International Circulation:  As a cardiac electrophysiologist， could you give us some advice on managing difficult ICD issues in the clinic?  Also， how do we choose ICD patients in the clinic?

    《国际循环》：您作为知名的心脏电生理学家，能否谈谈临床上如何选择合适的ICD患者？对于临床上复杂ICD情况的处理您有何建议？

    Bruce Lindsay:  There are two broad groups of patients who are referred for ICDs， those who are referred for primary prevention， which means they have never had a cardiac arrest but have risk factors for cardiac arrest.  There are several trials now that demonstrate these patients have improved survival with an ICD.  There are some qualifications on that， namely if they have many co-morbidities then their benefit is reduced.  If they are advanced in age they still are at risk of cardiac arrest but there are so many other things people die of their benefit from a defibrillator is questionable.  Those are judgements where you cannot just pick an age and use it as a cutoff but you have to take that into consideration.  The other group of patients was those who have already survived a cardiac arrest and in cases where there is not some transient problem that caused it， for example in this discussion today there was a case presented of a patient that had an acute myocardial infarction， they recovered well but had a cardiac arrest later.  Their overall heart function was good and the real answer was that the person needed their coronary arteries opened up and didn’t really need a defibrillator.  But most of the patients we see are patients who have had a cardiac arrest not associated with an acute myocardial infarction and have sever ventricular dysfunction.  The recurrence rates are high so they would need a defibrillator for that purpose.

   Bruce Lindsay教授：共有两大类患者需要植入ICD。一类是那些需要一级预防的患者，意思是他们从来没有发生过心脏骤停，但具有心脏骤停的危险因素。目前已有一些试验表明这样的患者植入ICD后能够改善生存，对此仍有一些条件限定，指的是如果他们患有其他很多伴发疾病，那么其获益会减少；如果年龄较大，他们仍会有发生心脏骤停的危险，但对这部分人来说会有多种致死的原因，所以他们能从除颤器上获益多少很值得质疑。你无法任意选出一个年龄作为断点，以此来决定是否植入ICD，但在选择时应考虑到这点（年龄）。另一类患者是那些已发生过心脏骤停的幸存者，而且不是一过性因素导致的骤停，例如急性心肌梗死后的患者，尽管恢复良好，但其后发生心脏骤停。这类患者总的心功能很好，真正的答案是其需要开通冠状动脉，而非植入除颤器。然而，我们看到的大部分发生心脏骤停的患者与急性心肌梗死无关，并且有严重左室功能障碍，由于复发率较高，为此他们需要除颤器植入。