How do I follow up the patient with the implantable cardioverter defibrillator?

Follow up of the patient with an implantable cardioverter defibrillator (ICD) demands an integrated team approach. The cardiologist, technical staff and nurses involved should have a wide experience and knowledge of pacemakers and general cardiac electrophysiology. Current generation ICDs do not just shock the heart but provide complex regimens of tachycardia discrimination and anti-tachycardia pacing (ATP) as well as single and dual chamber bradycardia therapy.

Routine follow up may occur in a tertiary centre or a local hospital as long as the expert staff and necessary equipment such as programmers and cardiac arrest kit are available. Follow up should start before the device is implanted with an educational programme and support for the patient and immediate family members. Videos, information booklets and meeting other patients with ICDs may be of benefit.

No consensus exists as to the interval between routine follow ups. Previously the patient had to return every month or two to have a capacitor reform. This is not now necessary, as all modern ICDs will undertake this automatically. With most current devices a 3 to 6 month interval is usual but treat each patient according to their individual circumstances.

Good management of the ICD should aim to achieve the following objectives:

1. Monitor the performance of the therapy delivered by the device, look at the success and failure of the programmed regimes and any acceleration of arrhythmias. Use this information to optimise clinical effectiveness of the programming.
2. Measure necessary parameters of the ICD and leads to ensure correct function. These should include lead impedance, shock coil impedance (if possible non-invasively), battery voltage, charge time, R and P wave amplitudes as well as pacing thresholds.
3. Review the intracardiac electrograms to ensure no inadvertent sensing of noise or other interference.
4. Maximise device longevity by safe and effective reprogramming of parameters.
5. Minimise the risk of complications occurring both from inappropriate therapy delivered to the patient and those associated with wound and pocket infection.1
6. Anticipate the elective replacement of the device and plan for this eventuality.
7. Provide a support structure for the patient and their family including advice, counselling and education. Some centres provide a formal patient support group; there are both positive and negative views on this practice.