Clinical Experience with a New Detection Algorithm for Differentiation of Supraventricular from Ventricular Tachycardia in a Dual-Chamber Defibrillator

Inappropriate therapies in modern implantable cardioverter-defibrillators: A propensity score-matched comparison between single- and dual-chamber discriminators in single-chamber devices THe sINGle lead Study (THINGS Study)

BACKGROUND

In patients with implantable cardioverter-defibrillators (ICDs), inappropriate therapies (ITs) are often caused by supraventricular tachyarrhythmias (SVTs).

OBJECTIVE

We aimed to estimate the incidence of IT in modern single-lead ICDs.

METHODS

The THINGS study enrolled patients with single-lead ICDs with 2 SVT discrimination modalities: dual chamber (DC) with an atrial floating dipole or single chamber (SC) with morphology criterion. All devices were programmed with 2-zone therapy: ventricular tachycardia (VT) zone from 170 beats/min with ≥15 seconds (≥36 beats) detection time and SVT discriminators; and ventricular fibrillation (VF) zone from 214 beats/min with ≥7 seconds (≥24 beats) detection time. The primary end point was the first occurrence of IT, adjudicated by an independent board.

RESULTS

A total of 526 patients (median age, 66 years; 83% male), 183 (34.8%) with DC and 343 (65.2%) with SC discrimination, were observed for a median of 2.2 years. The incidence rate of IT was 4.2% (95% confidence interval [CI], 2.7%-6.4%) at 1 year and 7.1% (95% CI, 5.0%-9.9%) at 2 years. Younger age (adjusted hazard ratio, 0.97; 95% CI, 0.95-0.99; P = .013) and history of atrial fibrillation (adjusted hazard ratio, 2.67; 95% CI, 1.30-5.46; P = .007) were significantly associated with increased IT risk. In a propensity score-matched comparison, DC discrimination showed a trend toward reduced IT rates compared with SC discrimination in the VT zone (1-year incidence, 1.8% vs 3.5%; P = .105).

CONCLUSION

High-rate VF cutoff and prolonged detection time programming resulted in a low IT rate in single-lead ICD patients with modern SVT discriminators. A trend favoring the DC system was observed in the VT zone.

[History of the implantable cardioverter-defibrillator in Germany]

The implantable cardioverter-defibrillator (ICD) was a breakthrough in the prevention of sudden cardiac death. After years of technical development in the USA, Michel Mirowski succeeded in proving reliable automatic defibrillation of ventricular tachyarrhythmias through initial human implantations in 1980, despite many obstacles. Nearly 4 years later, the first patients received ICDs at multiple centers in Germany. Subsequently, outside the USA, Germany became the country with highest implantation rates. The absolute number of implantations remained small as long as implantations required epicardial defibrillation electrodes and therefore thoracotomy by cardiac surgeons. Pacemaker-like implantation using a transvenous defibrillation electrode with a pectoral ICD became feasible in the early 1990s pushing implantation rates to the next level. Technical advancements were accompanied by clinical research in Germany, and often, the first-in-human studies were conducted in Germany. In 1991, the first guidelines for indications were established in the USA and Germany. Several randomized studies on indications were published between 1996 and 2009, mostly led by American teams with German participation, but also under German leadership (CASH, CAT, DINAMIT, IRIS). The DANISH study in 2016 questioned the results of these long-standing studies. Instead of providing ICDs to patients using a broad indication, future efforts aim to identify patients who, despite optimal medical therapy, cardiac resynchronization therapy (CRT), and/or catheter ablation, need protection against sudden cardiac death. Risk scores incorporating myocardial scars in magnetic resonance imaging (MRI) and genetic information are expected to contribute to more individualized and effective indications.

Ventricular arrhythmia detection for contemporary Biotronik and Abbott implantable cardioverter defibrillators with markedly prolonged detection in Biotronik devices

BACKGROUND

Implantable cardioverter defibrillators (ICDs) are typically programed with both ventricular tachycardia (VT) and ventricular fibrillation (VF) treatment zones. Biotronik and Abbott ICDs do not increment the VT counter when the tachycardia accelerates to the VF zone, which could result in a prolonged delay in tachycardia detection.

METHODS

Patients with Biotronik and Abbott ICDs receiving care at Veterans Affairs facilities in Northern California were identified. Patient information and device tracings for patients with any ICD therapies were examined to assess for possible delayed tachycardia detection.

RESULTS

Among 52 patients with Biotronik ICDs, 8 (15%) experienced appropriate ICD therapy over a median follow-up of 29 months. Among 68 patients with Abbott ICDs, 26 (38%) experienced appropriate ICD therapy over a median follow-up of 83 months. Three of the patients with Biotronik ICDs who received appropriate therapy experienced a delay in VT/VF detection due to the tachycardia rate oscillating between the VT and VF treatment zones (longest 31.2 s on detection), compared with four of the patients with Abbott ICDs (longest 4.1 s on the detection and 8 s on redetect). One of the patients with a Biotronik ICD experienced recurrent syncope associated with delayed detection and another died on the day of delayed detection. One of the patients with an Abbott ICD experienced syncope.

CONCLUSIONS

Because contemporary Biotronik and Abbott ICDs freeze the VT counters when tachycardia is in the VF zone, ICD therapies can be markedly delayed when the tachycardia oscillates between the VT and VF zone.

