(BQ) Part 2 book Implantable cardioverter - Defibrillators step by step includes: Cardiac tachyarrhythmias, ICD function with emphasis on stored electrograms, indications for ICD, ICD implantation and lead systems, cardiac resynchronization, complications of ICD therapy,...
9781405186384_4_011.qxd 10/27/08 220 Figure 11.03 3:56 PM Page 220 9781405186384_4_011.qxd 10/27/08 3:57 PM Page 221 221 Figure 11.04 9781405186384_4_011.qxd 10/27/08 222 Figure 11.05 3:57 PM Page 222 9781405186384_4_011.qxd 10/27/08 3:57 PM Page 223 223 Figure 11.06 9781405186384_4_011.qxd 10/27/08 224 Figure 11.07 3:57 PM Page 224 9781405186384_4_011.qxd 10/27/08 3:57 PM Page 225 225 Figure 11.08 9781405186384_4_011.qxd 10/27/08 226 Figure 11.09 3:58 PM Page 226 9781405186384_4_011.qxd 10/27/08 3:58 PM Page 227 227 Figure 11.10 9781405186384_4_011.qxd 10/27/08 228 Figure 11.11 3:58 PM Page 228 9781405186384_4_012.qxd 10/27/08 3:50 PM Page 229 229 Figure 12.00 Implantable Cardioverter-Defibrillators Step by Step: An Illustrated Guide Roland X Stroobandt, S Serge Barold and Alfons F Sinnaeve © 2009 R.X Stroobandt, S.S Barold and A.F Sinnaeve ISBN: 978-1-405-18638-4 9781405186384_6_index.qxd 10/27/08 5:02 PM Page 413 ischemic 22 nonischemic 22, 403 see also hypertrophic cardiomyopathy cardiopulmonary resuscitation (CPR) for syncope 375 cardioversion 363 – atrial 167 blanking periods 96 electromagnetic interference 384 EMI risks 226 proarrhythmia risk 363 CASQ2 gene mutations 36 catecholaminergic polymorphic ventricular tachycardia (CPVT) 36 indications for ICD 341, 405 cell membrane 76 maximum voltage 77 cellular phones 386 channelopathies 29, 34 charge 45 ChargeSaver operation 363 charging during ATP 317 see also capacitors, charging charging circuit, high-voltage 58 – 61, 346 chest X-ray after implantation 71 annual overpenetrated 207 chronaxie duration 84 cognitive behavioral therapy 373 coil reversal 180, 383 dual coil integrated defibrillation lead 302 combined count detection 111, 356 combined number of intervals to detect (CNID) 111, 356 committed systems 101 committed therapy 145 comparators 92 complications of ICD therapy 177– 94, 368–73, 351 coil reversal 180 generator-related 178, 370 –1 inappropriate delivery of therapy 179, 222, 300, 308, 328, 371 lead-related 177, 369, 372, 389 long-term 179 venous access 368 – component testing 196 composite wires 347 conduction autointrinsic search 364 intraatrial/interatrial delay 396 conductors coiled 64, 347 defects 376 defibrillation 347 fracture 376 congenital heart disease 401–3 connectors, oversensing of extracardiac signals 200, 383 coronary artery bypass graft 26 coronary artery disease, LV dysfunction and prolonged QRS interval 26 coronary sinus dissection/perforation 390 coronary venous system, ECG patterns during LV pacing 390 coughing, diaphragmatic myopotential interference 306 coupling interval (CI) 153, 154 adaptive 158 ATP sequence programming 158, 159 decrement 157, 158 coupling path 223 current see electric current DC fibber, ventricular fibrillation induction 301 DC voltage 60 ventricular fibrillation induction 74 DC–DC converter 346 DDD(R) mode 165 atrial pacing forcing 382 atrioventricular optimization 251 internal 395–6 with atrioventricular search hysteresis 365 resetting 387 decay delay 99 decremental scanning 160 decrementing in ATP therapy 157, 158, 159 defibrillation antiarrhythmic drug effects 185 and ATP to atrium and ventricle 230 biphasic waveforms 65, 69, 86 blanking periods 96 conductors 347 efficacy protocols 86 EMI risks 226 energy 69, 78, 350, 364 high-voltage coil 65 lead connections 65 lead evaluation 376–7 lead placement 71 monophasic shock 76 proarrhythmia induction 184 proarrhythmia treatment 189 pulses 350 requirements 84 shifts 83 safety margin 350 shock 43 single 88 single-energy success protocol 350 single-shock protocol 350–1 step-down protocol 350 success curve 82, 83 413 9781405186384_6_index.qxd 414 10/27/08 5:02 PM Page 414 testing 72–3, 349 threshold 350 ventricular with atrial defibrillation 166, 167 waveforms 76 –7, 349 – 50 biphasic 349 monophasic 349 programming 78 – 9, 89 Weiss–Lapicque strength–duration curve 84 see also atrial defibrillation defibrillation coil dual/single 62 impedance 377 defibrillation electrodes 62– ancillary 63 subcutaneous array 89 distribution 64 high-voltage 55 defibrillation patches, epicardial/subcutaneous 63 defibrillation thresholds 72, 73, 77, 82–6, 350–2 antiarrhythmic drug therapy 186, 187 decrease 184 factors influencing 351 first shock 81, 86 high 69, 72, 89, 351 management 352 methodology 350 raising 372 second shock 81 single shock safety-margin testing 88 protocol 350 –1 single-energy success 86 step-down protocol 86 strength–duration curve 55 testing contraindications 353, 369 deferred 88 follow-up 353 need 353 risks 88 single shock safety-margin 88, 350–1 upper limit of vulnerability 87, 352 ventricular fibrillation induction 87, 88 defibrillators 4-pole 66 shocks 54 delayed afterdepolarizations (DAD) 36, 333, 341 depolarization 27, 30 arrhythmogenic RV dysplasia/cardiomyopathy 35 cardiac action potential 338 diastolic 338 interventricular delay 253 pacemaker-induced 150, 151 depression 192 detection 91, 143, 147, 355 – algorithms 355 – sensitivity/specificity 359 atrial rate counting 358 