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Gold MR, Lambiase PD, El-Chami MF, Knops RE, Aasbo JD, Bongiorni MG, Russo AM, Deharo JC, Burke MC, Dinerman J, Barr CS, Shaik N, Carter N, Stoltz T, Stein KM, Brisben AJ, Boersma LVA. Primary Results From the Understanding Outcomes With the S-ICD in Primary Prevention Patients With Low Ejection Fraction (UNTOUCHED) Trial. Circulation 2020; 143:7-17. [PMID: 33073614 PMCID: PMC7752215 DOI: 10.1161/circulationaha.120.048728] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Supplemental Digital Content is available in the text. Background: The subcutaneous (S) implantable cardioverter-defibrillator (ICD) is safe and effective for sudden cardiac death prevention. However, patients in previous S-ICD studies had fewer comorbidities, had less left ventricular dysfunction, and received more inappropriate shocks (IAS) than in typical transvenous ICD trials. The UNTOUCHED trial (Understanding Outcomes With the S-ICD in Primary Prevention Patients With Low Ejection Fraction) was designed to evaluate the IAS rate in a more typical, contemporary ICD patient population implanted with the S-ICD using standardized programming and enhanced discrimination algorithms. Methods: Primary prevention patients with left ventricular ejection fraction ≤35% and no pacing indications were included. Generation 2 or 3 S-ICD devices were implanted and programmed with rate-based therapy delivery for rates ≥250 beats per minute and morphology discrimination for rates ≥200 and <250 beats per minute. Patients were followed for 18 months. The primary end point was the IAS-free rate compared with a 91.6% performance goal, derived from the results for the ICD-only patients in the MADIT-RIT study (Multicenter Automatic Defibrillator Implantation Trial–Reduce Inappropriate Therapy). Kaplan-Meier analyses were performed to evaluate event-free rates for IAS, all-cause shock, and complications. Multivariable proportional hazard analysis was performed to determine predictors of end points. Results: S-ICD implant was attempted in 1116 patients, and 1111 patients were included in postimplant follow-up analysis. The cohort had a mean age of 55.8±12.4 years, 25.6% were women, 23.4% were Black, 53.5% had ischemic heart disease, 87.7% had symptomatic heart failure, and the mean left ventricular ejection fraction was 26.4±5.8%. Eighteen-month freedom from IAS was 95.9% (lower confidence limit, 94.8%). Predictors of reduced incidence of IAS were implanting the most recent generation of device, using the 3-incision technique, no history of atrial fibrillation, and ischemic cause. The 18-month all-cause shock-free rate was 90.6% (lower confidence limit, 89.0%), meeting the prespecified performance goal of 85.8%. Conversion success rate for appropriate, discrete episodes was 98.4%. Complication-free rate at 18 months was 92.7%. Conclusions: This study demonstrates high efficacy and safety with contemporary S-ICD devices and programming despite the relatively high incidence of comorbidities in comparison with earlier S-ICD trials. The inappropriate shock rate (3.1% at 1 year) is the lowest reported for the S-ICD and lower than many transvenous ICD studies using contemporary programming to reduce IAS. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02433379.
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Affiliation(s)
- Michael R Gold
- Department of Medicine, Medical University of South Carolina, Charleston (M.R.G.)
| | - Pier D Lambiase
- Institute of Cardiovascular Science, University College of London, Barts Heart Centre and University College, London, United Kingdom (P.D.L.)
| | | | - Reinoud E Knops
- Department of Electrophysiology, Amsterdam University Medical Center, The Netherlands (R.E.K.)
| | - Johan D Aasbo
- Department of Cardiac Electrophysiology, Baptist Health Lexington, KY (J.D.A.)
| | | | - Andrea M Russo
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.)
| | - Jean-Claude Deharo
- Cardiologie and Rythmologie Division, Centre hospitalier Universitaire La Timone Hospital, Marseille, France (J.C.D.)
| | | | - Jay Dinerman
- Heart Center Research, LLC, Huntsville, AL (J.D.)
| | - Craig S Barr
- Russells Hall Hospital, Dudley, United Kingdom (C.S.B.)
