title: Implantable cardioverter-defibrillator. Evaluation of clinical neurologic outcome and electroencephalographic changes during implantation.
abstract: During placement of implantable cardioverter-defibrillators, ventricular arrhythmias are induced to test the function of the devices. Although cerebral hypoperfusion and ischemic electroencephalographic changes occur in patients while implantable cardioverter-defibrillators are being tested, no investigation has assessed neurologic outcome in these patients. Nine patients having either implantation or change of an implantable cardioverter-defibrillator underwent neurologic examination and neuropsychometric tests before and after the operation. After induction of general anesthesia and insertion of implantable cardioverter-defibrillator leads (when needed), ventricular fibrillation, ventricular flutter, or ventricular tachycardia, was induced by means of programmed electrical stimulation. Implantable cardioverter-defibrillator testing continued until satisfactory lead placement was confirmed. The intraoperative electroencephalographic recording was analyzed for evidence of ischemic change. In all, an electroencephalogram was recorded during 50 periods of circulatory arrest. Mean duration of the arrest periods was 13.6 seconds. By means of conventional visual inspection of the raw electroencephalogram, high-amplitude rhythmic delta or theta, voltage attenuation, or loss of fast frequency activity was observed in 30 of the arrests. By means of an automated technique of electroencephalographic interpretation based on power spectral analysis, electroencephalographic changes were correctly identified in 26 of the arrests. The incidence of these electroencephalographic changes was dependent on the arrest duration. The mean interval from arrest onset to electroencephalographic change was 7.5 seconds (standard deviation +/- 1.8 seconds). In patients with electroencephalographic changes during multiple arrests, no downward trend in this interval was detected in later arrests and no evidence of persistent ischemic change was observed in electroencephalograms recorded after the conclusion of implantable cardioverter-defibrillator testing. Postoperative neurologic and neuropsychometric testing was completed in eight patients, none of whom exhibited a new neurologic deficit, exacerbation of a preexisting neurologic condition, or significant deterioration in neuropsychometric performance. We conclude that the brief arrest of cerebral circulation induced during insertion of an implantable cardioverter-defibrillator is not associated with permanent neurologic injury.
authors.affiliation: Department of Anesthesiology, Columbia-Presbyterian Medical Center, New York, N.Y.
authors.forename: D C
authors.initials: DC
authors.lastname: Adams
authors.forename: E J
authors.initials: EJ
authors.lastname: Heyer
authors.forename: R G
authors.initials: RG
authors.lastname: Emerson
authors.forename: H M
authors.initials: HM
authors.lastname: Spotnitz
authors.forename: E
authors.initials: E
authors.lastname: Delphin
authors.forename: C
authors.initials: C
authors.lastname: Turner
authors.forename: M F
authors.initials: MF
authors.lastname: Berman
mesh_terms: D000328:Adult; D000368:Aged; D002560:Cerebrovascular Circulation; D017147:Defibrillators, Implantable / Q000009:adverse effects*; D004569:Electroencephalography; D005260:Female; D006324:Heart Arrest, Induced / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D009460:Neurologic Examination; D012815:Signal Processing, Computer-Assisted; D017180:Tachycardia, Ventricular / Q000628:therapy