© 2003 by European Society of Cardiology
A new algorithm for rhythm discrimination in cardioverter defibrillators based on the initial voltage changes of the ventricular electrogram
1Department of Signal Theory and Communications, Universidad Carlos III de Madrid 28.911 Leganés, Madrid, Spain; 2Department of Cardiology, University Hospital Gregorio Marañóm 28.007 — Madrid, Spain; 3Department of Cardiology, University Hospital Virgen de la Arrixaca 30.150 — Murcia, Spain
AIMS: Ventricular activation onset is faster in supraventricular beats than in ventricular rhythms. The aim of this study was to evaluate a criterion to differentiate supraventricular (SVT) from ventricular tachycardia (VT) based on the analysis of the initial voltage changes in ICD-stored morphology electrograms.
METHODS: Far field ICD-stored EGMs were obtained from 68 VT and 38 SVT episodes in 16 patients. The first EGM peak was detected, three consecutive time epochs were defined within the preceding 80 ms window and the voltage changes with respect to a sinus template were analysed during each time period and combined into a single parameter for rhythm discrimination.
RESULTS: The algorithm was tested in an independent validation group of 442 VT and 97 SVT spontaneous episodes obtained from 22 patients with a dual chamber ICD. The area under the receiver-operator characteristics (ROC) curve indicated that the arrhythmia separability with this method was 0.95 (tolerance interval: 0.85-0.99) and 0.98 (0.87-0.99) for the control and validation groups respectively. A specificity of 0.91 was obtained at 95% sensitivity in the validation group.
CONCLUSION: The analysis of voltage changes during the initial ventricular activation process is feasible using the far field stored electrograms of an ICD system and yields a high sensitivity and specificity for arrhythmia discrimination.
Key Words: Implantable cardioverter defibrillator, supraventricular tachycardia, ventricular tachycardia, electrogram morphology, tachyarrhythmia detection algorithms
Correspondence: Dr Arcadi Garc
a Alberola, Plaza del Roble 36, 30150 — La Alberca, Murcia, Spain. Tel.: +34 968 369 211; Fax: +34 968 369 558; E-mail: algamur{at}teleline.es
[1] Block M and Breithardt G. Implantable cardioverter-defibrillators: Clinical aspects. In Ziipes DP and Jalife J (Eds.). Cardiac Electrophysiology: From Cell to Bedside 2000; 3rd edn Philadelphia WB Saunders Co pp. 958–970.
[2] Grimm W, Flores B, Marchlinski F. Electrocardiographically documented unnecessary, spontaneous shocks in 241 patients with implantable cardioverter defibrillators. Pacing Clin Electrophysiol 1992; 15: 1008–1014.[CrossRef][Medline]
[3] Rosenqvist M, Beyer T, Block M, den Dulk K, Minten J, Lindemans F. Adverse events with transvenous implantable cardioverter-defibrillators: A prospective multicenter study. Circulation 1998; 98: 663–670.
[4] Swerdlow CD, Chen PS, Kass RM, Allard JR, Peter CT. Discrimination of ventricular tachyarrhythmia from sinus tachycardia and atrial fibrillation in a thiered-therapy cardioverter-defibrillator. J Am Coll Cardiol 1994; 23: 1342–1355.[Abstract]
[5] Higgins SL, Lee RS, Kramer RL. Stability: An ICD detection criterion for discriminating atrial fibrillation from ventricular tachycardia. J Cardiovasc Electrophysiol 1995; 6: 1081–1088.[CrossRef][Web of Science][Medline]
[6] Weber M, Böcker D, Bänsch D. Efficacy and safety of the initial use of stability and onset criteria in implantable cardioverter defibrillators. J Cardiovasc Electrophysiol 1999; 10: 145–153.[Web of Science][Medline]
[7] Barold HS, Newby KH, Tomassoni G, Kearney M, Brandon J, Natale A. Prospective evaluation of new and old criteria to discriminate between supraventricular and ventricular tachycardia in implantable defibrillators. Pacing Clin Electrophysiol 1998; 21: 1347–1355.[CrossRef][Medline]
[8] Gold MR, Hsu W, Marcovecchio AF, Olsovsky MR, Lang DJ, Shorofsky SR. A new defibrillator algorithm utilizing electrogram morphology analysis. Pacing Clin Electrophysiol 1999; 22: 179–182.[CrossRef][Medline]
[9] Unterberg C, Stevens J, Vollman D, Hasenfuss G, Buchwald AB. Long-term clinical experience with the EGM width detection criterion for differentiation of supraventricular and ventricular tachycardia in patients with implantable cardioverter defibrillators. Pacing Clin Electrophysiol 2000; 23: 1611–1617.[CrossRef][Medline]
[10] Grönefeld GC, Schulte B, Hohnloser SH. Morphology discrimination: A beat-to-beat algorithm for the discrimination of ventricular from supraventricular tachycardia by implantable cardioverter defibrillators. Pacing Clin Electrophysiol 2001; 24: 1519–1524.[CrossRef][Medline]
[11] Osswald S, Cron TA, Sterns L, Alt E, Stotts L, Coenen M. New ICD-technologies: First clinical experience with dual-chamber sensing for differentiation of supraventricular tachyarrhythmias. Pacing Clin Electrophysiol 1998; 21: 292–295.[Medline]
[12] Wilkoff BL, Kühlkamp V, Volosin K, et al. Critical Analysis of Dual-Chamber Implantable Cardioverter-Defibrillator Arrhythmia Detection. Results and Technical Considerations. Circulation 2001; 103: 381–386.
[13] Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation 1991; 83: 1649–1659.
[14] Hermida RC and Fernández JR. Computation of time-specified tolerance intervals for ambulatorily monitored blood pressure. Biomed Instrument and Technol 1996; 30: 256–266.
[15] Hook BG and Marchlinski FE. Value of ventricular electrogram recordings in the diagnosis of arrhythmias precipitating electrical device shock therapy. J Am Coll Cardiol 1991; 17: 985–990.[Abstract]
[16] Duru F, Schönbeck M, Luscher TF, Candinas R. The potential for inappropriate ventricular tachycardia confirmation using the intracardiac electrogram (EGM) width criterion. Pacing Clin Electrophysiol 1999; 22: 1039–1046.[CrossRef][Medline]
[17] Klingenheben T, Sticherling C, Skupin M, Hohnloser SH. Intracardiac QRS electrogram width. An arrhythmia detection feature for implantable cardioverter defibrillators: Exercise induced variation as a base for device programming. Pacing Clin Electrophysiol 1998; 21: 1609–1617.[Medline]
[18] Boriani G, Biffi M, Frabetti L, Lattuca JJ, Branzi A. Clinical evaluation of morphology discrimination: An algorithm for rhythm discrimination in cardioverter defibrillators. Pacing Clin Electrophysiol 2001; 24: 994–1001.[CrossRef][Medline]
[19] Scholkoff B, Sung KK, Vapnik VN. Comparing support vector machines with gaussian kernels to radial basis function classifiers. IEEE transactions on Signal Processing 1997; 45: 2758–2765.[CrossRef]
[20] Vapnik VN. The Nature of Statistical Learning Theory 1995; NY Springer-Verlag.
[21] Efron B and Tibshirani RJ. An Introduction to the Bootstrap 1998; FL Chapman & Hall/CRC.
[22] Papoulis A. Probability, Random Variables and Stochastic Processes 1991; NY McGraw-Hill.
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