Professional Statements and Societal Positions Guidelines
Clinical Input From Physician Specialty Societies and Academic Medical Centers
While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.
2015 Input
In response to requests, input was received from one (1) physician specialty society four (4) responses and five (5) academic medical centers, for a total of nine (9) responses, while this policy was under review in 2015. Input focused on the use of implantable cardioverter defibrillators (ICDs) as primary prevention for cardiac ion channelopathies and use of the subcutaneous implantable cardioverter defibrillator. Reviewers generally indicated that an ICD should be considered medically necessary for primary prevention of ventricular arrhythmias in adults and children with a diagnosis of long QT syndrome, Brugada syndrome, short QT syndrome, and catecholaminergic polymorphic ventricular tachycardia. Reviewers generally indicated that the subcutaneous implantable cardioverter defibrillator should be considered medically necessary particularly for individuals with indications for an ICD but who have difficult vascular access or have had transvenous ICD lead explanation due to complications.
2011 Input
In response to requests, input was received from six (6) academic medical centers while this policy was under review in 2011. For most policy indications, including pediatric, there was general agreement from those providing input. On the question of timing of ICD placement, input was mixed, with some commenting about the potential role of early implantation in select individuals. Reviewers indicated that a waiting period of nine (9) months for individuals with nonischemic cardiomyopathy was not supported by the available evidence or consistent with the prevailing practice patterns in academic medical centers. Input emphasized the difficulty of prescribing strict timeframes given the uncertainty of establishing the onset of cardiomyopathy and the inability to risk-stratify individuals based on time since onset of cardiomyopathy.
Practice Guidelines and Position Statements
American Heart Association et al
Heart Failure
The AHA, American College of Cardiology, and Heart Rhythm Society (HRS) (2017) published joint guidelines on the management of heart failure, which updated their 2012 guidelines. These guidelines made the following recommendations on the use of ICD devices (see Tables12-19). The recommendations for the use of an ICD apply only if meaningful survival is expected to be greater than one (1) year.
Table 12. Guidelines on Device-Based Therapy of Cardiac Rhythm Abnormalities
Recommendation |
COR |
LOE |
"In individuals with ischemic heart disease, who either survive SCA due to VT/VF or experience hemodynamically unstable VT (LOE: B-R) or stable VT (LOE: BNR) not due to reversible causes..." |
I |
B-R
B‑NR |
"A transvenous ICD provides intermediate value in the secondary prevention of SCD particularly when the individual's risk of death due to a VA is deemed high and the risk of non-arrhythmic death (either cardiac or noncardiac) is deemed low based on the individual's burden of comorbidities and functional status." |
|
B-R |
"In individuals with ischemic heart disease and unexplained syncope who have inducible sustained monomorphic VT on electrophysiological study..." |
I |
B-NR |
"In individuals resuscitated from SCA due to coronary artery spasm in whom medical therapy is ineffective or not tolerated..." |
IIa |
B-NR |
"In individuals resuscitated from SCA due to coronary artery spasm, an ICD in addition to medical therapy may be reasonable..." |
IIb |
B-NR |
"In individuals with arrhythmogenic right ventricular cardiomyopathy and an additional marker of increased risk of SCD (resuscitated SCA, sustained VT, significant ventricular dysfunction with RVEF or LVEF 35 percent)." |
I |
B-NR |
"In individuals with arrhythmogenic right ventricular cardiomyopathy and syncope presumed due to VA..." |
IIa |
B-NR |
COR: class of recommendation; ICD: implantable cardioverter defibrillator; LOE: level of evidence; LVEF: left ventricular ejection fraction; RVEF: right ventricular ejection fraction; SCA: sudden cardiac arrest; SCD: sudden cardiac death; VA: ventricular arrhythmia; VF: ventricular fibrillation; VT: ventricular tachycardia.
