[Observations on the implantable automatic defibrillator].

Thanks to the fantastic job made by Michel Mirowski, the automatic implantable cardioverter-defibrillator is now an effective treatment for patients with malignant, life-threatening arrhythmias. And in the last ten years, many technical improvements have been made (weight, size, reconfirmation, Holter function, endocardial implantation). But if sudden death has been significantly reduced in implanted patients, the long term global cardiac mortality remains very high in these people. This explains why the indications to implant such an expensive device are difficult to define. Apart from special cases in which the indications (or contraindications) are obvious, many factors must be taken into consideration, including the presentation of the arrhythmia, the results of the programmed ventricular stimulation, and the underlying cardiac disease. The European society of Cardiology has published guidelines for the use of A.I.C.D., but from our own experience in Hospital Lariboisière (Paris, France) we have learned that each case must be discussed; and, if it is possible to suggest some therapeutic orientations, it is yet illusory to believe that decisional algorithms will solve all the problems.