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Implantable cardioverter-defibrillator (ICD) devices were originally developed for prevention of sudden cardiac death (SCD). They are now widely regarded as the primary therapy for this condition. Clinical trials have led to a progressive expansion in indications for their use.1,2⇓ Recent clinical reports show effectiveness of these devices in patients with recurrent syncope, in the prevention of SCD in high-risk patients with coronary disease, and in the treatment of atrial fibrillation. Refinements in ICD technology have improved functionality and enhanced safety. Optimal patient management requires intimate knowledge of these complex devices and of the diverse arrhythmias that may be treatable by a single multifaceted ICD device.A 75-year-old man presented with near-syncope and ventricular arrhythmias. He had a past history of dilated cardiomyopathy, old cerebrovascular accident, symptomatic atrial flutter/fibrillation, and heart failure. He had been treated with anticoagulation and antiarrhythmic drugs, but it was noted on admission that he was in atrial flutter with a ventricular rate of 110 bpm. Electrophysiological evaluation revealed isthmus- (common or typical) and nonisthmus- (atypical) dependent atrial flutter and inducible hypotensive monomorphic sustained ventricular tachycardia. A linear ablation of the tricuspid valve-inferior vena cava isthmus interrupted common flutter, but atypical flutter persisted. The following day, a dual chamber ICD capable of defibrillation and antitachycardia, as well as standard demand pacing in both chambers, was inserted. An additional coronary sinus lead was placed to permit dual site right atrial pacing for prevention of atrial flutter and fibrillation (Figure 1A). The patient was given a handheld activator for termination of atrial fibrillation (AF) and flutter. Figure 1. A, Lateral radiograph of the chest showing the first dual chamber atrioventricular defibrillator inserted in patient with refractory atrial fibrillation. Note the distinct atrial and ventricular pacing and defibrillation leads. An additional coronary sinus pacing lead is placed …

Management of the Patient With an Implantable Cardioverter-Defibrillator in the Third Millennium