Table 13. Guidelines on Use of ICDs as a Primary Prevention of Ischemic Heart Disease
Recommendation |
COR |
LOE |
"In individuals with LVEF of 35 percent or less that is due to ischemic heart disease who are at least 40 days' post-MI and at least 90 days post-revascularization, and with NYHA class II or III HF despite GDMT..." |
I |
A |
" In individuals with LVEF of 30percent or less that is due to ischemic heart disease who are at least 40 days' post-MI and at least 90 days post-revascularization, and with NYHA class I HF despite GDMT..." |
I |
A |
"A transvenous ICD provides high value in the primary prevention of SCD particularly when the individual's risk of death due to a VA is deemed high and the risk of non-arrhythmic death (either cardiac or noncardiac) is deemed low based on the individual's burden of comorbidities and functional status..." |
|
B-R |
"In individuals with NSVT due to prior MI, LVEF of 40 percent or less and inducible sustained VT or VF at electrophysiological study..." |
I |
B-R |
"In non-hospitalized individuals with NYHA class IV symptoms who are candidates for cardiac transplantation or an LVAD..." |
IIa |
B‑NR |
"An ICD is not indicated for NYHA class IV individuals with medication-refractory HF who are not also candidates for cardiac transplantation, an LVAD, or a CRT defibrillator that incorporates both pacing and defibrillation capabilities." |
IIIa |
C-EO |
CRT: cardiac resynchronization therapy; COR: class of recommendation; ICD: implantable cardioverter defibrillator; GDMT: guideline-directed management and therapy; HF: heart failure; LOE: level of evidence; LVAD: left ventricular assist device; LVEF: left ventricular ejection fraction; MI: myocardial infarction; NSVT: nonsustained ventricular tachycardia; NYHA: New York Heart Association; SCD: sudden cardiac death; VA: ventricular arrhythmia; VF: ventricular fibrillation; VT: ventricular tachycardia.
a No benefit.
Table 14. Guidelines on Use of ICDs for Nonischemic Cardiomyopathy
Recommendation |
COR |
LOE |
"In individuals with NICM who either survive SCA due to VT/VF or experience hemodynamically unstable VT (LOE: B-R) (1-4) or stable VT (LOE: B-NR) (5) not due to reversible causes..." |
I |
B-R
B‑NR |
" In individuals with NICM who experience syncope presumed to be due to VA and who do not meet indications for a primary prevention ICD, an ICD or an electrophysiological study for risk stratification for SCD can be beneficial..." |
IIa |
B-NR |
"In individuals with NICM, HF with NYHA class II-III symptoms and an LVEF of 35 percent or less, despite GDMT..." |
IIa |
B-R |
"In individuals with NICM, HF with NYHA class I symptoms and an LVEF of 35 percent or less, despite GDMT..." |
IIb |
B-R |
"In individuals with medication-refractory NYHA class IV HF who are not also candidates for cardiac transplantation, an LVAD, or a CRT defibrillator that incorporates both pacing and defibrillation capabilities, an ICD should not be implanted." |
IIIa |
C-EO |
COR: class of recommendation; CRT: cardia resynchronization therapy; GDMT: guideline-directed management and therapy; HF: heart failure; ICD: implantable cardioverter defibrillator: LOE: level of evidence; LVAD: left ventricular assist device; LVEF: left ventricular ejection fraction; NICM: nonischemic cardiomyopathy; NYHA: New York Heart Association; SCA: sudden cardiac arrest; SCD: sudden cardiac death; VA: ventricular arrhythmia; VF: ventricular fibrillation; VT: ventricular tachycardia.
a No benefit.
Table 15. Guidelines on Use of ICDs for HCM
Recommendation |
COR |
LOE |
"In individuals with HCM who have survived an SCA due to VT or VF, or have spontaneous sustained VT causing syncope or hemodynamic compromise..." |
I |
B‑NR |
"In individuals with HCM and one (1) or more of the following risk factors...
- Maximum LV wall thickness 30 mm (LOE: B-NR).
