Programming a first shock at maximum output in the VT zone - Visia XT VR

Patient

Male implanted with a single chamber defibrillator (Visia XT VR) for ischaemic cardiomyopathy.

Trace

1- What diagnosis is suggested by the interval plot?
The plot shows an episode of ventricular arrhythmia with acceleration into the VT zone; the first 3 bursts and first 3 ramps do not revert the arrhythmia; a maximum output shock terminates the arrhythmia.

2- What is your final diagnosis?
Regular monomorphic ventricular tachycardia; the first 3 bursts (treatment 1) and first 3 ramps (treatment 2) are ineffective; maximum output shock (treatment 3) terminates the arrhythmia.

Take home message

Although there is no universal ‘optimal’ programming, the results of large studies concur on the need to reduce inappropriate or unnecessary therapies without compromising patient safety.
Empirically programming a first shock of maximum energy in the VT zone, as in this example, reduces the risk of a pro-arrhythmogenic effect, increases the probability of terminating VT with the first shock, minimises the number of shocks delivered as far as possible and increases the probability of reverting AF if the shock is inappropriate

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