Double anti-tachycardia pacing sequence - Viva Quad CRT-D

Patient


Male implanted with a triple chamber defibrillator (Viva Quad CRT-D) for ischaemic cardiomyopathy.


Trace

1- What diagnosis is suggested by the interval plot?
Probable episode of monomorphic VT detected in the VF zone and treated by a first burst which appeared ineffective and then by a second burst which appeared effective.

2- What is the first therapy delivered by the device?
The episode is detected in the VF zone; when the initial VF counter is full, a burst before charging is delivered.

3-Has the device charged its capacitors?
No, this is a burst before charging; when the burst is effective, the device does not charge its capacitors.

4- What is the second therapy delivered by the device?
The first burst was ineffective; the redetection criterion is verified (12 / 16 cycles classified as VF); the second therapy is a burst during charging (ATP + start of capacitor charging).

5- What does ‘abandon’ mean?
The burst was effective in terminating the arrhythmia; after 4 consecutive ventricular paced cycles, the criterion for confirming the persistence of the arrhythmia is not met (criterion of 2/5 rapid cycles) and the charge is interrupted (therapy discontinued).

Comments

Take home message

  • This tracing shows a specific aspect of Medtronic defibrillators: the possibility of programming 2 bursts of ATP in the VF zone for the same episode.
  • When ATP before charging is programmed, a first burst is delivered; if this burst proves ineffective, a burst during charging is delivered where the second burst and charging occur simultaneously; this helps increase the proportion of arrhythmias detected in the VF zone that are terminated by pacing rather than a shock.
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