binning 105, 106 combined count 111, 356 consecutive 102 consecutive interval counting 355 criteria 101–2 discriminators 113 electrogram morphology 118–24 enhancements 357–538 hierarchy 137 interval running average 105 multizone configuration 356 overlapping VT/VF zones 107–8, 356 post-therapy algorithms 148 processes 360 rate 355, 371 sequential 102 simultaneous counting in two zones 110–11 VF & VT 109 St Jude’s running average 105–6 sustained rate duration 359 ventricular fibrillation 147 algorithm 114 sliding window 104 ventricular rate counting 358 ventricular tachycardia 102, 103, 122, 123, 147 x out of y counting 104, 355 zones 103, 355 see also redetection device checks 374 device interrogation 204, 376 diabetes mellitus 402 diagnostics value 208, 379 diaphragmatic myopotentials 383 avoidance 233 interference 306 diaphragmatic pacing 390 diaphragmatic stimulation 370 avoidance 233 diathermy, radiofrequency/microwave 385 dielectric 46, 56 dieting 402–3 difference amplifier 92 dilated cardiomyopathy with conduction defects 341 nonischemic 403 direct current (DC) voltage 346, 349 discrimination algorithms 357 atrial fibrillation 286–7 chamber of origin 359 detection enhancements 357–538 interval–stability criterion 357 morphology 357–8 post-shock 127 PR pattern 359 9781405186384_6_index.qxd 10/27/08 5:02 PM Page 415 premature stimulation 359 sinus rhythm template 358 sudden-onset criterion 357 sustained rate duration 127, 359 VT/SVT 357– 9, 371 by VA rule 304, 358 dual-chamber 358 – single-chamber 357– discrimination algorithms 126 –39 for atrial fibrillation 138, 139 pattern codes 136 St Jude Medical system 130 – sudden onset 307 discriminators 113 dual chamber 125, 371 duration-based features to override 141–2 interval stability 132 morphology 123 onset 326 overriding 371 programmed 182 safety net features 141–2 single-chamber 115, 135, 371 stability criterion 116 sudden onset 128, 130, 307 criterion 117 diuretics 396 Doppler techniques AV optimization in cardiac resynchronization 395 – resynchronization 251 driving 375 dual chamber EGMs 10 –11 analysis 202, 378 – dual chamber ICDs 113, 115, 125, 143 atrioventricular association 133 atrioventricular crosstalk with ventricular inhibition 293 discriminators 115 EGM analysis 202 indications for 337 dual tachycardia 262 duration timer 109 duration-based safety net 371 dynamic sensitivity adjustment 95 – auto-adjusting sensitivity 98 automatic gain control 97 E99 defibrillation success 82, 83 early afterdepolarizations (EAD) 30, 333, 339 ectopic beats, atrial tachycardia electric current viii, 61 alternating 272 average 85 exponential decrease 84 flow 344 industrial settings 227 leakage 228, 284 electric tools 386 electrical desynchronization, biventricular pacing systems 244 electrical storm 191, 222, 372–3 clinical manifestations 372 prognosis 373 therapy 373 unsuccessful ATP 275–6 electrocardiogram (ECG) biventricular pacemakers 391–2 follow-up 204 intracardiac 71 patterns in cardiac resynchronization therapy 390–1 during LV pacing 390 electrocautery electromagnetic interference source 385 EMI in hospitals 226 in hospitals 226, 380 magnet response 380 noise due to 329 surgery 380 electrodes see defibrillation electrodes electrogram (EGM) 377–9 amplitude 204 atrial 125, 376 dual ventricular tachycardia 288–9 far-field 93, 124, 220, 377 hybrid 377 morphology 118–24, 378 near-field 93, 124, 220, 354, 377 real-time 204, 377 regularity 378 shock 93, 377 single-chamber 201, 378 stored 196, 198, 205, 377–8 reading 378 sudden onset 378 telemetered 376 ventricular 377, 378 see also dual chamber EGMs; ventricular electrogram (VEGM) electromagnetic compatibility (EMC) problems 384 electromagnetic fields 225, 375 electromagnetic interference (EMI) 219, 223, 225, 384–7 conducted 225 external 200 generator damage 387 in hospitals 226, 385–6 ICD response 282–4 power-on reset 387 premature pacing triggering 387 415 9781405186384_6_index.qxd 416 10/27/08 5:02 PM Page 416 radiated 225 rapid pacing triggering 387 responses 387 sources 224, 385 – daily life 386 industrial environment 227, 387 medical 385 – susceptibility of ICDs 384 – electromagnetic spectrum 224 electrophysiology expertise 70 strength–duration curve 85 study in Brugada syndrome 33 electrosurgery electromagnetic interference 226, 385 management of ICD patients 213 emergency room, ICD patient management 214 emergency situations 380 – 81 endocarditis 402 endocrine disorders 402 endoscopy with wireless video-capsule 226, 386 end-stage renal failure 402 energy battery 59 capacitors 53, 54, 345 delivered 80 stored 80, 345 defibrillation 69, 78, 350, 364 dose 85 delivered 80, 85, 350 E99 defibrillation success 82, 83 stored 80, 350 capacitor charging time 81, 350 transfer in transformers 59 – 60 units 54 voltage relationship 81 entrainment 11 epicardial patches 347 epsilon wave 341 erosion complications 370 European Society of Cardiology guidelines 400–5 exercise catecholaminergic polymorphic ventricular tachycardia 341 long QT syndrome 31, 339 T wave sensing 261 extracardiac signals, oversensing 200, 383–4 farads 45 far-field electrogram (EGM) 93, 124, 220 far-field P-wave oversensing 271 far-field R-wave criterion 138 far-field R-wave oversensing 100, 199, 354, 383 far-field R-wave sensing 139, 204 atrial 319 