Canadian Journal of Cardiology
Review| Volume 38, ISSUE 4, P515-525, April 2022

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Evolution of Devices to Prevent Sudden Cardiac Death: Contemporary Clinical Impacts

Published:February 03, 2022DOI:


      Implantable cardioverter defibrillators (ICDs) are recommended for primary and secondary prevention of sudden cardiac death and were first implanted more than 40 years ago. The addition of cardiac resynchronization improved outcomes in the heart failure population and is now an important part of optimized therapy for this population. In this review, we will address patient selection, risk stratification, and outcomes after ICD placement and technological improvements. Gender disparities in referral and outcomes will be discussed. Far from early technologies with limited pacing capabilities and no antitachycardia pacing (ATP), we have now moved to complex devices with the addition of ATP/ATP during charging, cardiac resynchronization therapy, remote monitoring, and improved battery longevity. The requirement for defibrillation testing at time of implantation has changed and in most implants are not required as part of new clinical guidelines. As the components most likely to fail are the leads, and many complications arise from the intravascular components, extravascular ICDs were developed, the subcutaneous ICD is now an option for many patients, and substernal devices are under clinical trials. Because shocks are associated with worse outcomes, optimized ICD programming is now recommended, with the benefit of reducing appropriate and inappropriate shocks with a decrease in mortality and no increase in the syncopal events. All these improvements will have a positive effect on patient outcomes and quality of life, and new technologies will be developed in the future.


      Les défibrillateurs cardioverteurs implantables (DCI) sont recommandés pour la prévention primaire et secondaire de la mort cardiaque subite. La première implantation d’un DCI remonte à plus de 40 ans. Depuis son introduction, la resynchronisation cardiaque a permis d’améliorer le devenir des patients atteints d’insuffisance cardiaque; elle fait maintenant partie intégrante de la thérapie optimisée au sein de cette population. Nous abordons ici la sélection des patients, la stratification du risque et les résultats obtenus à la suite de la mise en place d’un DCI et d’améliorations technologiques. Nous nous penchons aussi sur les disparités entre les sexes en matière d’aiguillage et d’issue thérapeutique. La technologie a beaucoup évolué depuis la création des premiers dispositifs aux capacités de stimulation limitées qui n’offraient aucune stimulation antitachycardie (SAT). Nous disposons maintenant de dispositifs complexes permettant la délivrance de la SAT avant et pendant la charge, la resynchronisation cardiaque, la télésurveillance et une meilleure autonomie des piles. Les exigences relatives au test du seuil de défibrillation au moment de l’implantation ont changé et ne s’appliquent pas à la plupart des implants selon les nouvelles lignes directrices cliniques. Comme les sondes sont les composants les plus susceptibles de subir une défaillance et que de nombreuses complications sont attribuables aux composants intravasculaires, des DCI extravasculaires ont été mis au point. Les DCI sous-cutanés sont maintenant une option pour de nombreux patients, et des dispositifs sous-sternaux sont en cours d’essais cliniques. Les chocs étant associés à de pires résultats, la programmation optimisée des DCI est maintenant recommandée. Celle-ci offre l’avantage de limiter la délivrance de chocs appropriés ou inappropriés et de réduire ainsi la mortalité, sans entraîner d’augmentation des manifestations syncopales. Toutes ces améliorations influeront favorablement sur le devenir et la qualité de vie des patients, et de nouvelles technologies sont à venir.
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