Recommendations for Implantable Cardioverter-Defibrillators

Class I
(1) ICD therapy is indicated in patients who are survivors of cardiac arrest due to ventricular fibrillation or hemodynamically unstable sustained VT after evaluation to define the cause of the event and to exclude any completely reversible causes.

(2) ICD therapy is indicated in patients with structural heart disease and spontaneous sustained VT, whether hemodynamically stable or unstable.

(3) ICD therapy is indicated in patients with syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or ventricular fibrillation induced at electrophysiological study.

(4) ICD therapy is indicated in patients with LVEF less than 35% due to prior myocardial infarction who are at least 40 days post-myocardial infarction and are in NYHA functional Class II or III.

(5) ICD therapy is indicated in patients with nonischemic dilated cardiomyopathy who have an LVEF less than or equal to 35% and who are in NYHA functional Class II or III.

(6) ICD therapy is indicated in patients with LV dysfunction due to prior myocardial infarction who are at least 40 days post--myocardial infarction, have an LVEF less than 30%, and are in NYHA functional Class I.

(7) ICD therapy is indicated in patients with nonsustained VT due to prior myocardial infarction, LVEF less than 40%, and inducible ventricular fibrillation or sustained VT at electrophysiological study.

Class IIa 
(1) ICD implantation is reasonable for patients with unexplained syncope, significant LV dysfunction, and nonischemic dilated cardiomyopathy.

(2) ICD implantation is reasonable for patients with sustained VT and normal or near-normal ventricular function.

(3) ICD implantation is reasonable for patients with hypertrophic cardiomyopathy who have 1 or more major risk factor for SCD.

(4) ICD implantation is reasonable for the prevention of SCD in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy who have 1 or more risk factor for SCD.

(5) ICD implantation is reasonable to reduce SCD in patients with long-QT syndrome who are experiencing syncope and/or VT while receiving beta blockers.

(6) ICD implantation is reasonable for nonhospitalized patients awaiting transplantation.

(7) ICD implantation is reasonable for patients with Brugada syndrome who have had syncope.

(8) ICD implantation is reasonable for patients with Brugada syndrome who have documented VT that has not resulted in cardiac arrest.

(9) ICD implantation is reasonable for patients with catecholaminergic polymorphic VT who have syncope and/or documented sustained VT while receiving beta blockers.

(10) ICD implantation is reasonable for patients with cardiac sarcoidosis, giant cell myocarditis, or Chagas disease.

Class IIb
(1) ICD therapy may be considered in patients with nonischemic heart disease who have an LVEF of less than or equal to 35% and who are in NYHA functional Class I.

(2) ICD therapy may be considered for patients with long-QT syndrome and risk factors for SCD.

(3) ICD therapy may be considered in patients with syncope and advanced structural heart disease in whom thorough invasive and noninvasive investigations have failed to define a cause.

(4) ICD therapy may be considered in patients with a familial cardiomyopathy associated with sudden death.

(5) ICD therapy may be considered in patients with LV noncompaction.

Class III
(1) ICD therapy is not indicated for patients who do not have a  reasonable expectation of survival with an acceptable functional status for at least 1 year, even if they meet ICD implantation criteria specified in the Class I, IIa, and IIb recommendations above.

(2) ICD therapy is not indicated for patients with incessant VT or ventricular fibrillation.

(3) ICD therapy is not indicated in patients with significant psychiatric illnesses that may be aggravated by device implantation or that may preclude systematic follow-up.

(4) ICD therapy is not indicated for NYHA Class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or implantation of a CRT device that incorporates both pacing and defibrillation capabilities.

(5) ICD therapy is not indicated for syncope of undetermined cause in a patient without inducible ventricular tachyarrhythmias and without structural heart disease.

(6) ICD therapy is not indicated when ventricular fibrillation or VT is amenable to surgical or catheter ablation (e.g., atrial arrhythmias associated with Wolff-Parkinson-White syndrome, right ventricular or LV outflow tract VT, idiopathic VT, or fascicular VT in the absence of structural heart disease).

(7) ICD therapy is not indicated for patients with ventricular tachyarrhythmias due to a completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma).

Recommendations for Implantable Cardioverter-Defibrillators in Pediatric Patients and Patients With Congenital Heart Disease

Class I
(1) ICD implantation is indicated in the survivor of cardiac arrest after evaluation to define the cause of the event and to exclude any reversible causes.

(2) ICD implantation is indicated for patients with symptomatic sustained VT in association with congenital heart disease who have undergone hemodynamic and electrophysiological evaluation. Catheter ablation or surgical repair may offer possible alternatives in carefully selected patients.

Class IIa
(1) ICD implantation is reasonable for patients with congenital heart  disease with recurrent syncope of undetermined origin in the presence of either ventricular dysfunction or inducible ventricular arrhythmias at electrophysiological study.

Class IIb
(1) ICD implantation may be considered for patients with recurrent syncope associated with complex congenital heart disease and advanced systemic ventricular dysfunction when thorough invasive and noninvasive investigations have failed to define a cause.

Class III  
(1) All Class III recommendations found in full-text guidelines, "Indications for Implantable Cardioverter-Defibrillator Therapy," apply to pediatric patients or patients with congenital heart disease, and ICD implantation is not indicated in these patient populations.



JACC. 2008; 51; 2085-2105.