control 367 detected as AF/AT 323 intermittent pre-ventricular/post-ventricular 318 far-field R-wave suppression 175 fever, Brugada syndrome 32 ‘fib therapy’ 142 fibrillation detection interval (FDI) 109 filters, band-pass 92, 384–5 flecainide 340 fluid index 254 fluoropolymers 348 follow-up of ICDs 196–216, 374–81 antiarrhythmic drugs 204, 376 audible alarms 380 automatic monitoring 380 delivered therapy 198 emergency situations 380–1 history taking 196, 197, 204, 375–6 outpatient 375 physical examination of patient 196, 375–6 remote 210–12, 377, 379–80 silent leads malfunction 291 symptoms before shock 197 fusion beats 13 gene mutations gain/loss of function 338 long QT syndrome 339 generator casing 342 complications 178, 370–1 electromagnetic interference damage 387 genetic arrhythmia syndromes 405 Guidant ICD 65 capacitor charging 146 deactivation using magnet 216 detection 356 discrimination algorithm 358 discriminator override 141 marker channel for CRT devices 257 morphology algorithm 118 OBDE discrimination algorithm 128, 129 redetection 149 RHYTHM ID™ discrimination algorithm 126–7, 129 simultaneous counting in two zones VF & VT 109 sustained-duration override 141, 359 tachycardia detection 147 tilt 78 timing cycles 172–4 ventricular fibrillation induction 75 Vitality–vector timing algorithm 124 guidelines for ICD therapy see indications for ICD, guidelines Haar wavelets 120, 121, 358 header of ICD 342 9781405186384_6_index.qxd 10/27/08 5:02 PM Page 417 heart disease advanced structural 25 congenital 401–2 valvular 401 heart failure cardiac resynchronization therapy 396–8 device monitoring 397– drug-refractory 26 indications for ICD 404 – volume overload 254 heart rate nocturnal 398 variability 398 hemoptysis, venous access complications 368 hemothorax, venous access complications 368 high rate timeout 359 high-voltage charging circuit 58 – 61, 346 high-voltage impedance 220, 221 His–Purkinje system, conduction 124 history taking 196, 204, 375 – symptoms before shock 197 home appliances 386 hospital admission 214 hospital discharge, patient instructions 193–4, 374–5 hypertrophic cardiomyopathy 37, 403 indications for ICD 340 –1 mitral regurgitation 37 risk stratification 38 sudden cardiac death 341 triggers 38 identification card 193 impedance high-voltage 220, 221 intrathoracic 398 low-voltage 221 pacing 71, 220, 221 shocking 221 implantable cardioverter-defibrillator (ICD) alert sounds/audible alarms 380, 381 automatic monitoring 380 biphasic high voltage pulse 52 biventricular 166, 230 complications 177– 94 conditions for which treatment not useful/effective 26 device viii interrogation 204, 376 diagnostic data 379 equipment complications 179 hardware 39 – 66, 342– identification 376 housing 385 identification card 193 inactivated 181, 371 monophasic high voltage pulse 52 reprogramming 207 special functions 166–7, 230–5 therapies 360–66 absent/delay 181, 371 complications 177–94, 368–73, 351 inappropriate delivery 179, 222, 300, 308, 328, 371 treatment withdrawal 373 turning off 381 see also dual chamber ICDs; single chamber ICDs implantation of ICD 67–89 bipolar endocardial signal 71 chest X-ray 71 defibrillation testing 72–3 electrophysiology expertise 70 equipment check 70 pacing function 71 pacing impedance 71 patient chart access 70 requirements 70 testing 72–3, 285 voltage threshold 71 incision monitoring 374 indications for ICD 21–38, 337–41 arrhythmias genetic syndromes 341, 405 in structurally normal hearts 405 ventricular associated with cardiomyopathies 403–5 arrhythmogenic RV dysplasia 341 Brugada syndrome 339–40, 405 catecholaminergic polymorphic ventricular tachycardia 341, 405 class I indications 23, 24, 337, 400 class II indications 23, 25, 337, 400 class III indications 23, 26, 337, 400 congenital heart disease 401–2 evidence weight 23, 24–6, 337 genetic arrhythmia syndromes 341, 405 guidelines 23, 24–6, 337, 400–6 heart failure 404–5 hypertrophic cardiomyopathy 340–1 inflammatory conditions 402–3 lamin A/C gene mutations 341 long QT syndrome 338–9, 405 LV dysfunction with prior myocardial infarction 397–8 metabolic conditions 402–3 primary prevention 22, 23 secondary prevention 22 torsades de pointes 339 valvular heart disease 401 ventricular arrhythmias associated with cardiomyopathies 403–5 infections cardiac resynchronization therapy 389 complications 370 417 9781405186384_6_index.qxd 418 10/27/08 5:02 PM Page 418 infiltrative cardiomyopathies 402 inflammatory conditions, indications for ICD 402–3 interburst decrement 362 interfascicular tachycardia 15 interstimulus interval 154 interval running average 105 interval stability, VV 137 interval stability discrimination (ISD) 132, 135 intervals, average/current 106 interventricular conduction delay 253 interventricular depolarization delay 253 interventricular dyssynchrony 231 interventricular interval programming 396 intracardiac signals, oversensing 199, 382–3 intrathoracic impedance 398 intraventricular dyssynchrony 231 ion channels malfunction 29, 338 short QT syndrome 34 ionic currents 27 equilibrium 28 ionizing radiation 225, 387 irradiation, direct 385 IS-1 connection 65, 347 ISO standards four-pole connector 66 lead connections 65 Jervell–Lange Nielsen syndrome 29, 339 joules 54, 345 KCNH2 gene mutations 34, 339, 340 