The utilization of atrial sensing dipole in single lead implantable cardioverter defibrillator for detection of new-onset atrial high-rate episodes or subclinical atrial fibrillation: A systematic review and meta-analysis

This meta-analysis aims to evaluate the performance of atrial sensing dipole in single lead implantable cardioverter defibrillator (VDD-ICD) recipients in particular diagnosing new-onset atrial high-rate episodes (AHREs) defined as rate threshold of 200 beats per minute, or subclinical atrial fibrillation (SCAF) defined as device-detected AF without symptoms. We comprehensively searched PubMed, Embase, and ClinicalTrials.gov. Studies comparing contemporary single- and dual-chamber ICD (VVI-/DDD-ICD) versus VDD-ICD were included. Restricted maximum likelihood method for random effect model and Mantel-Haenszel method for fixed effect model were used to estimate the effect size of new-onset AHREs, or SCAF detection in each group. Three prospective studies were identified and total of 991 participants were included. There were 330 (33.3%) in VDD-ICD and 661 (66.7%) in VVI-/DDD-ICD. Most (78%) participants were men. Median follow-up was from 365 days to 847 days. VDD-ICD has a higher likelihood of detecting AHREs or SCAF as compared to VVI-/DDD-ICD [(OR random effect : 2.6; 95% CI: 1.2, 5.8; p = .018); I-squared = 67.8%, p = .019]. This difference was more apparently seen in the comparison between VDD-ICD and VVI-ICD [(OR random effect: 3.8; 95% CI: 2.1, 6.6, p < .001), I-squared = 0.0%, p = .518]. The result is same as fixed effect. Rate of AHREs detection observed in VDD-ICD was not statistically different when compared to the only group with DDD-ICD from SENSE trial. In conclusion, this meta-analysis reveals that the use of floating atrial sensing dipole in VDD-ICD increases the detection of new-onset AHREs or SCAF when compared to VVI-ICD, with similar atrial sensing performance to DDD-ICD.

Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part 2: ventricular arrhythmias, channelopathies, and implantable defibrillators

This paper belongs to a series of recommendation documents for participation in leisure-time physical activity and competitive sports by the European Association of Preventive Cardiology (EAPC). Together with an accompanying paper on supraventricular arrhythmias, this second text deals specifically with those participants in whom some form of ventricular rhythm disorder is documented, who are diagnosed with an inherited arrhythmogenic condition, and/or who have an implanted pacemaker or cardioverter defibrillator. A companion text on recommendations in athletes with supraventricular arrhythmias is published in the European Journal of Preventive Cardiology. Since both texts focus on arrhythmias, they are the result of a collaboration between EAPC and the European Heart Rhythm Association (EHRA). The documents provide a framework for evaluating eligibility to perform sports, based on three elements, i.e. the prognostic risk of the arrhythmias when performing sports, the symptomatic impact of arrhythmias while performing sports, and the potential progression of underlying structural problems as the result of sports.

Novel two-lead cardiac resynchronization therapy system provides equivalent CRT responses with less complications than a conventional three-lead system: Results from the QP ExCELs lead registry

Introduction

The novel two‐lead cardiac resynchronization therapy (CRT)‐DX system utilizes a floating atrial dipole on the implantable cardioverter‐defibrillator lead, and when implanted with a left ventricular (LV) lead, offers a two‐lead CRT system with AV synchrony. This study compared complication rates and CRT response among subjects implanted with a two‐lead CRT‐DX system to those subjects implanted with a standard three‐lead CRT‐D system.

Methods and Results

A total of 240 subjects from the Sentus QP—Extended CRT Evaluation with Quadripolar Left Ventricular Leads postapproval study were selected to identify 120 matched pairs based on similar demographic characteristics using a Greedy algorithm. The complication‐free rate was evaluated as the primary endpoint. All‐cause mortality, heart failure hospitalizations, device diagnostic data, New York Heart Association (NYHA) class improvement, and defibrillator therapy were evaluated from clinical data, in‐office interrogations, and remote monitoring throughout the follow‐up period. Complication‐free survival favored the CRT‐DX group with 92.5% without a major complication compared to 85.0% in the CRT‐D cohort (P = .0495; 95% confidence interval: 0.1%‐14.9%) over a mean follow‐up of 1.3 and 1.4 years, respectively. Incidence of all‐cause mortality, heart failure hospitalizations, NYHA changes at 6 months postimplant, and percent of LV pacing during CRT therapy were similar in both device cohorts. Inappropriate shocks were more frequent in the CRT‐D cohort with 5.8% of subjects receiving an inappropriate shock vs 0.8% in the CRT‐DX cohort.

Conclusion

The results of this subanalysis demonstrate that the CRT‐DX system can provide similar CRT responses and significantly fewer complications when compared to a similar cohort with a conventional three‐lead CRT‐D system.

The efficacy of the LinoxSmart DX ICD lead from a single center experience

Purpose

The Biotronik Linox^Smart DX implanted cardioverter defibrillator (ICD) lead is a novel VDD lead with the advantage of integrated atrial sensing dipole combined with a special augmentation and filtering mechanisms. We sought to determine the efficacy of the Biotronik Linox^Smart DX ICD lead.

Methods

Non-randomized consecutive patients implanted with Biotronik Linox^Smart DX lead at Sheba Medical Center were included in this study. Electrical parameters and arrhythmic events were recorded during follow up of one year.

