Implantable-Cardioverter Defibrillator (ICD)
In some patients considered to be at high arrhythmic risk, an automatic defibrillator or ICD is proposed for implantation. The ICD is a relatively small, technologically advanced device, which can be implanted under the skin, and has the ability to recognize life-threatening arrhythmias and treat them, either by cardiac stimulation (anti-tachycardia pacing - ATP) or by electric shock, with restoration of the normal rhythm.
The device is usually implanted under local anesthesia, under the skin, under the left collarbone. Wires (catheters) are connected to the main device and positioned through the veins inside the right heart, where they have the function of detecting the cardiac electrical activity, stimulating the heart and possibly giving an electric shock if necessary. Usually the stay in hospital is one night. The ICD should be checked periodically to ensure that it works properly and is able to record any arrhythmias (sometimes the device can be controlled remotely). Normally the ICD battery should be changed every 5-6 years (depending on how much is used). There are also completely subcutaneous ICDs, with the device usually placed in the left hemithorax at the bottom and the catheter near the sternum without going inside the heart; these devices do not have the ability to stimulate in the heart, but only to give a shock in case of severe arrhythmias.
The ICD may be associated with certain complications and the physician, in proposing the ICD, also takes into account the risk of such complications; for example, the device may intervene with a shock in cases where the heart rate is very high (although not a life-threatening arrhythmia), or it may get infected, or there may be problems with catheters. There are also some complications related to the implant so it is advisable to ask your Doctor for explanations.
Pacemakers
Pacemakers are devices that are very similar to ICDs, but smaller in size, and are implanted in a similar way to ICDs. They have the ability to detect the electrical activity of the heart and stimulate it, but not to intervene in the case of severe arrhythmias. They are usually recommended in cases where the conduction of the heart impulse is very slow. In some cases, the implantation of a pacemaker is recommended in patients with symptomatic left ventricular outflow tract obstruction despite maximum pharmacological therapy, because stimulating the heart de-synchronizes it (reducing outflow obstruction) and because with a pacemaker it is possible to give greater doses of beta-blockers and calcium antagonists without risking to reduce too much the heart rate. The effectiveness of the pacemaker in improving symptoms in patients with obstruction is less than other procedures, such as surgery (myectomy), but can be considered when other invasive procedures are not recommended.
Alcohol septal ablation
Alcohol septal ablation is an invasive procedure that can be used in some patients with symptomatic left ventricular outflow tract obstruction despite maximum drug therapy. It is performed under local anesthesia; with catheters inserted from a peripheral artery (from the groin or arm) they arrive inside the coronary arteries, the arteries that carry the blood to the heart, and inject alcohol (usually 1-2 ml) into a small artery that carries the blood in the thickened part of the heart (the septum); this causes a heart attack in that area, which over time shrinks, thus favoring the passage of blood to the left ventricular outflow tract. The method has been introduced more recently than surgery, does not require total anesthesia, but is very dependent to the anatomy of the coronary arteries (which is variable) for success. It is also associated with a higher incidence of pacemaker implantation. In the current guidelines, surgery (myectomy) remains the recommended invasive procedure in the first instance ("gold standard"), while alcohol septal ablation can be considered if the surgery is contra-indicated or according to the patient's preferences.
Heart Transplant
Heart transplant is a surgical operation that replaces a very sick heart with a healthy heart from a donor who died. The operation is performed only in some specialized Centers (including our hospital). It is proposed to patients who believe that other therapies are no longer sufficient to treat the disease. In hypertrophic cardiomyopathy, heart transplant is indicated only in certain forms of severe cardiac dysfunction. This is the case in some patients with refractory heart failure, where the contractile function of the heart is progressively severely reduced (hypertrophic cardiomyopathy with dilated-hypokinetic evolution), or when the heart is extremely rigid (hypertrophic cardiomyopathy of a restrictive type) such as to cause accumulation of fluid in the body, and in particular in the lungs, despite an important therapy with diuretics.