KCNQ1 gene mutations 34, 340 lamin A/C gene mutations 341 leads 62– 4, 347– atrial abrading into RV 328 fracture 312 ventricular lead reversal 180 bipolar 347, 385 ’chatter’ 219 coaxial 64 complications 177, 370, 372, 389 conductor fracture/defect 376 connections 64, 347– construction 347 design 347 diaphragmatic stimulation 370 dislodgment 370, 372 LV lead 389 dual coil integrated 180, 347, 349 reversed coil connection 302 evaluation 376 –7 false signals 384 fractures 219 atrial 312 noise due to 330–1 impedance 204, 376–7 insulation 348 defects 219 failure 376 make and break signals 384 malfunction 370, 384 intermittent with oversensing 308 noise due to fracture 330–1 silent 291 malposition 369 multilumen 64 noise from contact 327 noise on sensing 327 oversensing of extracardiac signals 200, 384 pacing impedance/threshold 376 reversal 180 in header 328 R-wave amplitude 376 shocking 376–7 short circuit 376 short tip-to-ring spacing 347 single-coil 347, 349 subcutaneous array 347 systems 349–52 testing for problems 220 transvenous 347 true bipolar 347 ventricular polarity 232 reversal 180 leakage current 228 ICD response to electromagnetic interference 284 left bundle branch block 13–14 interventricular dyssynchrony 231 lithium-SVO battery 40–2 cathode 42 dual energy source 343 voltage 41 delay 42 lithotripsy 226, 386 long QT syndrome 29 acquired 29 arrhythmia source 30 beta-blockers 339 cardiac event triggers 31 cause 33 clinical phenotypes 339 clinical symptoms 31 congenital 29 exercise 31, 339 genetics 29, 339 indications for ICD 338–9, 405 phenotypes 29 9781405186384_6_index.qxd 10/27/08 5:02 PM Page 419 T wave oversensing 294 – types 31, 339 lookback window 122 low-voltage impedance 221 lung fluid monitoring 254 LV contraction 389 dysfunction with prior myocardial infarction 403 dyssynchrony 187, 394 – cardiac resynchronization 231 end-systolic volume (LVESV) 389 failing 402 filling, cardiac resynchronization therapy 250 function 22 hypertrophy, hypertrophic cardiomyopathy 37, 38 lead displacement 391 pacing ECG patterns 390 monochamber with RV anodal capture 242–3 rejection fraction (LVEF) 22 therapy indications 25 remodeling 397 magnesium 373 magnetic reed switches 215 closure 387 magnetic resonance imaging (MRI) contraindication 226 contrast-enhanced 234 electromagnetic interference source 385 magnets application over ICDs 215, 380 – 81 Guidant ICD deactivation 216 Mahaim fibers 12 Managed Ventricular Pacing (MVP) 165, 365 Markers 256 –258 maximum time to diagnosis (MTD) 142, 359 maximum time to fib therapy (MTF) 142 Medical Implant Communications System (MICS) 209 medications, ICD interactions 179, 184 Medtronic ICD 65 antitachycardia pacing delivery 363 atrial tracking recovery 246 capacitor charging during ATP 162 Cardiac Compass 208 combined count detection 111 detection 356 by electrogram morphology 120 –2 discrimination algorithm 358 empiric settings 160 high rate timeout 359 internet-based remote monitoring 210–11 Managed Ventricular Pacing 165, 365 markers 256 morphology algorithm 118 new battery technology 343 OptiVol Fluid Status Monitoring 254, 398 overlapping VT/VF zones 107–8 PR Logic™ discrimination algorithm 136–9 atrial fibrillation 286 sinus tachycardia therapy witheld 277 sinus tachycardia with long PR misinterpreted as VT 278 upgraded 140 programming for fast ventricular tachycardia 361–2 simplified 161 redetection 149 simultaneous counting in two zones 110–11 tachycardia detection 147 tilt 78 timing cycles 170–1 ventricular fibrillation induction 75 metabolic conditions, indications for ICD 402–3 mitral regurgitation 37 mode switching automatic 365 episodes 205 modulated high-frequency (HF) waves 227 monitor zone 364 morphology markers 259 myocardial infarction (MI), LV dysfunction 400–1 myocardial refractory period 151 myocarditis 402 myocardium, refractory period 169 myopotentials 27, 28 delivered/aborted shock due to oversensing 219 diaphragmatic 383 avoidance 233 diaphragmatic interference 306 oversensing 99, 200, 354, 383–4 pectoral 383–4 near-field electrogram (EGM) 93, 124, 220, 354, 377 neuromuscular disorders 404 noise-sampling window 385 non-committed systems 101 non-committed therapy 146 number of intervals needed to detect (NID) 102, 108, 111 combined 111, 356 programmable 355 redetection 148, 149 OBDE (One Button Detection Enhancement) discrimination algorithm 128, 129 obesity 402–3 obstructive subaortic pressure gradient 37 Ohm’s law 60, 221, 344 onset discriminator 326 OptiVol Fluid Index 398 419 9781405186384_6_index.qxd 420 10/27/08 5:02 PM Page 420 OptiVol Fluid Status Monitoring 254, 398 orthodromic AV reentrant tachycardia, wide QRS tachycardia 12 orthodromic reciprocating tachycardia (ORT) 2, 5, 334 antitachycardia pacing 17 oversensing 198, 382– during baseline rhythm 222 electromagnetic interference 219 extracardiac signals 200, 383 – far-field P-wave 271 far-field R-wave 100, 199, 354, 383 follow-up 207 inappropriate shocks 179, 308 intermittent lead malfunction 308 intracardiac signals 199, 382–3 myopotentials 99, 200, 354, 383–4 nonphysiologic signals 219 P wave 199, 218, 296, 382 far-field 271 R wave double counting 218 far-field 100, 199, 354, 383 shocks due to 218 –19 T wave 199, 218, 290, 313 –14, 383 long QT syndrome 294 – during slow VT 299 ventricular