Results

Seventy-three patients (69 males (94.5%), mean age 61 ± 12 years) were included. All patients were successfully implanted with a Biotronic VR-T DX device and Linox^Smart DX ICD lead (DX-17 in 37% and DX-15 in 63% patients). Mean P wave amplitude at time of implantation was 3.66 ± 2.9 mV and improved significantly throughout the follow-up (5.29 ± 4.39 mV, p = 0.009). Appropriate atrial sensing (defined as P wave amplitude of ≥0.8 mV) rate of 100% at implantation significantly decreased to 89% (p = 0.015) at 12 months. Three out of 67 (4.5%) patients without a known history of atrial fibrillation had documented new onset paroxysmal atrial fibrillation. Appropriate shocks occurred in 4 (5.5%) patients. One patient with atrial sensing less than 0.4 mV had inappropriate shock.

Conclusions

Among patients implanted with the Biotronik Linox^Smart DX ICD lead in our single center, appropriate atrial sensing rate decreased over 12 months. Larger studies are needed to evaluate the reliability of long term appropriate atrial sensing.

Cost Saving Potential of an Early Detection of Atrial Fibrillation in Patients after ICD Implantation

Atrial fibrillation (AF) is a relevant comorbidity in recipients of implantable cardioverter-defibrillators (ICD). Latest generation single-chamber ICD allow the additional sensing of atrial tachyarrhythmias and, therefore, contribute to the early detection and treatment of AF, potentially preventing AF-related stroke. The present study aimed to measure the impact on patient-related costs of this new ICD compared to conventional ICD. A Markov model was developed to simulate the long-term incidence of stroke in patients treated with a single-chamber ICD with or without atrial sensing capabilities. The median annual cost per patient and its difference, the number of strokes avoided, and the cost per stroke avoided were estimated. During a 9-year horizon, the costs for the ICD and stroke treatment were €570 per patient-year for an ICD with atrial sensing capabilities and €491 per patient-year for a conventional ICD. Per 1,000 patients, 4.6 strokes per year are assumed to be avoided by the new device. Higher CHA2DS2-VASc scores are associated with higher numbers of avoided strokes and larger potential for cost savings. Apart from clinical advantages, the use of ICD with atrial sensing capabilities may reduce the incidence of stroke and, in high-risk patients, may also contribute to reduce overall health care costs.

Tachycardia detection in modern implantable cardioverter-defibrillators

Implantable cardioverter-defibrillators (ICD) have to reliably sense, detect, and treat malignant ventricular tachyarrhythmias. Inappropriate treatment of non life-threatening tachyarrhythmias should be avoided. This article outlines the functionality of ICDs developed and manufactured by BIOTRONIK. Proper sensing is achieved by an automatic sensitivity control which can be individually tailored to solve special under- and oversensing situations. The programming of detection zones for ventricular fibrillation (VF), ventricular tachycardia (VT), and zones to monitor other tachyarrhythmias is outlined. Dedicated single-chamber detection algorithms based on average heart rate, cycle length variability, sudden rate onset, and changes in QRS morphology as used in ICDs by BIOTRONIK are described in detail. Preconditions and confirmation algorithms for therapy deliveries as antitachycardia pacing (ATP) and high energy shocks are explained. Finally, a detailed description of the dual-chamber detection algorithm SMART is given. It comprises additional detection criteria as stability of atrial intervals, 1:1 conduction, atrial-ventricular (AV) multiplicity, AV trend, and AV regularity to differentiate between ventricular and supraventricular tachyarrhythmias.

ICD discrimination of SVT versus VT with 1:1 V-A conduction: A review of the literature

Inappropriate ICD shocks are associated with increased mortality. They also impair patients' quality of life, increase hospitalizations, and raise health-care costs. Nearly 80% of inappropriate ICD shocks are caused by supraventricular tachycardia. Here we report the case of a patient who received a single-lead dual-chamber sensing ICD for primary prevention of sudden cardiac death and experienced inappropriate ICD shocks. V-A time, electrogram morphology, and response to antitachycardia pacing suggested atrioventricular nodal reentry tachycardia, which was confirmed in an electrophysiology study. Inspired by this case, we performed a literature review to discuss mechanisms for discrimination of supraventricular tachycardia with 1:1 A:V relationship from ventricular tachycardia with 1:1 retrograde conduction.

"Two for the Price of One": A Single-Lead Implantable Cardioverter-Defibrillator System with a Floating Atrial Dipole

In patients known to be a high risk for sudden cardiac arrest, implantable cardioverter defibrillators (ICD) are a proven therapy to reduce risk of death. However, in patients without conventional indications for pacing, the optimal strategy for type of device, dual- versus single-chamber, remains debatable. The benefit of prophylactic pacing in this category of patients has never been documented. Although available atrial electrograms in a dual chamber system improve interpretation of stored arrhythmia events, allow monitoring of atrial fibrillation and may potentially reduce the risk of inappropriate shocks by enhancing automated arrhythmia discrimination, the use of dual-chamber ICDs has a number of disadvantages. The addition of an atrial lead adds complexity to implantation and extraction procedures, increases procedural cost and is associated with a higher risk of periprocedural complications. The single lead pacing system with ability to sense atrial signals via floating atrial electrodes (VDD) clinically became available in early 1980's but did not gain much popularity due to inconsistent atrial sensing and concerns about the potential need for an atrial lead if sinus node fails. Most ICD patients do not have indications for pacing at implantation and subsequent risk of symptomatic bradycardia seems to be low. The concept of atrial sensing via floating electrodes has recently been revitalized in the Biotronik DX ICD system (Biotronik, SE & Co., Berlin, Germany) aiming to provide all of the potential advantages of available atrial electrograms without the risks and incremental cost of an additional atrial lead. Compared to a traditional VDD pacing system, the DX ICD system uses an optimized (15 mm) atrial dipole spacing and improved atrial signal processing to offer more reliable atrial sensing. The initial experience with the DX system indicates that the clinically useful atrial signal amplitude in sinus rhythm remains stable over time. Future studies are needed to determine reliability of atrial sensing during tachyarrhythmias, particularly atrial fibrillation as well as clinical utility and cost-effectiveness of this technology in different populations of patients.