| | | | - Nathan Carter
- Boston Scientific Corporation, St Paul, MN (N,C., T.S., K.M.S., A.J.B.)
| | - Thomas Stoltz
- Boston Scientific Corporation, St Paul, MN (N,C., T.S., K.M.S., A.J.B.)
| | - Kenneth M Stein
- Boston Scientific Corporation, St Paul, MN (N,C., T.S., K.M.S., A.J.B.)
| | - Amy J Brisben
- Boston Scientific Corporation, St Paul, MN (N,C., T.S., K.M.S., A.J.B.)
| | - Lucas V A Boersma
- St Antonius Ziekenhuis, Nieuwegein Department of Cardiology, Nieuwegein, The Netherlands (L.V.B.)
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Mizukami K, Yokoshiki H, Mitsuyama H, Watanabe M, Tenma T, Kamada R, Takahashi M, Sasaki R, Maeno M, Tsutsui H. Influence of myopotential interference on the Wavelet discrimination algorithm in implantable cardioverter-defibrillator. J Arrhythm 2017; 33:214-219. [PMID: 28607617 PMCID: PMC5459332 DOI: 10.1016/j.joa.2016.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/01/2016] [Accepted: 08/26/2016] [Indexed: 11/06/2022] Open
Abstract
Background Wavelet is a morphology-based algorithm for detecting ventricular tachycardia. The electrogram (EGM) source of the Wavelet algorithm is nominally programmed with the Can-RV coil configuration, which records a far-field ventricular potential. Therefore, it may be influenced by myopotential interference. Methods We performed a retrospective review of 40 outpatients who had an implantable cardioverter-defibrillator (ICD) with the Wavelet algorithm. The percent-match score of the Wavelet algorithm was measured during the isometric chest press by pressing the palms together. We classified patients with percent-match scores below 70% due to myopotential interference as positive morphology change, and those with 70% or more as negative morphology change. Stored episodes of tachycardia were evaluated during the follow-up. Results The number of patients in the positive morphology change group was 22 (55%). Amplitude of the Can-RV coil EGM was lower in the positive morphology change group compared to that in the negative group (3.9±1.3 mV vs. 7.4±1.6 mV, P=0.0015). The cut-off value of the Can-RV coil EGM was 5 mV (area under curve, 0.89). Inappropriate detections caused by myopotential interference occurred in two patients (5%) during a mean follow-up period of 49 months, and one of them received an inappropriate ICD shock. These patients had exhibited positive morphology change. Conclusions The Wavelet algorithm is influenced by myopotential interference when the Can-RV coil EGM is less than 5 mV.
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Affiliation(s)
- Kazuya Mizukami
- Department of Cardiovascular Medicine, National Hospital Organization Hokkaido Medical Center, Yamanote 5-7-1-1, Nishi-ku, Sapporo 063-0005, Japan
| | - Hisashi Yokoshiki
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan
| | - Hirofumi Mitsuyama
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan
| | - Masaya Watanabe
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan
| | - Taro Tenma
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan
| | - Rui Kamada
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan
| | - Masayuki Takahashi
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan
| | - Ryo Sasaki
- Division of Medical Engineering Center, Hokkaido University Hospital, Japan
| | - Motoki Maeno
- Division of Medical Engineering Center, Hokkaido University Hospital, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan
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ENRIQUEZ ANDRES, ELLENBOGEN KENNETHA, BOLES USAMA, BARANCHUK ADRIAN. Atrioventricular Nodal Reentrant Tachycardia in Implantable Cardioverter Defibrillators: Diagnosis and Troubleshooting. J Cardiovasc Electrophysiol 2015; 26:1282-1288. [DOI: 10.1111/jce.12772] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 07/07/2015] [Accepted: 08/31/2015] [Indexed: 11/26/2022]
Affiliation(s)
- ANDRES ENRIQUEZ
- Division of Cardiology; Queen's University; Kingston Ontario Canada
| | - KENNETH A. ELLENBOGEN
- Department of Medicine; Virginia Commonwealth University School of Medicine; Richmond Virginia USA
| | - USAMA BOLES
- Division of Cardiology; Queen's University; Kingston Ontario Canada
| | - ADRIAN BARANCHUK
- Division of Cardiology; Queen's University; Kingston Ontario Canada
