Anderson, Mark; (1994) A prospective evaluation of the implantable cardioverter defibrillator: Factors affecting implant success, outcome, therapy delivery, social adjustment and cost efficacy. Doctoral thesis (M.D), UCL (University College London).

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Abstract

The Implantable Cardioverter Defibrillator (ICD) offers an alternative to drug therapy, surgery or catheter ablation for the treatment of patients with life threatening ventricular tachyarrhythmias. This thesis reviews the development and current status of this therapy with reference to the first 48 patients to receive an ICD at St. George's Hospital. Data from these patients has been used to analyse the factors affecting success or failure of ICD implantation using a transvenous lead system, the patterns of ICD therapy delivery, long-term device performance and occurrence of complications. Using novel techniques for assessment of psychomotor performance and cerebral blood flow the impact of continuing transient episodes of arrhythmia on motor performance was studied. Risk analysis techniques have been applied to examine whether ICD recipients should be allowed to drive a motor vehicle and a flexible model has been developed by the author to enable the assessment of the cost-efficacy of ICD use in its present and potential future applications. The study concludes that smaller heart size on the chest radiograph is the best predictor of successful ICD implantation using a transvenous lead system and that low left ventricular ejection fraction is the best predictor of appropriate ICD therapy delivery. The psychomotor studies show that even transient hypotensive symptoms during an arrhythmia are associated with marked impairment of psychomotor performance. Risk analysis shows that ICD patients who have not received a therapy within the two years after ICD implant might safely be allowed to drive a private motor vehicle. Modelling techniques show that the current use of the ICD in high-risk cardiac arrest survivors is comparable in cost-efficacy to other invasive medical therapies. Relative reductions in equipment cost, increasing ICD life and reduced implant mortality could result in a fourfold improvement in cost-efficacy over the next decade. Prophylactic use of the ICD may prove cost-effective in the light of these changes but has major implications for health care expenditure because of the large numbers of ICD implants required.

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