Alternans of the Ventricular Electrogram in Patients with an Implanted Cardioverter-Defibrillator

BACKGROUND

The occurrence and significance of alternans of the ventricular electrogram (VEGM) in patients with an implanted cardioverter-defibrillator (ICD) has been rarely reported.

OBJECTIVES AND METHODS

This report describes our observations of VEGM alternans documented in nine patients with an ICD (seven new cases and two previously published cases for comparison).

RESULTS

We found seven new cases of near-field VEGM alternans and added two of our previously reported examples. Catecholaminergic polymorphic ventricular tachycardia (CPVT) was diagnosed in one patient based on ICD recordings. Alternans occurred during ventricular tachycardia (VT) in eight patients. A fast sinus tachycardia could not be ruled out in one patient. Stable cycle length alternans was found in five patients. QRS alternans of the left ventricular (LV) electrogram (EGM) was recorded in all five patients who had a device for cardiac resynchronization therapy capable of sensing by the LV channel. These five cases exhibited corresponding alternans of the right ventricular (RV) EGM in three cases, none in one patient, and a questionable recording in another. Alternans of the far-field (FF) VEGM occurred simultaneously with RV EGM alternans in all four patients whose device provided an FF tracing.

CONCLUSION

Ventricular alternans may be more common than realized in ICD patients with VT. The correlation of VEGM alternans with the surface electrocardiogram remains unknown. Although QRS alternans itself as an electrical pattern is generally benign, its cause may not be, as illustrated in our patient with CPVT. Furthermore, associated cycle length alternans or undersensing of the smaller alternans component may complicate ICD therapy.

Athletes with Implantable Cardioverter Defibrillators

Athletes with an implantable cardioverter defibrillator (ICD) represent a diverse group of individuals who may be at an increased risk of sudden cardiac death when engaging in vigorous physical activity. Therefore, they are excluded by the current guidelines from participating in most competitive sports except those classified as low intensity, such as bowling and golf. The lack of substantial data on the natural history of the cardiac diseases affecting these athletes as well as the unknown efficacy of ICDs in terminating life-threatening arrhythmias occurring during intense exercise has resulted in the restrictive nature of these now decade old guidelines.

Sleep-disordered breathing and inappropriate defibrillator shocks in chronic heart failure

PURPOSE

Supraventricular tachyarrhythmias are a major cause of inappropriate defibrillator shocks. Sleep-disordered breathing (SDB) is a known risk factor for atrial fibrillation (AF). We hypothesized that Cheyne-Stokes respiration (CSA) and obstructive sleep apnea (OSA) have an impact on inappropriate defibrillator discharges in patients witch chronic heart failure (CHF) and cardiac resynchronization therapy with defibrillator (CRT-D).

METHODS

In this study, 172 patients with CHF (LVEF ≤ 45 %, NYHA-class ≥ 2) and CRT-D underwent overnight polygraphy; 54 had no SDB (apnea-hypopnea index < 5/h), 59 had OSA, and 59 had CSA. During follow-up (36 months), inappropriate defibrillator shocks were documented.

RESULTS

In all, 17 patients had inappropriate defibrillator shocks (9.9 %; eight oversensing due to lead fractures, five caused by atrial fibrillation, four because of sinus tachycardia). Mean event-free survival time was 33.5 ± 1.2 months in the CSA group, 35.2 ± 0.7 months in the OSA group, and 32.1 ± 1.5 months in the no SDB group, respectively (CSA vs. no SDB p = 0.63; OSA vs. no SDB p = 0.31; CSA vs. OSA p = 0.45). Stepwise Cox proportional hazard regression analysis revealed an independent association for age (per year: hazard ratio 0.90, 95 % confidence interval 0.85-0.96, p < 0.001), but not for any kind of SDB.

CONCLUSIONS

SDB was not associated with inappropriate defibrillator shocks. We assume this is due to the low incidenceand low proportion of inappropriate therapies in response to AF.

Implantable cardioverter defibrillator system with floating atrial sensing dipole: a single-center experience

BACKGROUND

The concept of a single-lead dual-chamber implantable cardioverter defibrillator (ICD) with floating sensing atrial dipole has been proven safe and functional. We report a single-center experience with this ICD system; the major focus of the work is on the recorded atrial activation and its stability on a medium term follow-up.

METHODS

Thirteen patients received a DX ICD (BIOTRONIK SE & Co, Berlin, Germany) with the Linox Smart S DX(ProMRI) ICD lead; the implantation data were reported. Daily P- and R-wave sensing amplitude was collected and followed up during 200 days; their coefficient of variance (CV) was calculated. In addition, all the atrial and ventricular high-rate episodes were analyzed.

