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Sensing and detection in Medtronic implantable cardioverter defibrillators

Wahrnehmung und Detektion durch implantierbare Kardioverter-Defibrillatoren von Medtronic

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Abstract

Ensuring sensing and detection of ventricular tachycardia (VT) and ventricular fibrillation (VF) was a prerequisite for the clinical trials that established the survival benefit of implantable cardioverter defibrillators (ICDs). However, for decades, a high incidence of unnecessary shocks limited patients’ and physicians’ acceptance of ICD therapy. Oversensing, misclassification of supraventricular tachycardia (SVT) as VT, and self-terminating VT accounted for the vast majority of unnecessary shocks. Medtronic ICDs utilize sensitive baseline settings with minimal blanking periods to ensure accurate sensing of VF, VT, and SVT electrograms. Programmable algorithms reject oversensing caused by far-field R waves, T waves, and non-physiologic signals caused by lead failure. A robust hierarchy of SVT-VT discriminators minimize misclassification of SVT as VT. These features, combined with evidence-based programming, have reduced the 1‑year inappropriate shock rate to 1.5 % for dual-/triple-chamber ICDs and to 2.5 % for single-chamber ICDs.

Zusammenfassung

Die Wahrnehmung und Detektion von ventrikulären Tachykardien (VT) und Kammerflimmern (VF) sicherzustellen, war die Voraussetzung für klinische Studien, die den Überlebensvorteil durch implantierbare Kardioverter-Defibrillatoren (ICD) demonstrierten. Dennoch limitierte das häufige Auftreten unnötiger Schocktherapien für Jahrzehnte die Akzeptanz der ICD-Therapie bei Patienten und Ärzten. Ein Oversensing, die Fehlklassifizierung von supraventrikulären Tachykardien (SVT) als VT und nichtanhaltende VT sind die Ursache für die große Mehrzahl unnötiger Schocktherapien. ICD der Fa. Medtronic nutzen empfindliche Baseline-Einstellungen und minimierte Ausblendzeiten, um die korrekte Klassifikation eines Tachykardieelektrogramms zu VT, VF oder SVT zu ermöglichen. Programmierbare Algorithmen verhindern ein Oversensing durch ventrikuläre Fernfeldsignale, T‑Wellen und nichtphysiologische Signale aufgrund von Elektrodenfehlfunktionen. Eine robuste Hierarchie der VT/SVT-Diskriminatoren minimiert das Risiko der Fehlklassifizierung einer SVT als VT. Diese Eigenschaften reduzieren zusammen mit einer evidenzbasierten Programmierung die 1‑Jahres-Häufigkeit inadäquater Schocks auf 1,5 % für Zwei- und Dreikammer-ICD und auf 2,5 % für Einkammer-ICD.

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Notes

  1. When the median atrial cycle length is <15/16 (93.75 %) of the median ventricular cycle length, then A:V > 1:1.

  2. Modesum measure regularity. A histogram of the 18 most recent RR intervals is created. The sum of the two most populated bins is divided by 18 to compute modesum. Modesum >75 % is considered “regular”.

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Authors and Affiliations

  1. Medtronic plc., 8200 Coral Sea St NE, MS MVN41, 55112, Mounds View, MN, USA

    Mark L. Brown PhD

  2. Cedars-Sinai Heart Institute, Los Angeles, USA

    Charles D. Swerdlow MD

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  1. Mark L. Brown PhD
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  2. Charles D. Swerdlow MD
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Correspondence to Mark L. Brown PhD.

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Conflict of interest

Mark L. Brown is an employee of Medtronic. Charles D. Swerdow is a consultant to Medtronic and has received honoraria from Boston Scientific.

This article does not contain any studies with human participants or animals performed by any of the authors.

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Table 1 Medtronic programming recommendations
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Brown, M.L., Swerdlow, C.D. Sensing and detection in Medtronic implantable cardioverter defibrillators. Herzschr Elektrophys 27, 193–212 (2016). https://doi.org/10.1007/s00399-016-0450-6

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