Poster presented at 5th Annual Scientific Conference of the European Association of Psychosomatic Medicine

1. Severe Post Traumatic Stress Disorder As A Consequence of Pacemaker/Defibrillator Dysfunction Due to Sprint Fidelis
Lead Fracture - Case Report and Literature Review of ICD-induced Post Traumatic Stress Disorder
Dr. Frank W Meissner MD1,Dr. Cynthia Garza, JD, MD2, Dr. Henry Wiseman, MD3
1TTUHSC Paul L. Foster School of Medicine, PGY-2 Psychiatry Resident, El Paso TX
2TTUHSC Paul L. Foster School of Medicine, PGY-3 Psychiatry Resident, El Paso TX
3TTUHSC Paul L. Foster School of Medicine, Residency Program Director Psychiatry, El Paso TX
No Conflicts Of Interest
AIMS
Defibrillator therapy revolutionized the management of Heart Failure
with Reduced EF (HFrEF) by reducing the numbers of deaths due to
Sudden Cardiac Death (SCD). However this reduction in mortality can be
accompanied by a dramatic reduction in the implanted patient’s quality of
life if even a single clinically inappropriate defibrillator discharge occurs.
Two illustrative case of dramatic defibrillator dysfunction causing ICD
storm are presented. In spite of the similar course of the patient’s ICD
storm; in one case, the patient was left with a debilitating and treatment
resistant case of PTSD, while in the second case, the patient was entirely
without long term stigmata as a consequence of his ICD storm. A focused
literature review of defibrillator- induced PTSD is presented and
discussed and an expository model of adjustment to ICD storm is
presented,
Methods
Literature search of PubMed over the years 1980 - April 2017 was accomplished
with use of the following search terms: ICD, implant*, cardiover*, PTSD . The
resulting 41 papers could be organized in the following fashion: [case reports (5)],
[technical solutions to reduce symptoms - RF Abalation (1) vs SubQ ICD
Implantation (1) vs bilateral cardiac sympathetic denervation (1) vs lipophilic beta-
blocker therapy (1)], [target population incidence/prevalence rates - Pediatric (2),
Gender-based (1), Non-pediatric, Non-gender Based (6)], [screening for detection
of existing PTSD in ICD patients (2)], [analysis of psychosocial factors associated
with development of PTSD in ICD patients (5)], [therapy modalities for treatment of
ICD induced PTSD [(2 CBT (Randomized Trials), (1 EMDR), (1 ad hoc
interventions), (1 Psychotherapeutic Treatment),(1 Crisis Intervention)], [impact of
PTSD development on overall mortality of ICD patients (2)], [‘Phantom shocks’ (2)],
[Systematic Reviews (2)], [Subjective Patient Reports (2)], [Practice Guidelines (2
both in German)].
Results
In one case our patient was in his 8th decade of life, Caucasian, college-educated, well
traveled, financially well off, agnostic, who retired from a professional career as an electrical
engineer, and was on track to live out an average life span given his advanced age at the
time of ICD implantation. The contrasting case, was young, Hispanic, high-school educated,
not at all traveled, financially dependent on working 40-hr weeks, a devout Catholic, who had
an expectation of a dramatically reduced life-span.
What factors could have been in play that protected the second patient from PTSD and
failed to protect the first patient from the life altering effects of his ICD storm? The available
literature details pre-morbid risk factors which play a factor in predicting the occurrence of
PTSD in patients with an ICD storm.
The side panel entitled ‘Humanistic Model of Medicine’ makes the point that any medical
therapy, even one as highly sophisticated as ICD function and ICD - human interactions must
be interpreted in the context of the patient’s culture, the availability of technological solutions
and the patient’s individualistic concepts of spirit and spirituality as well as the more classical
bio-social-psychological factors seen in medical practice.
Perhaps no medical device or therapy emphasizes the relationships between a patient’s
concepts of mortality and his/hers acceptance or rejection of mankind intrinsic time limits/
length of liife.
Pre-implantation personality characteristics have been shown to be important in
predicting a subsequent risk of PTSD development, for example the presence of the so-
called Type D personality. However, although authors have claimed that identification of
these types of patients is important pre-implantation and they have recommend personalized
support to those at risk (the young, the depressed, and the Type D personality) no study has
demonstrated that aggressive pre-implantation interventions result in a different clinical
trajectory for patient’s with and without the markers of increased risk for development of
post-implantation PTSD.
However within the context of this case, non-psychological factors may have had a
deterministic impact on these two patients diametrical clinical trajectories.
Specifically, Patient B’s ICD storm was a direct consequence of poor device programming
and once corrected the patient held a defensible belief that he would not be further troubled
by ICD storm. The other patient had a uniquely troubling ICD storm based on lead failure
combined with AV node modification/ablation, with a high probability of persistent problems
without technical modification of the device and its leads.
Patient B as a consequence of his strong religious faith had an accepting but hopeful
orientation to his cardiac disease(s); he was in brief able to endure with heroic equanimity
the ‘slings and arrows of outrageous fortune.’ Patient A, had a psychological worldview best
characterized as cynical, unaccepting, and pessimistic.
Furthermore, his ICD storm experiences were socially isolated in ways Patient B’s never
were. Patient B had a wide circle of supportive friends and relatives. Patient A had outlived
all his close friends and his wife was herself in tenuous health.
Patient A ’s etiology for HF was due to progressive coronary artery disease, patient’s B
pathologically reduced EF less clearly defined and in fact was never definitively determined.