RESULTS

The total x-ray exposure time was 3.9 ± 1.8 minutes. The overall mean sensing was 4.2 ± 1.9 mV for P wave and 12.9 ± 4.5 mV for R wave. The CV was significantly higher for the P-wave amplitude than for the R-wave one (0.25 ± 0.11 vs 0.08 ± 0.06; P < 0.001). A total of 27 high ventricular rate episodes were recorded and correctly discriminated by the device. Fifty-six high atrial rate episodes were recorded, 49 were true arrhythmic events.

CONCLUSIONS

The single-lead ICD system with floating atrial dipole provides reliable atrial sensing amplitude over time. The physician, without the implantation of an additional lead, has the atrial information that may be used for the discrimination of supraventricular tachyarrhythmia/ventricular tachycardia, for the early detection of atrial fibrillation episodes and for the evaluation of changes in the patient's heart status.

Reduction of the inappropriate ICD therapies by implementing a new fuzzy logic-based diagnostic algorithm

AIMS

The aim of the study was to analyze the value of a completely new fuzzy logic-based detection algorithm (FA) in comparison with arrhythmia classification algorithms used in existing ICDs in order to demonstrate whether the rate of inappropriate therapies can be reduced.

METHODS

On the basis of the RR intervals database containing arrhythmia events and controls recordings from the ICD memory a diagnostic algorithm was developed and tested by a computer program. This algorithm uses the same input signals as existing ICDs: RR interval as the primary input variable and two variables derived from it, onset and stability. However, it uses 15 fuzzy rules instead of fixed thresholds used in existing devices. The algorithm considers 6 diagnostic categories: (1) VF (ventricular fibrillation), (2) VT (ventricular tachycardia), (3) ST (sinus tachycardia), (4) DAI (artifacts and heart rhythm irregularities including extrasystoles and T-wave oversensing-TWOS), (5) ATF (atrial and supraventricular tachycardia or fibrillation), and 96) NT (sinus rhythm). This algorithm was tested on 172 RR recordings from different ICDs in the follow-up of 135 patients.

RESULTS

All diagnostic categories of the algorithm were present in the analyzed recordings: VF (n = 35), VT (n = 48), ST (n = 14), DAI (n = 32), ATF (n = 18), NT (n = 25). Thirty-eight patients (31.4%) in the studied group received inappropriate ICD therapies. In all these cases the final diagnosis of the algorithm was correct (19 cases of artifacts, 11 of atrial fibrillation and 8 of ST) and fuzzy rules algorithm implementation would have withheld unnecessary therapies. Incidence of inappropriate therapies: 3 vs. 38 (the proposed algorithm vs. ICD diagnosis, respectively) differed significantly (p < 0.05). VT/VF were detected correctly in both groups. Sensitivity and specificity were calculated: 100%, 97.8%, and 100%, 72.9% respectively for FA and tested ICDs recordings (p < 0.05).

CONCLUSIONS

Diagnostic performance of the proposed fuzzy logic based algorithm seems to be promising and its implementation could diminish ICDs inappropriate therapies. We found FA usefulness in correct diagnosis of sinus tachycardia, atrial fibrillation and artifacts in comparison with tested ICDs.

Exercise and competitive sports in patients with an implantable cardioverter-defibrillator

Implantable cardioverter-defibrillators (ICDs) prevent sudden arrhythmic death in patients with different arrhythmogenic cardiac diseases. Because intense physical activity may trigger ventricular arrhythmias and may favour inappropriate shock delivery that impacts quality of life, current international recommendations only give clearance for moderate leisure-time physical activity to patients with an ICD. Hence, athletes are deemed non-eligible to compete with their ICD. The rationale for the current restriction from competitive sports is discussed in this review, as well as new insights that may alter these recommendations for certain sports participants in the foreseeable future. This review provides guidance for the choice of a durable lead and device system, careful programming tailored to the characteristics of the patient's physiological and pathological heart rhythms, instalment of preventive bradycardic medication, and guided rehabilitation with psychological counselling, allowing a maximum of benefit and a minimum of harm for physically active ICD patients.

Ventricular arrhythmias in patients with implanted cardioverter defibrillators

Implantable cardioverter-defibrillators (ICDs) are highly effective in reducing mortality related to ventricular arrhythmias. However, there is considerable morbidity associated with their use, mostly related to ICD shocks. In addition, the occurrence of arrhythmias and ICD shocks in patients with heart failure is associated with an adverse prognosis. Strategies to reduce or prevent ventricular arrhythmias and shocks are a prime area of focus and development in patients with ICDs.

Remote monitoring of implantable-cardioverter defibrillators: results from the Reliability of IEGM Online Interpretation (RIONI) study

AIMS

Intracardiac electrograms (IEGMs) recorded by implantable cardioverter-defibrillators (ICDs) are essential for arrhythmia diagnosis and ICD therapy assessment. Short IEGM snapshots showing 3-10 s before arrhythmia detection were added to the Biotronik Home Monitoring system in 2005 as the first-generation IEGM Online. The RIONI study tested the primary hypothesis that experts' ratings regarding the appropriateness of ICD therapy based on IEGM Online and on standard 30 s IEGM differ in <10% of arrhythmia events.

