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Controversies in Arrhythmia and Electrophysiology

Should patients with congenital heart disease and a systemic ventricular ejection fraction less than 30% undergo prophylactic implantation of an ICD?

Implantable Cardioverter Defibrillator Implantation Guidelines Based Solely on Left Ventricular Ejection Fraction Do Not Apply to Adults With Congenital Heart Disease

John K. Triedman, MD

From the Department of Cardiology, Children’s Hospital Boston, Boston, Mass.

Correspondence to John K. Triedman, MD, Department of Cardiology, Children’s Hospital Boston, 300 Longwood Ave, Boston, MA 02115. Email john.triedman@cardio.chboston.org

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
A number of important prospective studies have firmly validated the idea that patients at elevated risk for sudden cardiac death (SCD) can have that risk reduced by the use of implantable cardioverter defibrillators (ICDs). Among patients resuscitated from a potentially lethal cardiac event, ICD placement is termed secondary prevention. Primary prevention is the extension of this protective principle to groups of patients who have yet to experience a cardiac arrest, but who by virtue of specific and carefully defined clinical characteristics are determined to be at elevated risk for this event.

Response by Silka and Bar-Cohen see p 317

Given the cost of ICD therapy and the number of patients who may meet primary prevention indications, the potential societal cost of this approach to cardiac risk management is high. In the past decade, this has driven a vigorous debate within the fields of heart rhythm management and health care economics as to the optimal ways to delineate patient groups that will most benefit from ICD therapy. The Multicenter Automatic Defibrillator Implantation Trial II (MADIT-II) study¹ was a milestone in the evolution of this debate, providing evidence that a large group of patients—those with ischemic cardiomyopathy—could be rapidly and noninvasively sorted on the basis of left ventricular (LV) ejection fraction, with those having severe LV dysfunction realizing a clear survival benefit from ICD therapy.

In this article, I challenge the proposition that MADIT-II and subsequent studies of the efficacy of ICD therapy in patients with acquired LV dysfunction can be applied . . . [Full Text of this Article]

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