Appropriate Evaluation and Treatment of Heart Failure Patients After Implantable Cardioverter-Defibrillator DischargeTime to Go Beyond the Initial Shock
Joseph D. Mishkin, MD*,
Sherry J. Saxonhouse, MD*,
Gregory W. Woo, MD*,
Thomas A. Burkart, MD*,
William M. Miles, MD*,
Jamie B. Conti, MD*,
Richard S. Schofield, MD*,
Samuel F. Sears, PhD and
Juan M. Aranda, Jr, MD*,*
* Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
Departments of Psychology and Cardiovascular Sciences, East Carolina University, Greenville, North Carolina
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Figure 1 Algorithm for Evaluation and Management of ICD Shock
Evaluation of implantable cardioverter-defibrillator (ICD) shock based on time frame and etiology of shock, with current suggested management strategies. AF = atrial fibrillation; HF = heart failure; IV = intravenous; SVT = supraventricular tachycardia; VF = ventricular fibrillation; VT = ventricular tachycardia.
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Figure 2 Example of Inappropriate Shock for Atrial Fibrillation
A heart failure patient with a dual-chamber implantable cardioverter-defibrillator received multiple shocks. The atrial electrogram demonstrated atrial fibrillation (single arrow). The ventricular electrogram reveals fast and irregular activity. The device recognized the rate in the ventricular fibrillation zone, shown as "F" in the marker channel. An inappropriate shock was delivered (double arrow). AS and S = atrial sensed events; DDI = non-P-synchronous dual chamber pacing and sensing with an inhibited pacing mode (the pacing mode after shock); HV = high voltage; VS = ventricular sensed events.
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Figure 3 Example of Inappropriate Shock for T-Wave Oversensing
A patient with a dual-chamber ICD presented with frequent ICD shocks. (A) The interval plot demonstrates atrial and ventricular cycle length over time. The initial interval plot shows a 1:1 atrioventricular ratio (single arrow). Fifteen seconds before detection (double arrows) reveals a classic "train track" pattern of 2 ventricular sensing rates. (B) An intracardiac electrogram shows the device detecting the T waves as ventricular events (see marker channel), interpreting the episode as VF, resulting in an inappropriate shock. The patient was subsequently found to be hyperkalemic. Abbreviations as in Figure 1.
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