Journal of Interventional CardiologyVolume 9, Issue 6 p. 425-428 Can the AVID Trial Provide Meaningful Answers? IGOR SINGER MBBS, FRACP, FACP, FACC, FACA, IGOR SINGER MBBS, FRACP, FACP, FACC, FACA From the Division of Cardiology, University of Louisville Health Sciences Center, School of Medicine, Louisville, KentuckySearch for more papers by this author IGOR SINGER MBBS, FRACP, FACP, FACC, FACA, IGOR SINGER MBBS, FRACP, FACP, FACC, FACA From the Division of Cardiology, University of Louisville Health Sciences Center, School of Medicine, Louisville, KentuckySearch for more papers by this author First published: December 1996 https://doi.org/10.1111/j.1540-8183.1996.tb00653.xCitations: 3AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat References 1 Zipes D. Implantable cardioverter-defibrillator—Life saver or a device looking for a disease Circulation 1994; 89: 2934–2936. 2 Singh S, Fletcher R, Gisher S, et al. Amiodarone in patients with congestive heart failure and asymptotic ventricular arrhythmia. N Engl J Med 1995; 333: 77–82. 3 Swartz P, Camm AJ. European Myocardial Infarction Amiodarone Trial (EMIAT). Oral presentation during 45th annual scientific sessions. Am Coll Cardiol, Orlando, FL. March 26, 1996. 4 Cairns J, Connolly S. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial (CAMIAT). Oral presentation during 45th annual scientific sessions. Am Coll Cardiol, Orlando, FL, March 26, 1996. 5 Moss A, Hall J, Cannom D, et al, on behalf of the MADIT Investigators. Multicenter Automatic Defibrillator Implantation Trial (MADIT). (abstract) NASPE May 16, 1996. 6 Herre J, Sauve M, Malone F, et al. Long term results of amiodarone therapy in patients with recurrent sustained ventricular tachycardia or ventricular fibrillation. JACC 1989; 13: 442–449. 7 Weinberg BA, Miles WNM, Klein LS, et al. Five-year follow-up of 589 patients treated with amiodarone. Am Heart J 1993; 125: 109–120. 8 Böcker D, Block M, Isbruch F, et al. Do patients with an implantable defibrillator live longer JACC 1993; 21: 1638–1644. 9 Powell A, Finkelstein D, Garan H, et al. Influence of implantable cardioverter-defibrillators on long-term prognosis of survivors of out-of-hospital cardiac arrest. Circulation 1993; 88: 1083–1092. 10 Schlepper M, Neunzner J, Pitschner H. Implantable cardioverter defibrillator: Effect on survival. PACE 1996; 18(Pt. II): 569–5784. 11 Bigger JT Jr. Primary prevention of sudden cardiac death using implantable cardioverter-defibrillators. In: I Singer, ed. Implantable Cardiovener Defibrillator. Armonk . NY . Futura Publishing Co. 1994, pp. 515–546. 12 Mason J. on behalf of ESVEM Investigators. A comparison of seven antiarrhythmic drugs in patients with ventricular tachyarrhythmias. N Engl J Med 1993; 329: 452–458. 13 Rankin A, Hamilton L, Newell J, et al. Prediction of induced arrhythmia suppression and long term efficacy of oral sotalol in patients with drug refractory ventricular arrhythmias (abstract). Br Heart J 1991; 66: 108. 14 Waldo A, Camm AJ, DeRuyter J, et al., and the SWORD Investigators. Preliminary mortality results from the Survival with Oral D-Sotalol (SWORD) Trial. JACC 1995; 25: 15A. 15 Böcker E, Haverkamp W, Block M, et al. Comparison of d,I-Sotalol and implantable defibrillators for treatment of sustained ventricular tachycardia or fibrillation in patients with coronary artery disease. Circulation 1996; 94: 151–157. 16 Singer I. The AVID Trial. (Letter). PACE 1994; 17: 260–261. 17 Fogoros R. An AVID dissent. PACE 1994; 17: 1707–1711. 18 Josephson M, Nisam S. Prospective trials of implantable cardioverter defibrillators versus drugs: Are they addressing the right question Am J Cardiol 1996; 77: 859–863. Citing Literature Volume9, Issue6December 1996Pages 425-428 ReferencesRelatedInformation

EFFICACY of implantable cardioverter defibrillator therapy is critically dependent on the ICD's ability to terminate ventricular tachycardia and ventricular fibrillation in a variety of clinical circumstances. To ensure that a device is reliable, adequate testing procedures are required at the time of the implant to determine effective defibrillation energies. This information is needed to determine whether the ICD can be programmed with adequate energy margins so that the shock of the implanted device is sufficient to defibrillate the heart given the lead system and waveform.

Programming of third generation implantable cardioverter defibrillators (ICDs) is usually based on electrophysiologic (EP) testing in the supine position. However, efficacy and tolerance to tiered therapy for ventricular tachycardia (VT) may not be equivalent in the erect position. To test this hypothesis we studied 9 patients ages 36–72 years with implanted ICDs in the supine and erect position on a tilt table. ICDs were programmed to deliver ATP, cardioversion and defibrillation in the ascending order of agressivity for hemodynamically stable VTs. Perfusion was assessed by continuous intraarterial pressure and neuromonitoring techniques capable of assessing beat to beat cerebral perfusion (transcranial Doppler (TCD)), oxygen utilization (near infrared spectroscopy (NIRS)) and neuronal function (quantitative encephalography (QEEG)). Results 52 episodes of tachyarrhythmias were induced, 30 in the supine and 22 in the erect position. The duration of VT was 12 ± 5 secs in the supine and 17 ± 11 secs in the erect position (p = NS). Adequate perfusion was seen with programmed therapy in all patients in the supine but only in 5/9 patients in the erect position. Abnormal response in 4 patients was characterized by subnormal post-hypotensive hyperemic response l 40% increase in the blood flow velocity post-VT), delta wave slowing on the QEEG, and g 20% increase in NIRS post-hypotensive episode typical of cerebral ischemia. Of these 4 patients, syncope (2) and seizures (2) were experienced in the erect, but not in the supine position during testing. Conclusions 1) Supine testing may not predict optimal ICD therapy. 2) Neuromonitoring techniques are useful to assess cerebral perfusion during ICD testing. 3) Upright tilt should be considered forroutine ICD testing to optimize programming.

Basic mechanisms clinical approach to arrhythmias pacing for brady-arrhythmias electrical therapy for tachy-arrhythmias ablative therapy: surgery and catheter ablation - cardiopulmonary resuscitation.