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Milpied P, Dubois R, Roussel P, Henry C, Dreyfus G. Arrhythmia Discrimination in Implantable Cardioverter Defibrillators Using Support Vector Machines Applied to a New Representation of Electrograms. IEEE Trans Biomed Eng 2011; 58:1797-803. [DOI: 10.1109/tbme.2011.2117424] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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MANSOUR FADI, KHAIRY PAUL. Programming ICDs in the Modern Era beyond Out-of-the Box Settings. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 34:506-20. [DOI: 10.1111/j.1540-8159.2011.03037.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Wazni O, Wilkoff BL. Strategic choices to reduce implantable cardioverter-defibrillator-related morbidity. Nat Rev Cardiol 2010; 7:376-83. [DOI: 10.1038/nrcardio.2010.50] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Toquero J, Alzueta J, Mont L, Lozano IF, Barrera A, Berruezo A, Castro V, Peña JL, Fidalgo ML, Brugada J. Morphology discrimination criterion wavelet improves rhythm discrimination in single-chamber implantable cardioverter-defibrillators: Spanish Register of morphology discrimination criterion wavelet (REMEDIO). ACTA ACUST UNITED AC 2009; 11:727-33. [DOI: 10.1093/europace/eup099] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Tzeis S, Andrikopoulos G, Kolb C, Vardas PE. Tools and strategies for the reduction of inappropriate implantable cardioverter defibrillator shocks. Europace 2008; 10:1256-65. [PMID: 18708639 DOI: 10.1093/europace/eun205] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Stylianos Tzeis
- Faculty of Medicine, Deutsches Herzzentrum, Medizinische Klinik, Technische Universität München, Munich, Germany
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Wolber T, Binggeli C, Holzmeister J, Brunckhorst C, Strobel U, Boes C, Moser R, Becker D, Duru F. Wavelet-Based Tachycardia Discrimination in ICDs: Impact of Posture and Electrogram Configuration. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 29:1255-60. [PMID: 17100680 DOI: 10.1111/j.1540-8159.2006.00521.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Inappropriate therapy delivery is an important concern in the management of patients with implantable cardioverter defibrillators (ICDs). Recently, a morphology-based algorithm (wavelet feature) has been introduced for differentiation of ventricular and supraventricular tachycardia. In this study, we evaluated the performance of the wavelet algorithm using various electrogram (EGM) configurations during different body positions. METHODS Patients with a single-chamber Medtronic model 7230 ICD (Minneapolis, MN, USA) and a double-coil lead were included. EGM templates were collected during baseline rhythm in supine position for different EGM sources (right ventricular [RV] coil-can, RV coil-superior vena cava [SVC] coil, tip-ring, SVC coil-can). For each EGM configuration, morphologic similarity (match percentage) of EGMs obtained during different body positions (supine, left and right lateral, sitting, standing, walking) were compared with the templates. RESULTS Twenty-eight patients (24 males; age 58 +/- 17 years) were studied. A total of 9,775 intracardiac EGMs were analyzed. Median match percentage (interquartile range) was 88% (85-94), 88% (82-94), 82% (76-88), and 73 (58-85) for the RV coil-can, RV coil-SVC coil, tip-ring, and SVC coil-can configurations, respectively. Correct classification rates, as defined by match percentage of 70% or higher, were significantly higher with the RV coil-can, RV coil-SVC coil, and tip-ring EGM configurations, as compared to the SVC coil-can configuration (95, 91, and 91 vs 58% > or =70% match percent, P < 0.001). CONCLUSION Wavelet-based morphology scores in ICDs may change with various body positions. These variations are relatively minor using the nominal configuration (RV coil-can), as well as by using RV coil-SVC coil and tip-ring. However, morphology scores can vary considerably when SVC coil-can is used; therefore, this configuration should be avoided while using the wavelet algorithm.
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Affiliation(s)
- Thomas Wolber
- Cardiovascular Center, Cardiology, University Hospital Zurich, Zurich, Switzerland.
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