Der subkutane Defibrillator (S-ICD) – Beginn einer neuen Ära in der Prävention und Therapie des plötzlichen Herztodes?

Abstract

Being an entirely subcutaneous system the S-ICD avoids important periprocedural and long-term complications associated with transvenous implantable cardioverter-defibrillator (TV-ICD) systems such as lead fracture with recurrent lead revisions and systemic device infections. Further, in patients with challenging anatomic conditions or after infection the S-ICD might be reasonable. In multicenter studies and registries efficacy and safety of the S-ICD was equal or better compared to transvenous implantable defibrillators. The S-ICD^® predominately might be suitable in all patients with ICD indication except patients with pacing or CRT indication, VT < 170 bpm, negative screening or in the occasional patient whose arrhythmia might be suppressed by overdrive pacing. Initially observed complications such as inappropriate shocks due to T-wave-oversensing or infections were reduced by standardized implantation techniques, operator learning curves and modification of algorithms.

Kernaussagen

• Transvenös implantierbare ICDs sind seit Jahren fester Bestandteil der Prophylaxe und Therapie des plötzlichen Herztodes. Häufigste Komplikationen bei transvenösen ICD (TV-ICD) sind Elektrodendefekte mit inadäquaten Schocks, Re-Operationen und Infektionen.

• Typische Elektrodenkomplikationen des TV-ICD können mit dem S-ICD vermieden werden, weil sowohl das ICD-Aggregat als auch die Elektrode vollständig extrakardial bzw. extrathorakal implantiert werden.

• Der S-ICD ermittelt automatisch den besten Sensingvektor aus 3 vorhandenen Möglichkeiten. Die abgegebene maximale Schockenergie beträgt 80 J, ein Postshock-Pacing für 30 Sekunden mit 50 bpm ist integriert.

• Schockeffektivität und Sicherheit des S-ICD sind vergleichbar zu denen bei TV-ICDs.

• Die Implantationstechnik weicht von der bei TV-ICDs ab, kann aber von interventionell tätigen Kardiologen erlernt werden.

• Der S-ICD ist in Erwägung zu ziehen bei allen Patienten mit Ausnahme von Patienten mit Stimulations- oder eindeutigem ATP-Bedarf, Indikation zur kardialen Resynchronsisationstherapie, ventrikulären Tachykardien < 170 bpm oder negativem Screening.

• Der S-ICD kann prinzipiell mit anderen implantierbaren Geräten wie Schrittmacher, CRT oder Geräten zur kardialen Kontraktilitätsmodulation kombiniert werden. Initial aufgetretene Probleme wie inadäquate Schocks aufgrund von T-Wellen-Oversensing oder Infektionen konnten durch standardisierte Operationstechnik, durchlaufene Lernkurve der Operateure sowie Modifikation der Algorithmen weitgehend eliminiert werden.

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