- SCD in one (1) or more first-degree relatives presumably caused by HCM (LOE: C-LD).
- one (1) or more episodes of unexplained syncope within the preceding six (6) months (LOE: C-LD)"
|
IIa |
B-NR
C-LD
C-LD |
"In individuals with HCM who have spontaneous NSVT (LOE: C-LD) or an abnormal blood pressure response with exercise (LOE: B-NR), who also have additional SCD risk modifiers or high risk features..." |
IIa |
B-NR
C-LD |
"In individuals with HCM who have NSVT (LOE: B-NR) or an abnormal blood pressure response with exercise (LOE: B-NR) but do not have any other SCD risk modifiers, an ICD may be considered, but its benefit is uncertain." |
IIB |
B-NR
B-NR |
"In individuals with an identified HCM genotype in the absence of SCD risk factors, an ICD should not be implanted" |
IIIa |
B-NR |
COR: class of recommendation; HCM: hypertrophic cardiomyopathy; ICD: implantable cardioverter defibrillator; LOE: level of evidence; LV: left ventricular; NSVT: non-sustained ventricular tachycardia; SCA: sudden cardiac arrest; SCD: sudden cardiac death; VF: ventricular fibrillation; VT: ventricular tachycardia.
a No benefit.
Table 16. Guidelines on Use of Subcutaneous ICDs for Cardiac Sarcoiditis
Recommendation |
COR |
LOE |
"In individuals with cardiac sarcoidosis who have sustained VT or are survivors of SCA or have an LVEF of 35 percent or less, an ICD is recommended, if meaningful survival of greater than one (1) year is expected." |
I |
B‑NR |
"In individuals with cardiac sarcoidosis and LVEF greater than 35 percent who have syncope and/or evidence of myocardial scar by cardiac MRI or positron emission tomographic (PET) scan, and/or have an indication for permanent pacing, implantation of an ICD is reasonable, provided that meaningful survival of greater than one (1) year is expected." |
IIa |
B-NR |
"In individuals with cardiac sarcoidosis and LVEF greater than 35 percent, it is reasonable to perform an electrophysiological study and to implant an ICD, if sustained VA is inducible, provided that meaningful survival of greater than one (1) year is expected." |
IIa |
C-LD |
"In individuals with cardiac sarcoidosis who have an indication for permanent pacing, implantation of an ICD can be beneficial." |
IIa |
C-LD |
ICD: implantable cardioverter defibrillator; COR: class of recommendation; LOE: level of evidence; VT: ventricular tachycardia; SCA: sudden cardiac arrest; LVEF: left ventricular ejection fraction; MRI: magnetic resonance imaging; VA: ventricular arrhythmia
Table 17. Guidelines on Use of ICDs for Other Conditions
Recommendation |
COR |
LOE |
"In individuals with HFrEF who are awaiting heart transplant and who otherwise would not qualify for an ICD (e.g., NYHA class IV and/or use of inotropes) with a plan to discharge home, an ICD is reasonable" |
IIa |
B‑NR |
"In individuals with an LVAD and sustained VA, an ICD can be beneficial." |
IIa |
C-LD |
"In individuals with a heart transplant and severe allograft vasculopathy with LV dysfunction..." |
IIb |
B-NR |
"In individuals with neuromuscular disorders, primary and secondary prevention ICDs are recommended for the same indications as for individuals with NICM..." |
I |
B-NR |
In individuals with a cardiac channelopathy (see Guideline Tables 7.9 and 7.9.1) |
I |
B-NR |
In individuals with catecholaminergic polymorphic ventricular tachycardia and recurrent sustained VT or syncope (see Guideline Table 7.9.1.2) |
I |
B-NR |
"In individuals with Brugada syndrome with spontaneous type 1 Brugada electrocardiographic pattern and cardiac arrest, sustained VA or a recent history of syncope presumed due to VA..." |
I |
B-NR |
"In individuals with early repolarization pattern on ECG and cardiac arrest or sustained VA..." |
I |
B-NR |
"In individuals resuscitated from SCA due to idiopathic polymorphic VT or VF..." |
I |
B-NR |
"For older individuals and those with significant comorbidities, who meet indications for a primary prevention ICD, an ICD is reasonable." |
