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In addition to its beneficial effect on patient survival, the implanted cardioverter defibrillator (ICD) changes a patient's life physically, socially, and psychologically. For improved patient management, it is important to understand the quality-of-life changes that accompany this mode of treatment. To this end, 119 patients were surveyed retrospectively and interviewed concurrently regarding their emotional, physical, and behavioral responses to ICD shocks and to the device itself. Most (55%) correctly estimated the total number of shocks they had received within a 10% margin. They found the shocks severe, 79% assigning a score between 3 and 5 on a scale of 1-5. Common descriptions of the shock sensation were a blow to the body or a spasm causing the entire body to jump. Most patients tolerated the shocks as lifesaving, but 23% dreaded shocks and 5% even said they would rather be without the ICD and take their chances. After a shock, 50% of patients called their physician and 42% continued their daily routine. Thirty percent went to a hospital emergency room or called a rescue service. Sixty-five percent had no preshock prodromes. Fifty-four percent were interested in the programmable option of a warning signal prior to a shock, while 31% preferred no warning. Of the 74% who were advised not to drive after implantation, 29% drove anyway. Five patients were shocked while driving with no resulting accidents. We conclude that most patients find ICD shocks moderately uncomfortable, but they tolerate them because of the lifesaving protection provided by the device.

An examination of 632 consecutive pacemaker implantations performed at a single institution by 29 implanting physicians over a 5 year period was made to determine which factors affected the 37 perioperative complications experienced. The introducer method of vein access contributed significantly to the complication rate, which was also related to the number of physician implanters on the staff and the makeup of the implantation teams. Of greatest interest was the substantially large incidence of complications experienced by implanters who performed fewer than 12 implantations per year, and particularly the incidence of lead-related complications.

Nine hundred fifty patients who received three modes of primary pacemaker systems (581 dual-chamber universal [DDD], 84 atrioventricular-sequential ventricular-inhibited [DVI] and 285 ventricular-inhibited [VVI]) over 12 years were studied retrospectively to determine the effect of pacing mode on patient longevity and the subsequent development of chronic atrial fibrillation or flutter. All patients were followed up continuously for 7 to 8 years. Patients were classified according to indication for permanent pacing (sick sinus syndrome or other indication), age at pacemaker implantation (less than or equal to 70 or greater than 70 years) and history of atrial tachyarrhythmia. Fourteen percent of patients developed atrial fibrillation at some time during the study period. Of those, 4% had a DDD pacemaker, 8% had a DVI pacemaker and 19% had a VVI pacemaker. At 7 years, atrial fibrillation was significantly more frequent in the VVI group than in the DDD and DVI groups. In patients with sick sinus syndrome, the incidence rate was even higher in the VVI group but approximately the same in the DDD and DVI groups. Patients in the VVI and DVI groups who had had previous atrial tachyarrhythmia had a significantly higher incidence of atrial fibrillation at 7 years than did those in the DDD group. During the entire period there were 130 deaths in the study group, including 22% of patients with a DDD pacemaker, 38% of those with a DVI pacemaker and 50% of those with a VVI pacemaker. Patient survival at 7 years was lower in the VVI group than in the DDD or DVI groups.(ABSTRACT TRUNCATED AT 250 WORDS)

A survey of implanters of permanent cardiac pacemakers and ICDs in the United States during 1997 was conducted to identify present and changing patterns in indications for pacing, implantation techniques, pacing-mode selection, follow-up, and opinions regarding pacing and ICD related issues. This report is an update from 1993 of surveys performed every 4 years for the International Cardiac Pacing and Electrophysiology Society (ICPES). Questionnaires were sent to implanting physicians who were members of the North American Society of Pacing and Electrophysiology (NASPE), and who might, therefore, be expected to be more conversant than others with the state of the art. Four major manufacturers also provided estimates of the numbers of pacemakers and ICDs implanted in the United States from 1994 through 1997. In 1997, approximately 182,000 new rhythm management devices, including 153,000 primary pacing systems and 29,000 ICDs, were implanted, an increase of 24% for pacemakers and 90% for ICDs since 1994. In 1997, pacemaker implantations were performed by about 8,600 physicians working in 3,300 hospitals and 1,000 independent "surgi-centers." From 1994 to 1997, sales in the United States of dual chamber pacemakers rose from 58% to 69% of the total, and adaptive rate systems from 74% to 90%. ICD sales increased by about 29% per year from 18,700 to 35,000 units. This study disclosed significant differences among implanter subcategories and between present and earlier practices, and it provided useful insights into trends in pacemaker and defibrillator practice. Future surveys would be facilitated if a standardized implant registry like that used in Europe were established in the United States.

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In light of evolving pacemaker technology and increasing interest in multisite pacing, the Committee on the Development of Position Statements (CDPS) of the North American Society of Pacing and Electrophysiology (NASPE) created an ad hoc Pacemaker Mode Code Task Force in April 2001 under the chairmanship of David L. Hayes, MD, for the purpose of bringing the NASPE/British Pacing and Electrophysiology Group (BPEG) Generic Pacemaker Code (NBG Code) up to date. The task force, whose members are the authors of this article, designed a revised NBG Code in which three major issues were taken into account. First, it was recognized that all modern pacemakerpulse generators are capable of extensive bidirectional communication with an external programming device, making them "communicating" pulse generators as defined by the current (1987) NBG Code. Second, it was decided that a means of providing basic information regarding the location of multisite pacing would be a useful ingredient of the NBG Code. Third, in view of the extensive antibradycardia pacing capabilities common in modern implantable cardioverter defibrillators and the availability of the NASPE/BPEG Defibrillator Code (NBD Code), it was considered unnecessary for the NBG Code to address the presence or absence of antitachycardia features. The resulting updated version of the NBG Code as described herein was endorsed by the BPEG on September 20, 2001 and adopted by the NASPE Board of Trustees on October 18, 2001. The structure of the revised NBG Code differs from that of the previous version in two respects alone: Position IV specifies only the presence or absence of rate modulation, and Position V specifies only the location or absence of multisite pacing (i.e., biatrial or biventricular pacing with at least two stimulation sites in each case) more than one stimulation site in any single cardiac chamber, or any combination of these. The revised NBG Code is deliberately configured to avoid confusion with earlier mode codes, and it is the authors' hope that it will serve as an enhanced resource for communication among those engaged in every phase of the multidisciplinary practice of cardiac rhythm management.