Messy. That is how a bioengineer once described the environment within the human body to me. Many implantable medical devices are an achievement in ingenuity that overcomes “messiness” like biocompatibility, blood and torsion. But few are indestructible or 100 percent fail-safe.

In this issue, we explore management of patients with implantable cardioverter-defibrillators (ICDs).  As physicians in the article and elsewhere emphasize, these are life-saving technologies and allies in the care of patients with arrhythmia disorders. The devices’ typical longevity far outpaces the laptop on which I write, with reliability that probably surpasses my well-engineered car.

Many cardiology specialties incorporate technologies into practice, whether it is a stent, a catheter, a valve system, a debulking device and other tools that temporarily or permanently work in the “messy” environment inside a patient. Technologies wear out, though, and every device has its weakest link.

According to Anne M. Gillis, MD, president of the Heart Rhythm Society, the weakest link in this context is the lead. Electrophysiologists face two intertwined issues when a lead fails or is recalled: dealing with the lead itself and dealing with the patient in whom the lead is implanted.
Neither is easy and both require a careful assessment of each individual case. There are lessons learned and some evidence to guide decision-making for choosing the initial device and maintaining or replacing components.

I suspect most cardiologists, no matter what stripe, can appreciate the situation facing electrophysiologists as they counsel patients about a failed or replacement implantable device or component.  

Devices are not the sole resource for a patient in need. It is the doctor—the electrophysiologist, the interventional cardiologist, the surgeon—who manages the patient and ultimately provides the life-saving care.