Antitachycardia pacing programming in implantable cardioverter defibrillator: A systematic review

Abstract

Implantable cardioverter defibrillator (ICD) programming involves several parameters. In recent years antitachycardia pacing (ATP) has gained an increasing importance in the treatment of ventricular arrhythmias, whether slow or fast. It reduces the number of unnecessary and inappropriate shocks and improves both patient’s quality of life and device longevity. There is no clear indication regarding the type of ATP to be used, except for the treatment of fast ventricular tachycardias (188 bpm-250 bpm) where it has been shown a greater efficacy and safety of burst compared to ramp; 8 impulses in each sequence of ATP appears to be the best programming option in this setting. Beyond ATP use, excellent clinical results were obtained with programming standardization following these principles: extended detection time in ventricular fibrillation (VF) zone; supraventricular discrimination criteria up to 200 bpm; first shock in VF zone at the maximum energy in order to reduce the risk of multiple shocks. The MADIT-RIT trial and some observational registries have also recently demonstrated that programming with a widespread use of ATP, higher cut-off rates or delayed intervention reduces the number of inappropriate and unnecessary therapies and improves the survival of patients during mid-term follow-up.

Automatic adjustment of ventricular antitachycardia pacing and individualized device therapy

“…Overall, there is not a clear difference in the efficacy of burst or ramp ATP, in ischemic and nonischemic cardiomyopathies. 3 In most cases, the choice of programming is based on clinician’s preference or manufacturer nominal settings. Ramp sequences may have a greater likelihood of acceleration, especially in some patient cohorts, for example arrhythmogenic cardiomyopathy.…”

Hybrid subcutaneous and transvenous approach for cardiac resynchronization defibrillator implant in a patient with congenital heart disease and tricuspid bioprosthetic

“…Our approach can be used with any vendor's currently available devices and leads, with smaller device footprint and capability for pain-free termination of ventricular and some atrial tachycardias via antitachycardia pacing. 6 It allows for resynchronization therapy, too.…”

Optogenetic Termination of Cardiac Arrhythmia: Mechanistic Enlightenment and Therapeutic Application?

“…More likely, electrical shocks induce brief depolarization, which terminates arrhythmia by a mechanism called “filling of the excitable gap.” The excitable gap is the excitable myocardium (Figure 1A, green) between the trailing edge of the bypassed and the leading edge of the next reentrant wave front (Kleber and Rudy, 2004) and can be activated by the electrical shock or by antitachycardia pacing protocols producing a second wave front which will collide with the arrhythmic wave front. The effectiveness of this mechanism has been documented in clinical trials (De Maria et al., 2017) and depends on the duration and location of the excitable gap relative to the pacing site, which is rather difficult to predict. The excitable gap can also be reduced by increasing the cardiac wavelength [conduction velocity × action potential duration (APD)].…”