Recently several randomized trials have demonstrated the excellent role of the implantable cardioverter-defibrillator (ICD) in improving the mortality rate in patients with a high risk of sudden cardiac death regardless of its purpose or the underlying heart disease. However, because such large clinical trials have only been carried out in Western countries, those results may not be fully applicable to Japanese or other Asian patient populations.
According to a Japanese study, the total mortality in the patients was approximately 20% during 5 years of follow up, which was comparable to, or slightly better than that in the MADIT-II patients with ICDs. In such a patient population with an excellent prognosis, the MADIT-II criteria can not easily be applied. Therefore, we should strengthen the criteria, i.e. from an EF≤35% to 25% or adopt the usage of additional examinations (e.g. signal averaging ECG, micro-volt T wave alternance or EPS).

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INTRODUCTION: As indication for implantable cardioverter defibrillators (ICDs) has expanded, prophylactic implantations have increased. It has been well understood that some ICD recipients have psychological problems. Some of those problems are recognized as maladjustment syndromes.
METHODS: We studied 35 ICD recipients regularly followed at outpatient department of Kyushu University Hospital in order to clarify the psychological distress and the quality of their daily lives (QOL). By using questionnaire instruments (SF-8, Beck Depression Inventory, Impact of Event Scale Revised, and State-Trait Anxiety Inventory), we studied their psychological status.
RESULTS: Depression, anxiety, and post-stress syndromes existed in 45.5% of the ICD recipients and their QOL was compromised. Female ICD recipients reacted to the stress related to ICD implantation differently from male recipients. Elder ICD recipients had a different way of adjustment from the younger recipients. Various ICD related psychological problems were noted in terms of magnitude and diversity.
CONCLUSION: To support ICD recipients both physically and mentally, not only the cardiologists but also specialists from other fields such as psychologists and nurse specialists are needed. Ancillary care must be provided through the support team. Cardiologists who determine whether ICD implantation is required must keep in mind potential psychological sequelae.

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Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is an uncommon type of cardiomyopathy with fibrofatty tissue replacement. Magnetic resonance imaging (MRI) is a sophisticated method for the diagnosis of ARVD/C. Electroanatomical mapping has been reported to rapidly provide accurate data that facilitates catheter ablation of VT in ARVD/C. In addition, multislice CT (MSCT) is fast, easy to perform, and has a more reliable image quality. MSCT is considered a clinically valuable, noninvasive tool for assessment of myocardial pathology. However, the relationship between MSCT, cardiac MRI and electroanatomical mapping imaging in patients with ARVD/C is unknown. We report two cases diagnosed as ARVD/C by endomyocardial biopsy. In one case MRI imaging revealed marked wall thinning and a decrease in wall motion in the inferior wall and basal interventricular septum of the left ventricle. In another case an electroanatomical map of the RV was created. Endocardial voltage mapping in sinus rhythm revealed a large low voltage area and a focal pattern of activation was documented in activation mapping during VT. In both cases MSCT demonstrated low density areas indicative of focal fatty infiltration and morphological and functional abnormalities which were simultaneously assessed with MRI or electroanatomical mapping.

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A 65-year-old man developed syncope following palpitation during an outdoor activity in the daytime. The 12-lead electrocardiogram (ECG) showed Brugada-type ST segment elevation. Holter ECG monitoring documented an episode of regular wide QRS tachycardia. During an electrophysiologic study (EPS), ventricular tachyarrhythmia was not induced. However, a common (slow-fast) type atrioventricular nodal reentrant tachycardia with aberrant ventricular conduction, which was the same configuration as the wide QRS tachycardia recorded by the Holter ECG monitoring, was induced. The patient has been asymptomatic for the 12-month follow-up after the successful slow pathway ablation. This patient reminds us of the importance of EPS in the differential diagnosis of a wide QRS tachycardia.

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We experienced a case of pacing failure with transient rise of the pacing threshold more than one year after implantation. Neither the generator nor lead system was found to be defective. During the antibiotics therapy to treat cholecystitis, which was found on admission, pacing failure was improved. The clinical course suggested that the infection was related to the improvement, although accurate mechanisms were unknown.

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This case report describes a patient with a biventricular pacing system in whom right ventricular anodal capture had no hemodynamic benefit. While controlling the ventricular output, three morphologies of the paced QRS complex were obtained: right ventricular stimulation, biventricular stimulation, and biventricular pacing with additional stimulation from the anodal electrode in the right ventricle. While the QRS duration was 5 ms longer, the left ventricular systolic pressure and dP/dt_max during biventricular pacing without anodal capture of the right ventricle were greater than that during biventricular pacing with anodal capture. To avoid useless high output settings, the hemodynamic and clinical data should be compared with and without right ventricular anodal capture in each individual patient.

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In patients with cardiac sarcoidosis, ventricular tachycardia (VT) is observed in some cases. However, effective therapies for the VT are still unknown.
Case: A 50-year old female with cardiac sarcoidosis underwent DDD pacemaker implantation for a high degree atrioventricular block with symptoms of faintness and shortness of breath. One month after the surgery, she was admitted for frequent episodes of non-sustained VT. In the electrophysiologic study (EPS), sustained monomorphic VT and ventricular fibrillation were induced; therefore pacemaker was replaced with implantable cardioverter-defibrillator (ICD). Amiodarone was started orally but it couldn’t suppress frequent VT episodes, and frequent ICD shocks were delivered. When the oral steroid therapy was initiated for the cardiac sarcoidosis, it not only suppressed the frequent VT but also improved the atrioventricular nodal dysfunction.
In conclusion, steroid therapy might be an option to consider in cardiac sarcoidosis with refractory VT.

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