METHODS AND RESULTS

A total of 619 ICD patients were enrolled and followed for 1 year. According to a predefined procedure, 210 events recorded by the ICDs were selected for evaluation. Three expert board members rated the appropriateness of ICD therapy and classified the underlying arrhythmia using coded IEGM Online and standard IEGM to avoid bias. The average duration of IEGM Online was 4.4±1.5 s. According to standard IEGM, the underlying arrhythmia was ventricular in 135 episodes (64.3%), supraventricular in 53 episodes (25.2%), oversensing in 17 episodes (8.1%), and uncertain in 5 episodes (2.4%). The expert board's rating diverged between determinable IEGM Online tracings and standard IEGM in 4.6% of episodes regarding the appropriateness of ICD therapy (95% CI up to 8.0%) and in 6.6% of episodes regarding arrhythmia classification (95% CI up to 10.5%).

CONCLUSION

By enabling accurate evaluation of the appropriateness of ICD therapy and the underlying arrhythmia, the first-generation IEGM Online provided a clinically effective basis for timely interventions and for optimized patient management schemes, which was comparable with current IEGM recordings.

Comparison of a Novel, Single-Lead Atrial Sensing System With a Dual-Chamber Implantable Cardioverter-Defibrillator System in Patients Without Antibradycardia Pacing Indications

Background—

Supraventricular tachyarrhythmias are the main cause for inappropriate therapy by implantable cardioverter-defibrillators (ICDs). For better rhythm discrimination, an atrial electrogram is helpful and usually obtained from an additional atrial lead, even in the absence of sinus node or atrioventricular nodal disease. An A+-ICD system with integrated atrial sensing rings mounted 15 to 18 cm from the tip of an ICD lead may obviate the need to implant a separate atrial lead. The aim of the study was to compare the novel A+-ICD and a conventional dual-chamber (DR)-ICD.

Methods and Results—

Two hundred forty-nine patients with standard ICD indications but no requirement for antibradycardia pacing were randomized to receive an A+-ICD (n=124) or a DR-ICD (n=125). Implantation details, need for ICD system revision, long-term sensing, documented arrhythmia episodes, and the respective rhythm discrimination during follow-up were analyzed. The implantation time was significantly shorter in the A+-ICD group (67±30 vs 79±30 minutes, P =0.003). Mean P-wave amplitudes were 3.5±0.8 mV (A+-ICD) and 3.2±0.6 mV (DR-ICD) and remained stable during the follow-up period of 12 months. Surgical revision was necessary in 13 patients in the DR-ICD and 10 in the A+-ICD group. All 593 ventricular tachyarrhythmia episodes were correctly discriminated. Sensitivity and specificity of supraventricular tachyarrhythmia discrimination were not different between the study groups.

Conclusions—

The novel A+-ICD system can be implanted faster and is equivalent to a standard DR-ICD with regard to the detection of ventricular tachyarrhythmias and supraventricular tachyarrhythmias. It represents a useful alternative to obtain atrial sensing.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00324662.

Tools and strategies for the reduction of inappropriate implantable cardioverter defibrillator shocks

Implantable cardioverter defibrillators (ICDs) have been shown to provide a survival benefit in patients at high risk of sudden cardiac death. A major problem associated with ICD therapy is the occurrence of inappropriate shocks which impair patients' quality of life and may also be arrhythmogenic. Despite recent technological advances, the incidence of inappropriate shocks remains high, thus posing a challenge that we have to meet. In the present review we summarise the available tools and the strategies that can be followed in order to reduce inappropriate ICD shocks.

Incidence and Significance of Far-Field R Wave Sensing in a VDD-Implantable Cardioverter Defibrillator

BACKGROUND

A VDD-implantable cardioverter-defibrillator (ICD) provides atrioventricular (AV) synchronous stimulation when necessary and incorporates the advantages of dual chamber arrhythmia discrimination algorithms both at potentially lower costs and less periprocedural complications than a DDD-ICD system. A prerequisite for correct dual chamber ICD function is reliable atrial sensing.

METHODS

We evaluated atrial near- and ventricular far-field sensing and its impact on the dual-chamber detection algorithm in 106 patients with a single-lead VDD-ICD during a 12-month follow-up period.

RESULTS

Six hundred and thirty-nine follow-ups were included. Mean near-field amplitude was 3.82 +/- 1.76 mV; mean far-field amplitude was 0.31 +/- 0.15 mV. 46% of patients had far-fields >0.35 mV and 35% of patients showed atrial EGM markers corresponding to a ventricular far-field in at least one follow-up. Six hundred and forty-five tachycardia episodes were evaluated. Due to far-field sensing, three of 66 episodes (4.5%) of sinus tachycardia were misclassified as ventricular tachycardia (VT), leading to antitachycardia therapies. Delayed detection of VT was seen in a 12 of 323 episodes (3.7%) in five of 62 patients (8%) having VT events (delay 6.4 +/- 6.0 seconds (range 2-24 seconds)). Stable far-field amplitudes <0.2 mV in a follow-up had a high negative predictive value for the occurrence of malfunction during tachycardia-conversely, high far-field amplitudes or a high incidence of far-field markers are only moderately correlated with malfunction.

CONCLUSIONS

Ventricular far-field sensing in a VDD-ICD is not uncommon, however, tachycardia detection by the dual chamber algorithm is not seriously impaired by far-field sensing.

