Europace 2008 10(9):1110-1111; doi:10.1093/europace/eun200
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
EHRA EDUCATION COMMITTEE: EDUCATION IN EP
How to prevent ICD shocks: part I
Sandra Buck1,
Alexander H. Maass1 and
Isabelle C. Van Gelder1,2,*
1 Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands;
2 The Interuniversity Cardiology Institute Netherlands, Utrecht, The Netherlands
Manuscript submitted 3 July 2008. Accepted after revision 4 July 2008.
* Corresponding author. Tel: +31 50 361 2355; fax: +31 50 361 4391. E-mail address: i.c.van.gelder{at}thorax.umcg.nl
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Introduction
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A 63-year-old male with non-ischaemic cardiomyopathy due to
a hereditary autosomal-dominant desmin mutation (left ventricular
ejection fraction 30%) and a history of persistent atrial fibrillation
and flutter since 1990 received an implantable cardioverter-defibrillator
(ICD, Medtronic
® Virtuoso DDD ICD) in December 2006. He
was known with a first-degree atrioventricular block, intermittent
second-degree atrioventricular block, Mobitz type I, while taking
low-dose sotalol (40 mg twice daily). In September 2007, he
visited our outpatient ICD clinic because of two shocks (
Figure 1). He complained of a small decrease in exercise tolerance.
Physical examination revealed basal pulmonary rales.
Figure 2 shows the cardiac compass trends. At the time of the shocks,
he was treated with enalapril 10 mg twice daily, bumetanide
1 mg daily, sotalol 40 mg twice daily, and acenocoumarol. His
pacing mode was DDD lower rate 40 bpm and upper rate 130 bpm.
The detection border for atrial arrhythmias started above 171
bpm, without therapies. The detection and therapies for ventricular
arrhythmias started above 200 bpm. Therapies for ventricular
arrhythmias included anti-tachycardia pacing during discharge
and five shocks thereafter (first shock 25 J, second, third,
fourth, and fifth shocks 35 J). Analysis of the ICD after the
shocks showed a normal impedance of the atrial (368 ohm) and
RV lead (536 ohm), and the amount of ventricular pacing was
28%.
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Questions
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- Were there adequate shocks? Was the first shock effective? What happened before the first shock?
- What was the atrial rhythm before and after the first shock?
- How to interpret the cardiac compass trend?
- How can we possibly prevent (part of the) shocks in the future?
For answers see page 1126
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