibrillator. Figure Legend:

3. Date of download: 6/23/2016 Copyright © The American College of Cardiology. All rights reserved. From: Implantable Cardiac Defibrillator Lead Failure and Management J Am Coll Cardiol. 2016;67(11):1358-1368. doi:10.1016/j.jacc.2015.12.067 ICD Leads: Approach to the Patient With Suspected LF This diagram shows the differential diagnosis and a deductive approach to the determination of the most likely cause of lead failure. ICD = implantable cardioverter-defibrillator; LF = lead failure. ∗ Real time electrograms including pace-sense electrograms with muscle exercise and pocket manipulation, shock electrograms, differential electrograms, and pacing and sensing thresholds. Figure Legend:

4. Date of download: 6/23/2016 Copyright © The American College of Cardiology. All rights reserved. From: Implantable Cardiac Defibrillator Lead Failure and Management J Am Coll Cardiol. 2016;67(11):1358-1368. doi:10.1016/j.jacc.2015.12.067 Interrogated Data and Lead Analysis for ICD LF An example of diagnostics from a patient with a Medtronic Sprint Quattro lead failure (LF) detected by the lead integrity alert (LIA). Upper panel: Components of LIA are shown with thresholds for alert. In this case, the pace-sense impedance trend was normal. LIA was activated by the combination of rapid oversensing of nonphysiological short intervals cumulated in the sensing integrity count (SIC) and 2 episodes of rapid nonsustained tachycardia (NST). Chest x-ray showed that the DF4 pin was inserted completely into header and revealed no abnormalities of lead or sharp angles. Lower panel: The region under the tie-down sleeve shows combined insulation breach and fracture of the central helix caused by pressure from a suture. (A) Low-power light microscopy shows indented insulation overlying helix, which has separated into proximal and distal fragments (yellow bracket). This is seen in high- resolution inset at lower left. White arrow shows compressed insulation. (B) Low-power scanning electron micrograph (SEM) provides clearer image of compressed insulation under suture, resulting in silicon cold flow (“creep”). As silicone is compressed away from the sleeve, ethylene-tetrafluoroethylene (ETFE) covering of the cable to the RV ring electrode is exposed. (C) Light microscopy shows that the helix has been removed from the lead body and mounted on a stylet. The fractured ends (yellow arrow) have separated due to tension. Inset at lower left shows SEM of the distal fractured end. PU = polyurethane. Figure Legend: