ICD Proarrhythmia as a Consequence of an Interaction with an Algorithm to Prevent Atrial Arrhythmias

Martínez‐Sánchez, Juan; García‐Alberola, Arcadi; Sánchez-Muñoz, Juan J.; Peñafiel-Verdú, Pablo; Giner-Caro, José A.; Valdés‐Chávarri, Mariano

doi:10.1111/j.1540-8159.2009.02444.x

Cited by 6 publications

(2 citation statements)

References 7 publications

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“…Proposed mechanisms for pacing-induced VT/VF induction by the ICDs are short-long-short (S-L-S) sequences that are either pacing facilitated or pacing permitted, 57 atrial preference pacing, 58 and noncompetitive atrial pacing mode. 59 When the paced QRS morphology and VT morphology are similar, one should consider mechanical irritation from the lead as a potential mechanism of VT. 60 Studies aimed at reducing S-L-S sequences by using rate-smoothing algorithms have not shown consistent benefit.…”

Section: Icd Proarrhythmiamentioning

confidence: 99%

Minimizing Inappropriate or “Unnecessary” Implantable Cardioverter-Defibrillator Shocks

Koneru

Swerdlow

Wood

et al. 2011

Circ: Arrhythmia and Electrophysiology

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L ife-saving shocks are the raisons d'être of implantable cardioverter-defibrillators (ICDs). Paradoxically, shocks also cause much of the morbidity associated with ICDs. Consistently, shocks reduce quality of life, 1,2 and rarely, they may cause proarrhythmia. 3,4 Additionally, shocks have been reported to be associated with excess mortality. 5 Experts disagree about whether shocks are responsible for this excess mortality, 6 but they do agree that ICDs should deliver the fewest shocks necessary to protect patients from ventricular tachycardia (VT) or ventricular fibrillation (VF).Minimizing ICD shocks requires a comprehensive approach, beginning with patient selection, 7 general medical care (eg, preventing electrolyte abnormalities), and general cardiac care (preventing ischemia and treating heart failure). It includes the use of antiarrhythmic drugs and catheter ablation both to prevent VT or supraventricular tachycardia (SVT) and to control the ventricular rate in atrial fibrillation (AF) as well as the appropriate choice of hardware and device programming. This review focuses on ICD features and programming to minimize shocks. OverviewFigure 1 summarizes the sequential processes required for an ICD to deliver a shock. The sense amplifiers convert the continuous electrogram (EGM) from the tip of the right ventricular (RV) lead into a series of instantaneously sensed events representing ventricular depolarization. This series of sensed events is processed by ICD algorithms, including those for initial detection; SVT-VT discrimination; and in some models of ICDs, enhancements to minimize oversensing. If the rhythm is classified as a VT, antitachycardia pacing (ATP) can be delivered. The ICD then performs a redetection process, which results in determination that the devicedefined VT either has terminated or persists. If VT is redetected, the process iterates until all programmed ATPs are delivered. The ICD then charges the high-voltage capacitors, during which time a final round of ATP may be delivered. After capacitor charging, the ICD confirms that VT/VF is present before delivering a shock. Each step provides opportunities to minimize unnecessary shocks. Although Figure 1 shows the ICD process, we consider features and programming in the approximate order that most electrophysiologists program ICDs: (1) rate and duration for initial detection, (2) SVT-VT discrimination, (3) ATP and shock strength, (4) redetection/confirmation, and (5) sensing enhancements.Historically, shocks were classified as appropriate if delivered during VT/VF and inappropriate if delivered during other rhythms. However, some shocks delivered during VT may be avoided by programming ATP or permitting nonsustained VT to spontaneously terminate. In this review, we classify shocks as either necessary to ensure patient safety or unnecessary. Necessary shocks are those that terminate ventricular tachyarrhythmias that would not spontaneously terminate or cannot be terminated by ATP. Unnecessary shocks include those that have been traditional...

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Section: Icd Proarrhythmiamentioning

confidence: 99%

Minimizing Inappropriate or “Unnecessary” Implantable Cardioverter-Defibrillator Shocks

Koneru

Swerdlow

Wood

et al. 2011

Circ: Arrhythmia and Electrophysiology

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“…Implantable cardioverter defibrillator (ICD) therapy reduces mortality in high-risk patients; however, it is expensive and has associated morbidity from implant complications and potential mechanical dysfunction. Furthermore, ICDs treat ventricular arrhythmias without preventing them, and in fact can be proarrhythmic [6][7][8]. Therefore, antiarrhythmic drugs (AADs) with direct antiarrhythmic effects are often used in the acute setting or for chronic therapy and may play an important role in reducing the arrhythmia burden.…”

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confidence: 99%

Delayed and Indirect Effects of Antiarrhythmic Drugs in Reducing Sudden Cardiac Death

Malhotra

Das²

2011

Future Cardiol.

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In the USA, two-thirds of sudden cardiac deaths (SCDs) are caused by sustained ventricular tachycardia and ventricular fibrillation. Implantable cardioverter defibrillator (ICD) therapy has been demonstrated to decrease mortality caused by these arrhythmias, when used both for primary and secondary prevention. However, ICD use is expensive, has proarrhythmic effects and does not prevent ventricular arrhythmias. Antiarrhythmic drugs (AADs) can be used for acute or chronic therapy to prevent ventricular arrhythmias and SCD. Most commonly, AADs are often used in patients with an ICD who have recurrent ICD shocks due to ventricular arrhythmias. Class I AADs are used in patients with a structurally normal heart and are contraindicated in patients with structural heart disease. β-blockers have been demonstrated to be beneficial in preventing mortality and malignant tachyarrhythmias in postmyocardial infarction and congestive heart failure patients, and in patients who have an ICD. Amiodarone has a neutral effect on mortality, while other class III drugs may increase mortality in certain subgroups of patients. Dronedarone, a new class III drug, may reduce mortality, but sufficient data are not available to allow for its use in the prevention of malignant tachyarrhythmias. Few drugs that are not classified as AADs can also prevent arrhythmias, via their beneficial effects on cardiovascular remodeling. These non-ADDs have delayed and indirect effects, which are mediated by the renin-angiotensin-aldosterone system and lipid metabolism - n-3 polyunsaturated fatty acids (fish oil), and statins, and can thus can reduce the likelihood of future malignant ventricular arrhythmias in patients with coronary artery disease or congestive heart failure. The role of chronic drug therapy alone for primary and secondary prevention of SCD is less than desirable because of proarrhythmic and adverse side effects. The non-ADDs are well tolerated and have no proarrhythmic actions, thus their benefit could outweigh risks, although currently there are no concrete data to suggest this.

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Troubleshooting: Interpreting Diagnostic Information to Ensure Appropriate Function

Swerdlow

Friedman

Asirvatham

et al. 2012

Cardiac Pacing, Defibrillation and Resynchronization

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ICD Proarrhythmia as a Consequence of an Interaction with an Algorithm to Prevent Atrial Arrhythmias

Cited by 6 publications

References 7 publications

Minimizing Inappropriate or “Unnecessary” Implantable Cardioverter-Defibrillator Shocks

Minimizing Inappropriate or “Unnecessary” Implantable Cardioverter-Defibrillator Shocks

Delayed and Indirect Effects of Antiarrhythmic Drugs in Reducing Sudden Cardiac Death

Troubleshooting: Interpreting Diagnostic Information to Ensure Appropriate Function

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