electrogram 218 P wave atrial tachycardia automatic unlocking from PVARP 395 delayed restoration of tracking 393 duration 252 far-field sensing/oversensing 271 locking inside PVARP 394 – oversensing 199, 218, 296, 382 far-field 271 premature ventricular complex 260 tracking and ventricular desynchronization 245 upper rate limitation 393 pacemaker(s) automatic mode switching 365 biventricular anodal stimulation 391–2 ECG 392 upper rate response 392–3 upper rate response programming 393–4 capacitor output 345 connector system 66 interference with ICD 181 magnet application 215 output pulse 50 programmer 71 pulse 55 duration 51, 345 pacemaker stimulus biventricular systems 239 reentry tachycardia termination 151 pacemaker syndrome 187 Pacemaker System Analyzer (PSA) 71 pacing antibradycardia 164 atrium 252 biventricular 389 anodal stimulation 390–1 QRS duration 390–1 with RV lead located at apex 391 capture threshold increase 184 diaphragmatic 390 ICD battery depletion 187 ICD function 293 impedance 71, 204, 220, 221, 376 inhibition by electromagnetic interference 387 interval 153 lead impedance 204 LV ECG patterns 390 monochamber 236 monochamber with RV anodal capture 242–3 modes 365 parameters 164 post-shock 164, 365 premature 387 programming of antitachycardia 88 RV monochamber 235 single chamber ventricular 235 threshold, tests 204, 375 triggering of rapid by electromagnetic interference 387 ventricular antitachycardia 377–8 ventricular sensing lead 375 see also antitachycardia pacing (ATP); biventricular pacing systems; bradycardia pacing patient(s) clinical history 382 follow-up 196–216 history 196, 197, 204, 375–6 management with multiple shocks 222 pacemaker-dependent 385 physical activity monitoring 398 physical examination 196, 375–6 problems 179 psychological problems 192, 204, 373 patient instructions device checks 194 follow-up 194 hospital discharge 193–4, 374–5 psychological problems 192, 373 shocks 374 pattern codes 136 pectoral myopotentials 383–4 pericardial disease 403 9781405186384_6_index.qxd 10/27/08 5:02 PM Page 421 phrenic nerve stimulation 233, 390 physical activity monitoring 398 see also exercise physical examination of patient 196, 375–6 pneumothorax 368 pockets/pocket-related complications 177, 370 electrical noise artifacts 384 hematoma 370 manipulation 384 monitoring 373 seroma 370 polyurethane 348 postshock pacing 164 postventricular atrial blanking (PVAB) 100, 170, 171, 172, 367 postventricular atrial refractory period (PVARP) 172, 173, 367 P wave automatic unlocking/locking inside 395 P wave upper rate limitation 393 pre-empted Wenckebach upper rate response 392–3 resynchronization loss 244 upper rate programming 393 – ventricular desynchronization 245 potassium channel blockers 186 potassium channels, short QT syndrome 340 potential energy 345 power-on reset 387 PP intervals median 138 tachycardia with 1:1 AV relationship 10 PR intervals, discrimination algorithm 140 PR Logic™ discrimination algorithm 136–9 atrial fibrillation 286 sinus tachycardia therapy witheld 277 sinus tachycardia with long PR misinterpreted as VT 278 upgraded 140 PR pattern 359 premature ventricular complex (PVC) 260 ventricular tachycardia initiation 262, 266 primary prevention 22 antitachycardia pacing programming 362 trials supporting 23 proarrhythmia 184, 372 after cardiac resynchronization therapy 399 antiarrhythmic drug-induced 187, 188, 376 ATP-induced 189 classification 188 ICD-induced 179, 189, 190 risk with cardioversion 363 procainamide 340 programmers 348 programming 196 complications 179 simplified ICD 160 –1 wireless 209 propofol 373 psychiatric illness aggravated by device implantation 26 psychological problems of patients 192, 204, 373 pulmonary arterial hypertension 403 pulmonary embolism 368–9 pulse duration fine tuning 79 fixed 79 length 85 short 78 pulse increment 154 QRS complex detection by electrogram morphology 122 double counting 218 frontal plane axis 391 narrow 388, 391 negative in lead V1 391 paced duration 390–1 peak 252 see also wide QRS tachycardias QT interval 27 depolarizing currents 338 repolarizing currents 338 see also long QT syndrome; short QT syndrome Quick-Opt 252, 253 Timing Cycle Optimization 396 R wave amplitude 376 discrimination algorithm 136 dominant during biventricular pacing 239 double counting 199, 218, 310, 383 ATP-induced intermittent 305 far-field criterion 138 oversensing of far-field 100, 199, 354, 383 pacing pulse measurement 95 premature ventricular complex 260 railroad track pattern 383 sensing 92 sensing of far-field 139, 204, 319, 367 detected as AF/AT 323 intermittent pre-ventricular/post-ventricular 318 signals 354 radiation acoustic 225 industrial sources 227 ionizing 225 radiofrequency ablation 373, 386 radiotherapy electromagnetic interference 385 risks 226 ramp decrement 157, 159 ramp pacing 154, 156, 362 421 9781405186384_6_index.qxd 422 10/27/08 5:02 PM Page 422 cycle length 160 electrical storm and unsuccessful ATP 276 ramp scheme, adaptive 159 ramp-scan scheme 159 Rate Branch algorithm 130 recommendations for ICD therapy 406–7 recommendations for cardiac resynchronization therapy 407 rectifier 92 rectifying diode 58, 60 –1 redetection 139, 143, 148 – 9, 360 –61 antitachycardia pacing 154 number of intervals needed to detect 148, 