IIa |
B-NR |
"In individuals with adult congenital heart disease with SCA due to VT or VF in the absence of reversible causes..." |
I |
B-NR |
"In individuals with repaired moderate or severe complexity adult congenital heart disease with unexplained syncope and at least moderate ventricular dysfunction or marked hypertrophy, either ICD implantation or an electrophysiological study with ICD implantation for inducible sustained VA is reasonable..." |
IIa |
B-NR |
COR: class of recommendation; ECG: electrocardiogram; HFrEF; heart failure with reduced ejection fraction; ICD: implantable cardioverter defibrillator; LOE: level of evidence; LV: left ventricle; LVAD: left ventricular assist device; NICM: nonischemic cardiomyopathy; NYHA: New York Heart Association; SCA: sudden cardiac arrest; VA: ventricular arrhythmia; VF: ventricular fibrillation; VT: ventricular tachycardia.
Table 18. Guidelines on Use of Subcutaneous ICDs
Recommendation |
COR |
LOE |
"In individuals who meet criteria for an ICD who have inadequate vascular access or are at high risk for infection, and in whom pacing for bradycardia or VT termination or as part of CRT is neither needed nor anticipated, a subcutaneous implantable cardioverter-defibrillator is recommended." |
I |
B‑NR |
"In individuals who meet indication for an ICD, implantation of a subcutaneous implantable cardioverter-defibrillator is reasonable if pacing for bradycardia or VT termination or as part of CRT is neither needed nor anticipated." |
IIa |
B-NR |
"In individuals with an indication for bradycardia pacing or CRT, or for whom anti-tachycardia pacing for VT termination is required, a subcutaneous implantable cardioverter-defibrillator should not be implanted." |
IIIa |
B-NR |
CRT: cardiac resynchronization therapy; COR: class of recommendation; ICD: implantable cardioverter defibrillator; LOE: level of evidence; VT: ventricular tachycardia.
a Harm.
The 2013 update made the following recommendations on ICD therapy for children (see Table 19).
Table 19. Guidelines on ICD Therapy for Children
Recommendation |
COR |
LOE |
ICD implantation is indicated in the survivor of cardiac arrest after evaluation to define the cause of the event and to exclude any reversible causes. |
I |
B |
ICD implantation is indicated for individuals with symptomatic sustained VT in association with congenital heart disease who have undergone hemodynamic and electrophysiological evaluation. Catheter ablation or surgical repair may offer possible alternatives in carefully selected individuals. |
I |
C |
ICD implantation is reasonable for individuals with congenital heart disease with recurrent syncope of undetermined origin in the presence of either ventricular dysfunction or inducible ventricular arrhythmias at electrophysiological study. |
IIa |
B |
ICD implantation may be considered for individuals with recurrent syncope associated with complex congenital heart disease and advanced systemic ventricular dysfunction when thorough invasive and noninvasive investigations have failed to define a cause. |
IIb |
C |
All class III recommendations found in Section 3, "Indications for Implantable Cardioverter-Defibrillator Therapy," apply to pediatric individuals and individuals with congenital heart disease, and ICD implantation is not indicated in these individual populations. |
IIIa |
C |
COR: class of recommendation; ICD: implantable cardioverter defibrillator; LOE: level of evidence; VT: ventricular tachycardia.
a Not recommended.
ICD Therapy in Individuals Not Well Represented in Clinical Trials
The HRS, the American College of Cardiology, and AHA (2014) published an expert consensus statement on the use of ICD therapy for individuals not included or poorly represented in ICD clinical trials. The statement presented a number of consensus-based guidelines on the use of ICDs in select individual populations.