Conclusions
1. A multitude of dynamic interacting factors (psychological, physiological, social, spiritual, and
technological) resulted in divergent clinical outcomes in spite of near identical clinical circumstances
as determined by the technical analysis of the devices functioning. Given the enhanced
understanding of the interplay of all factors noted in our conceptual model, we are able to rationalize
the observed differences in the psychological responses to CBT of Patient A and Patient B.
2. In accounting and/or accurately predicting divergent responses to therapies aimed at reducing the
likelihood of PTSD post-implantation consideration of all relevant factors (as outlined in our
conceptual model) is necessary.
A 70 year old Caucasian male underwent dual chamber ICD
implantation three years prior to his emergency clinical evaluation by
the principle author. He had a Sprint Fidelis lead implanted in
combination with his Meditronic Dual Chamber ICD done in
combination with AV nodal ablation, making him pacemaker
dependent. According to Medtronic follow up data, the Fidelis lead
failure probabilities transition at 3 years from an exponential to linear
pattern, with a stabilized probability of lead failure of 4.5% per year.
Our patient presented to the Emergency Department since his
fractured lead resulted in false sensing of biological myotonic
electrical signals and the embedded defibrillator logic interpreted the
myotonic electrical activity as ventricular fibrillation. Consequently
defibrillator shock was delivered and his ICD subsequently paced
asynchronously at 60 beats per minute at maximum electrical output
for the 1st minute post defibrillator shock.
Once the period of asynchronous pacing was completed the
device then looked for evidence of spontaneous QRS complexes, it
then mischaracterized the self same myoclonic potentials as
spontaneous heart beats and so stopped pacing the patient inducing
severe dizziness and near syncope due to the failure of his
spontaneous atrial beats to traverse the ablated A-V node. His
syncope was then punctuated by another defibrillator discharge as the
ICD again misclassified the situation.
This terrifying cycle of complex mutually exclusive
misinterpretations of the lead failure resulted in more than one hour of
alternating near syncope followed in short order by full discharge
cardiac defibrillation.
Once in the Emergency Department, Cardiology was called and
the device placed into asynchronous pacing mode at 70 beats per
minute and the defibrillator function inactivated. However, as a
consequence of the greater than 30 defibrillation events the patient
was left with a highly resistant case of post traumatic stress disorder.
A 30 year old Hispanic male with idiopathic cardiomyopathy
and a LVEF less than 30% underwent prophylactic ICD
implantation. He continued to work as a security guard in a grade
school.
Shortly after implantation of the defibrillator, he responded to a
altercation involving two eighth graders. The implanting
Electrophysiologist for unknown reasons programmed the device
threshold for defibrillation at any heart rate > 100 bpm. While
running to respond to the altercation his heart rate understandably
and predictably exceeded 100 bpm.
He subsequently experienced the rapid delivery of
approximately 30 full energy defibrillator shocks (40 joules
delivered energy) over the course of 15 minutes.
The excess number of defibrillator shocks occurred because
the pain from the defibrillator events kept his heart rate greater
than 100 bpm.
After device reprogramming to a threshold of 180 bpm, he
experienced no further defibrillator shocks. He never complained
of or experienced any post ICD storm PTSD symptoms and
retained a cheerful and positive outlook to his life.
Case #1
Case #2
Medtronic Sprint Fidelis lead (268,000 implanted
worldwide) underwent a FDA Class I device recall 15 Oct
2007 due to excessive lead fracture rates.
Specifically, chronic conductor fractures have occurred
involving Sprint Fidelis leads: 1) the distal portion of the
lead, affecting the anode (ring electrode) and 2) near the
anchoring sleeve tie-down, predominantly affecting the
cathode (helix tip electrode), and occasionally the high
voltage conductor.
High voltage conductor fractures resulted in inability to
deliver defibrillation therapy. Anode or cathode conductor
fractures (at either location) presents clinically as increased
impedance, oversensing (as in our case), increased interval
counts, multiple inappropriate shocks, and/or loss of pacing
output.
Based on Medtronic surveillance information as of Y2007,
there were identified five patient deaths in which a Sprint
Fidelis lead fracture were a possible or likely contributing
factor. Additionally, 665 chronic fractures were seen in
returned leads. Approximately 90% of these fractures
occurred in the anode or cathode conductors, while 10%
occurred in the high voltage conductors.
Considering the ICD as a system of systems, the lead is
the weakest link, since failure of the generator (software and
battery and circuit board) occurs at much lower rate than
lead failures. The average ICD lead while a miracle of
materials engineering may incorporate a total of 30
subcomponents in its manufacture.
Given the complexity of Defibrillator lead design and
construction, failure mode analysis may result in the ICD
being considered a ‘wicked problem’ , i.e., a problem that is
difficult or impossible to solve because of incomplete,
contradictory, and changing requirements that are often
difficult to recognize. This concept may well be extended to
include the individual psychological responses to ICD
‘storm.’
.
.
In Classical Conditioning theory repeated shocks
given by the ICD may be paired with previously
neutral environmental or behavioral stimuli
resulting in a conditioned response, i.e., anxiety
or fear.
In Learned Helplessness theory, ICD patents
feel they have no control over the delivery of
painful & disruptive shocks & develop
hopelessness & depression.
In cognitive appraisal theory, ICD shocks
represent a ‘sickness scorecard’ in which
presence of shocks represent a forecast of future
health. Under this last theory, higher levels of
shocks, such as ICD storm, are interpreted as
indicators of impending catastrophe and leads to
heightened anxiety & avoidance behavior.1
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General Theories - Psychological
Adjustment to ICD Shock/‘Storm’
Cognitive Map of ICD Behavior on Psychological Function2
Psych
Social
Bio Spiritual
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Technology
A Humanistic Model of Medicine
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