149 treatment intensity 148 reed switch 387 reentrant tachycardias reentry 333 refractory periods 169 absolute 367 relative 367 timing cycles 170, 172, 175, 367 remote monitoring, internet-based 210–12, 375, 379 – 80 repolarization 28, 30 arrhythmogenic RV dysplasia/cardiomyopathy 35 Brugada syndrome 340 cardiac action potential 338 short QT syndrome 34 reset 150 respiration, lead malfunction 331 resting membrane potential 337–8 resynchronization loss 244 rheobase current 84, 85 rheumatic disease 402 rhythm confirmation 360 RHYTHM ID™ discrimination algorithm 126–7, 129 right bundle branch block 13 –14 ECG patterns during LV pacing 390 RV anodal capture with monochamber LV pacing 242–3 RV perforation 368 RV anodal stimulation 241 biventricular pacing 392 RV myocardium, fibrofatty infiltration 35 RV pacing, minimizing 165, 364 –5 Romano–Ward syndrome 29, 339 RR intervals discrimination algorithm 136, 140 follow-up 205 median 138 tachycardia with 1:1 AV relationship 10 ryanodine (RyR2) gene mutations 36, 341 sarcomeric protein mutations 38 scan decrement 157, 159 SCN5A gene mutations 34, 340 secondary prevention 22 sense amplifier, blanking period 169 sensed refractory period 99 sensing 91, 94–100, 143, 354 amplifiers 384 atrial 166, 252 bipolar 227 circuits 92 decay delay 354 dynamic sensitivity adjustment 95– lead evaluation 376 rate 354 sensitivity 354 signal amplitude 94, 354 small amplitutde signals in ventricular fibrillation 94 T wave during exercise 261 VA far-field 358 see also far-field R wave sensing sensitivity 354, 359 auto-adjusting 96, 354 measure 114 threshold 95, 96, 98 setscrew, loose 369, 370, 384 shock (HV) impedance 72, 384 shock electrogram 93, 377 shock truncation 345 shocking coils 347 shocking pathway 220 impedance 376 shocking vectors 349 active can systems 69 non-active can 68 shock-on-T-wave 349 shock/shock therapy 145, 146, 147 aborted 218–19, 360 appropriate 222 biphasic 77, 85, 349–50 cause diagnosis 382 committed 145, 147, 222, 360 unsustained ventricular tachycardia 316 ventricular fibrillation redetection 313–14 defibrillation 43 defibrillators 54 efficacy 366 misclassification 183 electrical storm and unsuccessful ATP 276 failure 148 first 81, 86 high-energy 364 high-voltage 164 ICD testing at implantation 285 impedance 77, 84, 89, 207, 221, 375–6 inappropriate 179, 222, 371 and combined count during AF 300 intermittent lead malfunction 308 9781405186384_6_index.qxd 10/27/08 5:02 PM Page 423 lead reversal in header 328 oversensing 179, 308 leads 376 –7 malfunction checking 291 low-energy 149 magnet application 215 management 382 maximum 149 misclassified 372 monophasic 76, 85 multiple 214, 222, 374 noncommitted 146, 147, 372 number for ventricular tachycardia 191 oversensing 218 –19 patient instructions 194, 374 patient-related factors 372 phantom 198, 214, 382 psychological problems of patients 192 second 81 single 214 symptoms before 197 therapy 143 traveling wavefronts 82 unsuccessful 371–2 upper limit of vulnerability 87 ventricular fibrillation induction 273, 274 ventricular tachyarrhythmias 198 ventricular tachycardia with 1:1 conduction causing acceleration 309 treatment 270 voltage 76 waveform 76, 77, 85 energy 80 short QT syndrome 34 indications for ICD 340 silicon controlled rectifiers (SCRs) 52 silicone 348 silver vanadium oxide (SVO) 342–3 single chamber ICDs 113, 115, 143 dscriminators 115 EGM analysis 201 indications for 337 single-energy success 86 sinus bradycardia induction 184 sinus interval history (SIH) 135 sinus rhythm antiarrhythmic drug effects 185 atrial tachycardia AV-nodal reentry tachycardia detection zones 103 EGM amplitude 204 normal 124 orthodromic reciprocating tachycardia P-wave oversensing 199 template 358 ventricular fusion 240 sinus tachycardia (ST) 2, 269 desynchronization 244 detection rule 140 discrimination algorithms 139, 140 discrimination from VT 140 with long PR misinterpreted as VT 278 onset speed 115, 117 tachycardia with 1:1 AV relationship 10 therapy witheld by PR Logic 277 VEGM rate increase 115 slot machines 386 SMARTSensing™ 174 sodium channel blockers 186 specificity of algorithm 359 measure 114 St Jude Medical ICD 65 DC fibber ventricular fibrillation induction 301 detection 355 by electrogram morphology 123 discrimination algorithm 130–5, 357 sudden onset 307 discriminator override 142 dual chamber approach 131 dynamic sensitivity adjustment 98–9 fixed pulse width 79 markers 258–9 maximum time to diagnosis/fib therapy 142, 359 morphology algorithm 118 Quick-Opt 252, 253, 396 redetection 149 running average for initial detection 105–6 sudden onset discriminator 307 tachycardia detection 147 tilt 78 timing cycles 175 ventricular fibrillation induction 74 ST segment, long QT syndrome 29 stability algorithm 129 stability criterion 116 stability discrimination, atrial fibrillation 286–7 Staphylococcus infections 370 step-down protocol 86 stimulus interval 154 ATP sequence programming 158, 159 strength–duration curve 84, 85 stress 192 catecholaminergic polymorphic ventricular tachycardia 341 reduction 373 stun guns 386–7 sudden cardiac death arrhythmogenic RV cardiomyopathy 35 arrhythmogenic RV dysplasia 35, 341 catecholaminergic polymorphic ventricular tachycardia 36 423 9781405186384_6_index.qxd 424 10/27/08 5:02 PM Page 424 