Devices A substantial body of evidence supports the use of implantable cardioverter-defibrillators (ICDs) to prevent sudden cardiac Kulik et al Secondary Prevention After CABG 941 death among patients with reduced EF.255 257 However, ICD therapy at the time of surgical revascularization has failed to improve patient outcomes. In the CABG Patch Trial,258 routine ICD insertion did not improve survival among patients with an EF <35% if an ICD was implanted prophylactically at the time of elective CABG. Notably, 71% of deaths in this trial were not arrhythmogenic, hence the lack of mortality benefit,258 and empirical ICD therapy was even associated with diminished quality of life 6 months after CABG.259 As per previous AHA/ ACCF guidelines, patients with reduced EF should be treated with optimal neurohormonal therapies after surgical revascu- If the EF remains severely reduced (<35%) in a noninvasive assessment of LV function 3 months after surgery, then consideration should be given to implantation of an ICD for primary prevention at that time.260 In patients with reduced LV function who undergo CABG after resuscitation from cardiac arrest, the decision for ICD therapy early after CABG should be individualized.260 Among these patients, CABG can suppress malignant arrhythmias and reduce subsequent episodes of cardiac arrest,261,262 espe- cially if the arrhythmias are related to ischemia.263 On the other hand, CABG may not mitigate all the conditions pre- disposing to ventricular arrhythmias, as in the case of patients with sustained monomorphic ventricular tachycardia and prior MI, and concomitant ICD insertion after CABG may be war- ranted in such patients. Progression of LV dysfunction to clinical heart failure is frequently accompanied by impaired electromechanical coupling, which may further diminish effective ventricular contractility. 