The Proarrhythmic Potential of Implantable Cardioverter-Defibrillators

Abstract

The implantable cardioverter-defibrillator (ICD) is remarkably effective in preventing sudden cardiac death in high-risk patients, but it also has the capacity to provoke or worsen cardiac arrhythmias. Tachyarrhythmias or bradyarrhythmias may result from the delivery of antitachycardia or antibradycardia therapies by tiered-therapy defibrillators. This proarrhythmia, although rarely fatal, increases the morbidity associated with defibrillator therapy. Proarrhythmia is related as much to suboptimal programming as to technical limitations of the device. The proarrhythmic potential of ICD therapy can be minimized by tailoring the "electrical prescription" according to characteristics of the clinical arrhythmia and individual ICD idiosyncrasies.

2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement on optimal implantable cardioverter-defibrillator programming and testing

“…With the advent and then dominance of primary prevention indications, avoidable shocks assumed a relatively larger proportion of total therapy [78][79][80][81][82][83]. Gradually, publications have increased awareness of the frequency and the diverse range of adverse outcomes associated with avoidable ICD therapy, and have demonstrated that avoidable ICD shocks can be reduced by evidence-based programming of the detection rate, detection duration, antitachycardia pacing (ATP), algorithms that discriminate supraventricular tachycardia (SVT) from VT, and specific programming to minimize the sensing of noise [81][82][83][84][85][86][87][88][89][90][91][92].…”

Adverse Interactions between ICD and Permanent Pacemaker Systems

“…Finally, reprogramming or damage to the PM need to be excluded. [Pinski & Fahy, 1995]. [Blanck et al, 1994] …”

“…9). This could lead to misinterpretation of a supraventricular tachyarrhythmia as VT. Pro-arrhythmic effects of inadequate ICD-therapies have also been described [Sticherling et al, 1997;Epstein et al, 1989;Pinski & Fahy, 1995] (fig. 10).…”

“…Shocks with higher energy seem to cause a higher increase in stimulation threshold (compare fig. 22b and 23b) [Sticherling et al, 1997;Brode et al, 1997;Pinski & Fahy, 1995]. Among the 30 patients described by Calkins et al there was a transient impairment of pacing and/or sensing in 7 cases with a duration of < 10 seconds in 4 patients, < 35 seconds in 2 patients and > 56 seconds in 1 patient.…”

Potential Energy and the Body Electric

“…In their article "The Proarrhythmic Potential of Implantable Cardioverter-Defibrillators," cardiologist Sergio Pinski and his colleague Gerard J. Fahy (1995) warn that "the implantable cardioverter-defibrillator (ICD) is remarkably effective in preventing sudden cardiac death in high-risk patients, but it also has the capacity to provoke or worsen cardiac arrhythmias" (1651). The use of prompts for action potentials, aimed at extending potential life, can harbor potential uncertainty.…”