American Heart Association
AHA (2010) issued a scientific statement, endorsed by HRS, on cardiovascular implantable electronic device infections and their management. This statement made the following recommendations on the removal of device-related infections (see Table 20).
Table 20. Guidelines on the Management of CIED Infections
Recommendation |
COR |
LOE |
Complete device and lead removal is recommended for all individuals with definite CIED infection, as evidenced by valvular and/or lead endocarditis or sepsis. |
I |
A |
Complete device and lead removal is recommended for all individuals with CIED pocket infection as evidenced by abscess formation, device erosion, skin adherence, or chronic draining sinus without clinically evident involvement of the transvenous portion of the lead system. |
I |
B |
Complete device and lead removal is recommended for all individuals with valvular endocarditis without definite involvement of the lead(s) and/or device. |
I |
B |
Complete device and lead removal is recommended for individuals with occult staphylococcal bacteremia. |
I |
B |
CIED: cardiovascular implantable electronic device; COR: class of recommendation; LOE: level of evidence.
Heart Rhythm Society- Arrhythmogenic Cardiomyopathy
In 2019, the HRS published a consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy. Recommendations related to ICD risk stratification and placement decisions are shown in Table 21.
Table 21. Guidelines on Risk Stratification and ICD Decisions
Recommendation |
COR1 |
LOE2 |
In individuals with ARVC with hemodynamically tolerated sustained VT, an ICD is reasonable. |
IIa |
B-NR |
ICD implantation is reasonable for individuals with ARVC and three major, two major and two minor, or one major and four minor risk factors for ventricular arrhythmia. |
IIa |
B-NR |
ICD implantation may be reasonable for individuals with ARVC and two major, one major and two minor, or four minor risk factors for ventricular arrhythmia. |
IIb |
B-NR |
In individuals with ACM with LVEF 35 percent or lower and NYHA class II-III symptoms and an expected meaningful survival of greater than one (1) year, an ICD is recommended. |
I |
B-R |
In individuals with ACM with LVEF 35 percent or lower and NYHA class I symptoms and an expected meaningful survival of greater than one (1) year, an ICD is reasonable. |
IIa |
B-R |
In individuals with ACM (other than ARVC) and hemodynamically tolerated VT, an ICD is recommended. |
I |
B-NR |
In individuals with phospholamban cardiomyopathy and LVEF less than 45 percent or NSVT, an ICD is reasonable. |
IIa |
B-NR |
In individuals with lamin A/C ACM and two or more of the following: LVEF less than 45 percent, NSVT, male sex, an ICD is reasonable. |
IIa |
B-NR |
In individuals with FLNC ACM and an LVEF less than 45 percent, an ICD is reasonable. |
IIa |
C-LD |
In individuals with lamin A/C ACM and an indication for pacing, an ICD with pacing capabilities is reasonable. |
IIa |
C-LD |
ICD: Implantable cardioverter defibrillator; ACM: arrhythmogenic cardiomyopathy; ARVC: arrhythmogenic right ventricular cardiomyopathy; LVEF: left ventricular ejection fraction; NYHA: New York Heart Association; NSVT: nonsustained ventricular tachycardia; VT: ventricular tachycardia; FLNC: filamin-C; COR: Class of Recommendation; LOE: Level of Evidence
1 Class I: Strong; Class IIa: Moderate; Class IIb: Weak. 2 B-R: Randomized; B-NR: nonrandomized; C-LD: limited data
Heart Rhythm Society et al- Inherited Primary Arrhythmia Syndromes
The HRS, the European Heart Rhythm Association, and the Asia-Pacific Heart Rhythm Society (2013) issued a consensus statement on the diagnosis and management of individuals with inherited primary arrhythmia syndromes, which included recommendations on ICD use in individuals with long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, and short QT syndrome (see Table 22).