Design and analysis issues in cardiac arrhythmia trials: insights from the Detect Supraventricular Tachycardia Trial

Background The Detect Supraventricular Tachycardia (Detect SVT) trial was a randomized single blind study in subjects receiving a dual chamber implantable cardioverter defibrillator (ICD). The primary goal was to evaluate whether dual chamber enhancements result in greater discrimination between supraventricular tachycardia (SVT) and ventricular episodes when compared to ventricular-only enhancements.

Purpose The purpose of this report is to describe our experiences from an analytic perspective, including overall study design, the value of blinded episode review, and the statistical analysis plan.

Methods The Detect SVT study was a parallel group study, with blinded central review of all arrhythmia episodes occurring over a six-month period. The primary response was the proportion of inappropriate detections (SVT episodes that are inappropriately classified as ventricular by the device).

Results A parallel group design was essential as unplanned crossovers were very differential. The blinded review of episodes was a major use of resources, with over 2300 episodes observed. This review did not materially alter the findings, however, the avoidance of any perceived bias was a major strength. The value of collecting large numbers of episodes on a single subject was found to be minimal. A Kaplan–Meier analysis of the number of SVT episodes until first inappropriate detection was found to add additional information.

Limitations The recommendations reported here relate to cardiac arrhythmia trials, or other studies with very similar endpoints. These observations are based on the results of a single trial and should be confirmed in other studies.

Conclusions The parallel group design was essential, as was accounting for within-subject correlation in the analysis. The blinded review process was also important, but significant resources could be saved by closing-out episode collection after a fixed number of episodes. Lessons learned from the Detect SVT trial may prove useful to others designing trials in this active research area.

Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part II: ventricular arrhythmias, channelopathies and implantable defibrillators

This consensus paper on behalf of the Study Group on Sports Cardiology of the European Society of Cardiology follows a previous one on guidelines for sports participation in competitive and recreational athletes with supraventricular arrhythmias and pacemakers. The question of imminent life-threatening arrhythmias is especially relevant when some form of ventricular rhythm disorder is documented, or when the patient is diagnosed to have inherited a pro-arrhythmogenic disorder. Frequent ventricular premature beats or nonsustained ventricular tachycardia may be a hallmark of underlying pathology and increased risk. Their finding should prompt a thorough cardiac evaluation, including both imaging modalities and electrophysiological techniques. This should allow distinguishing idiopathic rhythm disorders from underlying disease that carries a more ominous prognosis. Recommendations on sports participation in inherited arrhythmogenic conditions and asymptomatic gene carriers are also discussed: congenital and acquired long QT syndrome, short QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, arrhythmogenic right ventricular cardiomyopathy and other familial electrical disease of unknown origin. If an implantable cardioverter defibrillator is indicated, it is no substitute for the guidelines relating to the underlying pathology. Moreover, some particular recommendations for patients/athletes with an implantable cardioverter defibrillator are to be observed.

Does the rate of inappropriate therapy differ in implantable cardioverter–defibrillators from different manufacturers?

OBJECTIVE

We conducted this study to compare the rate of >/=1 inappropriate therapy between ICDs from two manufacturers which use different discriminatory protocols.

METHOD

One hundred sixty two patients (mean age 58 +/- 13 years, 126 male) who received ICDs between January 2001 and 2005 were included in the study. Clinical, electrocardiographic, and ICD stored data and electrograms were collected and analyzed. Immediately after implantation all the detection and discrimination criteria were activated with the nominal values in order to compare the two discriminatory protocols under the default manufacturer's settings.

RESULTS

During the follow up period of 14.3 +/- 10 months, 49 (30%) patients received >/=1 inappropriate ICD therapy. The rate of >/=1 inappropriate ICD therapy in manufacturer A and B ICDs was 26% (n = 29) and 41% (n = 20), respectively. Comparing the rate of >/=1 inappropriate ICD therapy between the two groups by Kaplan-Meier analysis and the log rank test resulted in P = 0.04.

CONCLUSION

Having all discriminatory variables activated with the nominal values, discriminatory performance differs between the two manufacturers. Further larger-scale studies are warranted to prospectively compare the performance of various available ICDs' discriminatory protocols, and define the optimum combination of discriminators in each ICD to decrease the rate of inappropriate therapy.

A new method to investigate the response to the morphology discrimination algorithm in patients with ICD

BACKGROUND

Inappropriate therapy for supraventricular tachyarrhythmia is still a major problem in implantable cardioverter defibrillators (ICD). The morphology discrimination algorithm compares the morphology of a tachycardia electrogram with a stored template on a beat-to-beat basis. However, algorithm responders could not yet be identified prior to the occurrence of first tachycardia episodes. We analyzed whether rapid atrial pacing and/or exercise testing can be used for identification of responders and compared the results with ICD detected tachycardia.

METHODS

22 patients (16 male, 61+/-14 years) with dual-chamber ICDs have been enrolled. Patients underwent a standardized bicycle exercise testing and an atrial pacing protocol. For both tests, morphology match scores of 8 consecutive beats were analyzed for each 10-bpm-step increment above sinus rhythm. Patients were categorized as responders, if morphology match was > or = 90% of tested heart rates. During follow-up, ICD stored episodes with morphology discrimination activated were evaluated.