guidelines for prevention 400 –5 hypertrophic cardiomyopathy 37, 38, 341 short QT syndrome 34 unexplained 25 sudden onset (SO) criterion 117 sudden onset (SO) discriminators 128, 130, 134 superior vena cava single lead 63 supraventricular tachyarrhythmias 333–4 antiarrhythmic drug effects 185 management 222 supraventricular tachycardia (SVT) 1, 1:1 AV conduction 139, 371 after ventricular tachycardia treatment 182 antitachycardia pacing 378 –9 atrioventricular conduction 202 detection 101, 122, 123 diagnosis 182, 203, 378 –9, 379 from stored electrograms 16–20, 378–9 discriminators 182, 371 fast 160 ICD-induced 190 inappropriate therapy 303 limit 137 mechanisms –9 morphology of EGM 115 onset rate 134 recorded episode evaluation 205 response to therapy 203 shock-induced 183 sinus morphology 201 tachycardia with 1:1 AV relationship 10, 11 ventricular antitachycardia pacing 378–9 ventricular tachycardia discrimination 357–9, 371 by VA rule 304 wavelet reconstructions 120 wide QRS tachycardia 12, 14 supraventricular tachycardia (SVT)–ventricular tachycardia (VT) discriminators 371 see also discriminators sustained rate duration (SRD) 127, 359 sustained-duration override 141, 359 swimming 31, 339 syncope advanced structural heart disease 25 cardiopulmonary resuscitation 375 catecholaminergic polymorphic ventricular tachycardia 36 hospital admission 214 hypertrophic cardiomyopathy 37, 38 short QT syndrome 34 sudden 31 sustained ventricular arrhythmias 25 undetermined origin 22, 24, 26 unexplained etiology 25 system component testing 196 T wave long QT syndrome 29, 294–5 oversensing 199, 290, 313–14, 354, 383 long QT syndrome 294–5 during slow VT 299 of spontaneous 218 sensing during exercise 261 shock during vulnerable period 74 ‘tach therapy’ 142 tachyarrhythmias 1–20 ICD-induced 190 St Jude Medical markers 259 therapies during electrosurgery 213 see also supraventricular tachyarrhythmias; ventricular tachyarrhythmias tachycardia mechanisms 333 thoracic impedance trend 254 threshold start (TS) 99 tiered therapy 141–2, 148, 152, 360 advantages 152 antitachycardia pacing 361 atrial 167 disadvantages 152 tilt 51, 52, 53, 78, 345 time constant (τ) 48, 77 timing cycles 367 blanking periods 171, 172, 173, 174, 175, 367 noise-sampling periods 367 refractory periods 170, 172, 175, 367 timing in ICDs 169–75 Medtronic ICD 170–1 St Jude Medical 175 tissue Doppler, resynchronization 251 torsades de pointes 30, 335 adrenergic stimuli 31 after cardiac resynchronization therapy 399 indications for ICD 339 total atrial refractory period (TARP) 245 transformers 58, 59–60, 346 energy transfer 60 transient arrhythmias 403 treatment withdrawal 373 troubleshooting 217–28, 382–7 truncation 349 undersensing 371 upper limit of vulnerability (ULV) 87, 352 upper rate response of biventricular pacemakers 392–3 programming 393–4 V Fib burst, ventricular fibrillation induction 75 valvular heart disease 401 vector timing algorithm 124 vector timing and correlation (VTC) 126, 127, 358 venous access complications 177, 368–9 9781405186384_6_index.qxd 10/27/08 5:02 PM Page 425 venous thrombosis 368 ventricular antitachycardia pacing 378 –9 ventricular arrhythmias 334 – associated with cardiomyopathies 403–5 detection 101, 184 guidelines 400 – sustained 25 ventricular ATP 1, 11, 16 –20 with atrial entrainment and AAV response 18 termination of tachycardia without depolarization of atria 20 without atrial entrainment 19 ventricular blanking/blanking periods 170, 171, 172, 174, 367 ventricular burst pacing, high frequency 349 ventricular channel dual-chamber mode 174 P wave oversensing 296 timing cycles 170, 172, 175 ventricular defibrillation with atrial defibrillation 166, 167 ventricular desynchronization, P wave tracking 245 ventricular electrogram (VEGM) 93, 377–9 amplitude 104 fluctuations 181 amplitude reduction 73 automatic gain control 97 discrimination 357– far-field 93 morphology detection 119 near-field 93 oversensing 218 rate 104 rectified 95 supraventricular tachycardia 10 undersensing 181 ventricular fibrillation 94 ventricular events paced 96, 98 sensed 96, 97, 98 sensing 95 ventricular extrasystole ventricular fibrillation (VF) 2, 335 arrhythmias amenable to ablation 26 bin count 105 cardiac arrest 24, 25 counter 110 –11 detection 147, 355 – algorithm 114 interval 103, 104 sliding window 104 dual tachycardia 262, 288 –9 failure to terminate 222 ICD response to electromagnetic interference 282– ICD-induced 190 inappropriate detection/cessation after shock 228 incessant 26 induction 72, 73, 74–5 by 50 Hz and DFT testing 274 by AC current 272 by DC fibber 301 by shock and ICD testing 273 Medtronic ICD empiric settings 160 Medtronic markers 256 noise detected as 264 overlapping with VT zone 107–8 redetection with committed shock 313–14 sensing potentials 72 sensitivity of algorithm 114 simultaneous counting in two zones with VT 109 sliding window 109 small amplitutde signal sensing 94 specificity of algorithm 114 spontaneous 88 successful conversion 349 sustained 24 upper limit of vulnerability 87 ventricular electrogram 94 ventricular flutter 335 ventricular fusion 240 beats with native conduction 391 ventricular leads dislodgement 372 noise from contact 327 polarity 232 reversal 180 ventricular pacing safety 171 single chamber 235 