Table 22. Guidelines on the Diagnosis and Management of Inherited Primary Arrhythmia Syndromes
Recommendation |
COR |
Long QT syndrome |
|
ICD implantation is recommended for individuals with a diagnosis of LQTS who are survivors of a cardiac arrest |
I |
ICD implantation can be useful in individuals with a diagnosis of LQTS who experience recurrent syncopal events while on beta-blocker therapy |
IIa |
Except under special circumstances, ICD implantation is not indicated in asymptomatic LQTS individuals who have not been tried on beta-blocker therapy |
IIIa |
Brugada syndrome |
|
ICD implantation is recommended in individuals with a diagnosis of BrS who:
- Are survivors of a cardiac arrest and/or
- Have documented spontaneous sustained VT with or without syncope.
|
I |
ICD implantation can be useful in individuals with a spontaneous diagnostic type I ECG who have a history of syncope judged to be likely caused by ventricular arrhythmias. |
IIa |
ICD implantation may be considered in individuals with a diagnosis of BrS who develop VF during programmed electrical stimulation (inducible individuals). |
IIb |
ICD implantation is not indicated in asymptomatic BrS individuals with a drug-induced type I ECG and on the basis of a family history of SCD alone. |
IIIa |
Catecholaminergic polymorphic ventricular tachycardia |
|
ICD implantation is recommended for individuals with a diagnosis of CPVT who experience cardiac arrest, recurrent syncope or polymorphic/bidirectional VT despite optimal medical management, and/or left cardiac sympathetic denervation. |
I |
ICD as a standalone therapy is not indicated in an asymptomatic individual with a diagnosis of CPVT |
IIIa |
Short QT syndrome |
|
ICD implantation is recommended in symptomatic individuals with a diagnosis of SQTS who: Are survivors of cardiac arrest and/or have documented spontaneous VT with or without syncope. |
I |
ICD implantation may be considered in asymptomatic individuals with a diagnosis of SQTS and a family history of sudden cardiac death. |
IIb |
BrS: Brugada syndrome; COR: class of recommendation; CPVT: catecholaminergic polymorphic ventricular tachycardia; ECG: electrocardiogram; ICD: implantable cardioverter defibrillator; LQTS: long QT syndrome; SCD: sudden cardiac death; SQTS: short QT syndrome; VF: ventricular fibrillation; VT: ventricular tachycardia.
a Not recommended.
ICD implantation may be considered in individuals with LVEF in the range of 36 less than 45 percent - 49 less than 45 percent and/or RV ejection fraction less than 40 percent, despite optimal medical therapy and a period of immunosuppression (if indicated).
Heart Rhythm Society - Cardiac Sarcoid
In 2014, the HRS published a consensus statement on the diagnosis and management of arrhythias associated with cardiac sarcoiditis, including recommendations for ICD implantation in individuals with cardiac sarcoid (Table 23). The writing group concluded that although there are few data specific to ICD use in individuals with cardiac sarcoid, data from the major primary and secondary prevention ICD trials were relevant to this population and recommendations from the general device guideline documents apply to this population.
Table 23. Recommendations for ICD Implantation in Individuals with Cardiac Sarcoid
Recommendation |
COR1 |
ICD implantation is recommended in individuals with cardiac sarcoid and one or more of the following:
- Spontaneous sustained ventricular arrhythmias, including prior cardiac arrest
- LVEF less than 35 percent, despite optimal medical therapy and a period of immunosuppression (if there is active inflammation).
