13
Management strategies Key points
• Management options considered
included primary prevention ICD
implantation.
• Continued cardiovascular medical
therapy was recommended regardless of
arrhythmia management strateg y.
• Values elicited in discussion included
current quality of life, actual anticipated
benefit of ICD implantation, and
expected surgical risks and recovery.
• Deferral of ICD implantation was
ultimately recommended and preferred
due to unfavorable risk–benefit of device
insertion.
• Limited quality of life was raised as the
main driver of the final management
decision.
• Lack of representation of patient
substrate in previously published trials
was noted.
• Likely nonarrhythmic mechanism
of death limits the benefit of ICD
implantation.
• Technical/procedural aspects of
ICD implantation—kyphoscoliosis,
sedation-related risks including
respiratory infection, and possible
prolonged recovery—were cited as
additional determinants to defer ICD
implantation.
• Management options discussed included
continued medical therapy, implantation
of CRT-P, or implantation of CRT-D.
• Values elicited in discussion included
options to improve quality of life
through treatment of heart failure
symptoms and desire for protection
against VAs.
• CRT-D implantation was successfully
performed to address the above issues.
• CRT-D was indicated based on
traditional guideline-based criteria.
• Risk of sudden death due to VT or
VF and ventricular dyssynchrony
due to LBBB was addressed by
CRT-D implantation. Relatively mild
neuromuscular impairment, patient
preference, and young age all lend
themselves well to CRT-D (as opposed
to CRT-P) implantation.
• Following lengthy discussion, CRT-D
was deemed compatible with patient's
goals of care by all stakeholders.
