Chapter 5 · Remote monitoring · Transmission 8
Lead Parameters Evaluation (LPE) RV alert
Patient
- 78-year old patient implanted with a dual chamber ICD (Talentia DF4 DR) four months prior because of dilated cardiomyopathy.
You receive the following transmission:
Your turn
What are the appropriate next steps?
- Call the patient to the clinic in order to deactivate the therapies
- Tell the patient not to drive to the clinic themselves
- This appears to be a measurement error. Schedule a new transmission in a week.
- Perfom lead testing in the clinic with arm and breathing manoeuvres
- The RV lead most likely needs to be changed.
Clinical case
The patient was contacted and asked to come into the device clinic for a manual check-up. The 12-lead ECG showed ventricular escape rhythm and ventricular pacing spikes without capture. The patient had no new symptoms, NYHA II.
Interrogation
The overview screen shows abnormal sensing values for the RV, 0 episodes but multiple alerts (red button).
The alert list confirms the presence of the Lead Parameter Evaluation (LPE) alert based on changes in sensing amplitude, autothreshold and impedance. There is also an older alert for RV threshold only.
Lead parameter evaluation (LPE)
The Lead Parameter Evaluation (LPE) is an alert, which aims to enhance patient’s protection through earlier lead failure detection. It is a multi-parametric algorithm which may trigger a red alert through an evaluation of daily lead checks (impedance, threshold, sensing) and other information (non treated VF episodes, short VV interval counter). In more details, the electrical settings assess daily lead impedance, coil continuity, lead pacing threshold and lead sensing amplitude. The rhythmic settings assess the daily number of non-treated episodes in VF rate zone and the daily number of short ventricular intervals (<= 180ms) outside an episode in VF rate zone. The LPE issues a lead alert if 1 electrical setting is abnormal for 3 days in a row, or 2 settings (electrical/electrical, or electrical/rhythmic) are abnormal in a 7-day window.
This alert, which could be considered one of the most important alerts for ICD patients, should always be associated with a rapid response, ensuring the patient is secure and not at risk for inappropraite and/or ineffective therapies.
Lead trends
The lead trends show that since a few days, the lead parameters had been deteriorating with low sensed values, high/out-of-range pacing thresholds and decreasing impedance. In fact, an alert had already been sent a few days earlier due to the inability to perform pacing threshold but review of the lead showed no other arguments for lead dysfunction at the time and careful remote evaluation had been continued. Because of high suspicion of RV lead dysfunction, the therapies were deactivated.
A chest X-ray was performed showing RA and RV lead displacement.
The next day, both leads were removed and new atrial and RV ICD leads were placed.
Practice out loud
Just describe the tracing. What do you think is going on? Describing the numbers can help.
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From Implantable Cardioverter Defibrillator — Clinical cases from patients with MicroPort™ ICDs by M. Strik, A. Thiyagarajah, S. Ploux, P. Bordachar, P. Ritter. Published by Cardiocases. Each case is a question on real device interrogations: pick your answer, check it, then read the authors’ interpretation. Tap any figure to open it full screen.