|
I |
ICD implantation can be useful in individuals with cardiac sarcoid, independent of ventricular function, and one or more of the following:
- An indication for permanent pacemaker implantation;
- Unexplained syncope or near-syncope, felt to be arrhythmic in etiology;
- Inducible sustained ventricular arrhythmias (>30 seconds of monomorphic VT or polymorphic VT) or clinically relevant VF.*
|
IIa |
ICD implantation may be considered in individuals with LVEF in the range of 36 percent-49 percent and/or an RV ejection fraction less than 40 percent, despite optimal medical therapy for heart failure and a period of immunosuppression (if there is active inflammation). |
IIb |
ICD implantation is not recommended in individuals with no history of syncope, normal LVEF/RV ejection fraction, no LGE on CMR, a negative EP study, and no indication for permanent pacing. However, these individuals should be closely followed for deterioration in ventricular function. ICD implantation is not recommended in individuals with one or more of the following:
- Incessant ventricular arrhythmias;
- Severe New York Heart Association class IV heart failure.
|
III |
ICD: Implantable cardioverter defibrillator; COR: Class of Recommendation; LVEF: left ventricular ejection fraction; RV: right ventricular; LGE-CMR: late gadolinium-enhanced cardiovascular magnetic resonance; LOE: Level of Evidence
1Class I: Strong; Class IIa: Moderate; Class IIb: Weak.
Pediatric and Congenital Electrophysiology Society and Heart Rhythm Society
The Pediatric and Congenital Electrophysiology Society and HRS (2014) issued an expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease. The statement made the following recommendations on the use of ICD therapy in adults with congenital heart disease (see Table 24).
Table 24. Guidelines on the Management of CHD
Recommendation |
COR |
LOE |
ICD therapy is indicated in adults with CHD who are survivors of cardiac arrest due to ventricular fibrillation or hemodynamically unstable ventricular tachycardia after evaluation to define the cause of the event and exclude any completely reversible etiology. |
I |
B |
ICD therapy is indicated in adults with CHD and spontaneous sustained ventricular tachycardia who have undergone hemodynamic and electrophysiologic evaluation. |
I |
B |
ICD therapy is indicated in adults with CHD and a systemic left ventricular ejection fraction less than 35 percent, biventricular physiology, and NYHA class II or III symptoms. |
I |
B |
ICD therapy is reasonable in selected adults with tetralogy of Fallot and multiple risk factors for sudden cardiac death, such as left ventricular systolic or diastolic dysfunction, non-sustained ventricular tachycardia, QRS duration greater than 180 ms, extensive right ventricular scarring, or inducible sustained ventricular tachycardia at electrophysiologic study. |
IIa |
B |
ICD therapy may be reasonable in adults with a single or systemic right ventricular ejection fraction less than 35 percent, particularly in the presence of additional risk factors such as complex ventricular arrhythmias, unexplained syncope, NYHA functional class II or III symptoms, QRS duration greater than 140 ms, or severe systemic AV valve regurgitation. |
IIb |
C |
ICD therapy may be considered in adults with CHD and a systemic ventricular ejection fraction less than 35 percent in the absence of overt symptoms (NYHA class I) or other known risk factors. |
Ib |
C |
ICD therapy may be considered in adults with CHD and syncope of unknown origin with hemodynamically significant sustained ventricular tachycardia or fibrillation inducible at electrophysiologic study. |
Ib |
B |
ICD therapy may be considered for non-hospitalized adults with CHD awaiting heart transplantation. |
Ib |
C |
ICD therapy may be considered for adults with syncope and moderate or complex CHD in whom there is a high clinical suspicion of ventricular arrhythmia and in whom thorough invasive and noninvasive investigations have failed to define a cause. |
Ib |
C |
Adults with CHD and advanced pulmonary vascular disease (Eisenmenger syndrome) are generally not considered candidates for ICD therapy. |
IIIa |
|
Endocardial leads are generally avoided in adults with CHD and intracardiac shunts. Risk assessment regarding hemodynamic circumstances, concomitant anticoagulation, shunt closure prior to endocardial lead placement, or alternative approaches for lead access should be individualized. |
IIIa |
|
AV: arteriovenous; CHD: coronary heart disease; COR: class of recommendation; ICD: implantable cardioverter defibrillator; LOE: level of evidence; NYHA: New York Heart Association.
a Not recommended.