ventricular premature contractions 136 ventricular proarrhythmia after CRT 399 ventricular rate atrial fibrillation 202 counting 125, 358 ventricular tachycardia 202 ventricular refractory period 174 ventricular resynchronization, mechanical 390–1 ventricular safety pacing 171 ventricular sensing, CRT device memorizing 248 ventricular stability 115 ventricular tachyarrhythmias 198 electrical storm 372 familial/inherited conditions 25 reversible 337 shock 198 spurious detection 387 tiered therapy 152 transient/reversible disorder 26 underdetection 179, 181 ventricular tachycardia (VT) 2, 335 with 1:1 AV relationship 10–11 425 9781405186384_6_index.qxd 426 10/27/08 5:02 PM Page 426 with 1:1 retrograde VA conduction 358 with 1:1 VA conduction 10, 267 accelerated by low-energy shock programmed for cardioversion 149 by shock with 1:1 VA conduction 309 accelerated by ATP 281, 372 intermittent double R wave counting 305 and terminated by maximum shock 149 acceleration 270, 361 Wenckebach block 320 antiarrhythmic drug effects 185 and ATP 268 no termination by 16 atrial flutter treated as 279 atrial rate 202 atrioventricular conduction 202 atrioventricular dissociation 266 bidirectional 36, 335 biventricular ATP 297 bundle branch reentrant 335 – cardiac arrest 24 catecholaminergic polymorphic ventricular tachycardia 36 clinical data 203 conduction vector 124 continuation after therapy 182 during capacitor charging 146 counter 110 –11 cycle lengths 103 antiarrhythmic drug therapy 187 deceleration 372 detection 102, 103, 122, 123, 147, 355–6 with combined count 324 interval 102, 103, 147, 286, 287 diagnosis 113, 182 discriminators 182, 326 double 325 dual 288 –9 EGM morphology 201 electrocardiographic diagnosis 336 failure to terminate 222 fast 107– 8, 155 ATP use 361 Medtronic ICD empiric settings 160 Medtronic ICD programming 361–2 Medtronic ICD simplified programming 161 rule of 160 treatment 363 hypertrophic cardiomyopathy 38 ICD response to electromagnetic interference 282– ICD-induced 190 idiopathic 405 inappropriate programmed therapy 181 incessant 26, 191, 222 induction by premature ventricular complex 260, 262 irregular 311 Medtronic ICD empiric settings 160 Medtronic markers 256 monomorphic 335 morphology of EGM 115 no termination by ATP 16 nonsustained with coronary artery disease 24, 25 onset discriminator response 326 overlapping with VF zone 107–8 polymorphic 335 proarrhythmia after cardiac resynchronization therapy 399 recurrent during electrical storm 275–6 reentrant termination by ATP 150 –1 repetitive 372 response to therapy 203 resulting from arrhythmias amenable to ablation 26 retrograde conduction 280, 315 retrograde Wenckebach block 320 shock to with 1:1 conduction causing acceleration 309 shocks 191 simultaneous counting in two zones with VF 109 sinus interval history 135 sinus tachycardia discrimination 140 with long PR misinterpreted as 278 sliding window 109, 148, 149 slow 155, 156, 358 ATP use 361 T wave oversensing 299 slower than programmed detection rate 371 spontaneous 88 sustained 24 sudden onset 115, 117, 134, 201, 378 sustained 24 SVT discrimination 357–9, 371 by VA rule 304 tachycardia with 1:1 AV relationship 10 termination by ATP 16 during capacitor charging 145 undetected 183 ventricular rate 202 wavelet reconstructions 120 wide QRS tachycardia 12, 14 see also electrical storm ventricular tachycardia–supraventricular tachycardia boundary 136, 139 voltage AC for ventricular fibrillation induction 75 capacitors 344, 345 9781405186384_6_index.qxd 10/27/08 5:02 PM Page 427 conversion of low to high 59 – 60 DC 60 ventricular fibrillation induction 74 decay rate 349 energy delivered calculation 85 energy relationship 81 force generation 80 high in industrial settings 227 induced by transformer 60 shock 76 shocking impedance 84 threshold at implantation 71 volume overload 254 Vtip seal plug, air escape 327 VV intervals 137, 138 median 137 optimization 250 –3 warm-up phenomenon wavelet algorithm 122 wavelet analysis 121 wavelet coefficient 120 Weiss–Lapicque strength–duration curve 84 Wenckebach block pre-empted behaviour with short atrioventricular delay after sensing 247 retrograde 320 upper rate response 247 pre-empted 248, 392–3 ventricular tachycardia with retrograde conduction 315 wide QRS tachycardias 1, 12–14, 335–6 approach 13–14 causes 12 differential diagnosis 336 left bundle branch block 13–14 precordial leads 14 right bundle branch block 13–14 wireless communication devices 386 wireless programming 209 work 54 X-rays 226 see also chest X-ray 427 ... 10 /27 /08 3:58 PM Page 22 7 22 7 Figure 11.10 9781405186384_4_011.qxd 10 /27 /08 22 8 Figure 11.11 3:58 PM Page 22 8 9781405186384_4_0 12. qxd 10 /27 /08 3:50 PM Page 22 9 22 9 Figure 12. 00 Implantable Cardioverter- Defibrillators. .. 9781405186384_4_0 12. qxd 10 /27 /08 3: 52 PM Page 23 9 23 9 Figure 12. 10 9781405186384_4_0 12. qxd 10 /27 /08 24 0 Figure 12. 11 3: 52 PM Page 24 0 9781405186384_4_0 12. qxd 10 /27 /08 3: 52 PM Page 24 1 24 1 Figure 12. 12 9781405186384_4_0 12. qxd... 9781405186384_4_0 12. qxd 10 /27 /08 23 0 Figure 12. 01 3:50 PM Page 23 0 9781405186384_4_0 12. qxd 10 /27 /08 3:51 PM Page 23 1 23 1 Figure 12. 02 9781405186384_4_0 12. qxd 10 /27 /08 23 2 Figure 12. 03 3:51 PM Page 23 2 9781405186384_4_0 12. qxd