RESULTS

There were no significant differences between morphology match (85+/-29% vs. 84+/-27%) and linear regression slope B (-0.19+/-0.87 vs. -0.20+/-0.48) during exercise testing and atrial pacing. 16 patients (73%) were classified as responders. During follow-up (739+/-338 days) 121 sustained supraventricular (n=88) and ventricular tachycardia (n=33) were detected in 10 patients (45%). Specificity for tachycardia discrimination was 78% overall, 100% in responders and 22% in non-responders.

CONCLUSION

Exercise testing and atrial pacing were equally suitable for identification of patients who seem to respond to the morphology discrimination algorithm with a high specificity for ventricular tachycardia discrimination. Thus, morphology match tests are suggested to optimize tachycardia discrimination and to reduce inadequate therapies.

What are the professional and logistic demands to appropriately follow patients with an implantable cardioverter-defibrillator?

OBJECTIVES

To determine events during follow-up of patients with implantable cardioverter-defibrillators (ICD) and the specific experience cardiologists need for trouble-shooting.

DESIGN

Prospective evaluation of all patient visits in an outpatient clinic.

SETTING

University hospital, single centre performing ICD controls in a region of 1.5 Mio inhabitants.

SUBJECTS

A total of 351 patients with 1118 consecutive visits during 14 months.

INTERVENTIONS

Classification of events according to predefined training levels.

MAIN OUTCOME MEASUREMENTS

Skill levels A: simple visit, e.g. for switching the device 'off'. B: normal visit, no further measures taken (no device reprogramming), even though the patient might have experienced ICD interventions. C: complex visit, electrophysiologist actively involved. Correlation of these levels with timing (routine, emergency on/off office hours) and reason of visits.

RESULTS

Seventy-six per cent of visits were scheduled routine visits, 5% performed within 24 h because of shocks, 19% performed for other reasons (shock tests; switching the device 'off/on'; reported dizziness, syncope, palpitations without ICD interventions). Required skill levels were A in 44 (4%), B in 796 (71%) and C in 278 (25%) visits. Emergency visits were more often classified as level C (60%) than regular visits (20%), Skill level C was more often encountered during emergency (30%) than during regular visits (6%) (both P = 0.001).

CONCLUSIONS

Our study suggests that for standard follow-up in patients without obvious problems, a cardiologist might be sufficient, whereas presentations due to/with clinical problems most likely will need the expertise of an electrophysiologist.

Intraoperative Comparison of a Subthreshold Test Pulse with the Standard High-Energy Shock Approach for the Measurement of Defibrillation Lead Impedance

There are two methods to measure shocking lead impedance: delivery of high-energy shocks that require patient sedation, and the painless measurement of impedance from subthreshold test pulses. The aim of this study was to compare the two methods.

METHODS

The study included 131 patients implanted with a standard DR (n = 71) or VR (n = 60) ICD connected to either single-coil (n = 39) or dual-coil (n = 92) defibrillation leads. The noninvasive high-energy impedance test was done using a 17 J shock after induction of ventricular tachyarrhythmias and compared to a 0.4 microJ test pulse used by the ICD for the subthreshold measurements.

RESULTS

Defibrillation lead impedance measurements were not significantly different between patients with the same shocking vector configuration. In patients with a single-coil defibrillation lead the impedance was 62 +/- 9 Omega with the high-energy shock and 62 +/- 8 Omega with the subthreshold test pulses (P = 0.13). Patients with a dual-coil configuration recorded average impedances of 40 +/- 5 Omega from both tests (P = 0.44). While there was no difference in values recorded within each lead configuration, there was a significant difference in impedance between the single-coil and the dual-coil patient groups (P = 0.001).

CONCLUSIONS

There was no significant difference between shocking lead impedances measured with the high-energy shock or the subthreshold test pulses. This offers the possibility of noninvasive, low-energy serial measurements of shocking lead impedance at follow-up visits and removing the need for sedation.

Incidence and Clinical Relevance of Slow Ventricular Tachycardia in Implantable Cardioverter-Defibrillator Recipients

Background— This study aims to assess the incidence and clinical relevance of slow ventricular tachycardia (VT) and the effectiveness and/or deleterious effects of antitachycardia pacing in slow VT in implantable cardioverter-defibrillator recipients.

Methods and Results— This multicenter prospective randomized study included 374 patients (326 men) without prior history of slow VT (<148 bpm) implanted with a dual-chamber implantable cardioverter-defibrillator. Patients had a 3-zone detection configuration: a slow VT zone (101 to 148 bpm), a conventional VT zone (>148 bpm), and a ventricular fibrillation zone. Patients were randomized to a treatment group (n=183) with therapy activated in the slow VT zone or a monitoring group (n=191) with no therapy in the slow VT zone. During follow-up (11 months), 449 slow VTs occurred in 114 patients (30.5% slow VT incidence); 181 VTs (54 patients) occurred in the monitoring group; 3 were readmitted to the hospital; and lightheadedness and palpitations occurred in 4 and 250 (60 patients) in the treatment group treated by antitachycardia pacing (89.8% success rate) and shock delivery (n=2). There were 10 crossovers from the monitoring to treatment group and 3 crossovers from the treatment to monitoring group ( P =0.09). Quality of life scores were not different between groups.

Conclusions— Slow VT incidence (<150 bpm) is high (30%) in implantable cardioverter-defibrillator recipients without prior history of slow VT, has limited clinical relevance, and is efficiently and safely terminated by antitachycardia pacing.