ClinicalDevicesAntitachycardia pacing reduces appropriate and inappropriate shocks in children and congenital heart disease patients
Introduction
The use of an implantable cardioverter-defibrillator (ICD) to prevent sudden cardiac death is well established, with indications for primary and secondary prevention in patients at risk for ventricular arrhythmias.1 While efficacious, ICD shocks can have adverse consequences, including reduced quality of life and possibly increased mortality.2, 3 ICD therapy has also become the primary modality for children and patients with congenital heart disease (CHD) at risk for ventricular arrhythmias,4, 5 with a 4-fold increase in ICD implants in children from 1997 to 2006.6, 7 In addition to potential adverse consequences of appropriate ICD shocks, young patients have a high rate of inappropriate shocks ranging from 18% to 50%.8, 9, 10 Antitachycardia pacing (ATP) is a painless ICD modality to treat ventricular tachycardia (VT), and multiple studies have shown its benefit in terminating VT.11, 12, 13, 14, 15, 16, 17, 18 The Pain FREE Rx II trial confirmed its efficacy in a broad ICD population and showed that ATP did not cause significant event acceleration, arrhythmic syncope, or increase in mortality when compared with primary shock therapy.13
Despite the long-standing and encouraging data on ATP safety and efficacy in specific and general ICD populations, there is limited literature on ATP results in children and young patients with CHD. Concern regarding ATP being ineffective, resulting in delay in treatment, arrhythmic syncope, or proarrhythmia, has led some practitioners to avoid its use in young patients.19 The purpose of the present study was to examine the safety and efficacy of ATP in an ICD cohort consisting of pediatric and CHD patients when ATP therapy is empirically and routinely programmed ON as the initial therapy for VT.
Section snippets
Methods
We performed a retrospective review of all the pediatric and CHD patients with ICDs implanted at our institution from May 1996 to May 2010. We also included patients with ICDs implanted at other facilities but followed at our institution. Patients were excluded if there was little or no follow-up after the ICD implantation. We collected information on patient characteristics, including age, underlying diagnosis, details of ICD implantation, the delivered therapy, and the ICD follow-up duration.
Patient characteristics
After excluding patients with no or very limited follow-up, there were 79 patients aged 2–52 years (median 22 years; interquartile range 17–27 years) who were followed for a median of 4 years (6 months to 15 years) after ICD implantation. Age at implant ranged from 6 months to 49 years (median 17 years; interquartile range 13–21 years). A total of 28 (35%) patients had CHD, 26 (33%) had primary electrical disease, and 25 (32%) had cardiomyopathy (CM). Transvenous systems were used in 71 (90%),
Discussion
Our study demonstrates that routine empiric programming of ATP reduces both appropriate and inappropriate shocks in pediatric and CHD patients. ATP was highly efficacious for VT (88% success), and the majority of episodes of true VT did not require shocks for termination. We observed efficacious ATP in patients with a broad range of diagnoses, including repaired/palliated CHD, as well as dilated CM, HCM, and arrhythmogenic right ventricular cardiomyopathy, while efficacious ATP was rare among
Conclusions
Routine empiric programming of ATP in children and patients with CHD with ICDs is safe and effectively reduces both appropriate and inappropriate shocks. Despite the heterogeneity in population, we show that ATP successfully terminates VT with 88% efficacy, with failure and proarrhythmia rates similar to shocks. Lead failures, electromagnetic interference, and atrial fibrillation resulting in the misdiagnosis of VF are problematic, but inappropriate shocks due to sinus or supraventricular
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Cited by (29)
2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients
2021, Heart RhythmCitation Excerpt :Appropriate ICD shock rates of 3%–6% per year have been shown with an increased frequency of appropriate shocks for secondary prevention indications.204 Antitachycardia pacing has been shown to be effective in VT termination and reducing ICD shocks.214 Patients with CHD receiving an ICD have an increased rate of complications as high as 26%–45%, as well a high rate of inappropriate shocks.130,131,212,213
2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Developed in collaboration with and endorsed by the Heart Rhythm Society (HRS), the American College of Cardiology (ACC), the American Heart Association (AHA), and the Association for European Paediatric and Congenital Cardiology (AEPC) Endorsed by the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS)
2021, JACC: Clinical ElectrophysiologyCitation Excerpt :Appropriate ICD shock rates of 3%–6% per year have been shown with an increased frequency of appropriate shocks for secondary prevention indications (204). Antitachycardia pacing has been shown to be effective in VT termination and reducing ICD shocks (214). Patients with CHD receiving an ICD have an increased rate of complications as high as 26%–45%, as well a high rate of inappropriate shocks (130,131,212,213).
2021 PACES expert consensus statement on the indications and management of cardiovascular implantable electronic devices in pediatric patients
2021, Indian Pacing and Electrophysiology JournalCitation Excerpt :Appropriate ICD shock rates of 3%–6% per year have been shown with an increased frequency of appropriate shocks for secondary prevention indications [204]. Antitachycardia pacing has been shown to be effective in VT termination and reducing ICD shocks [214]. Patients with CHD receiving an ICD have an increased rate of complications as high as 26%–45%, as well a high rate of inappropriate shocks [130,131,212,213].
Management of People With a Fontan Circulation: a Cardiac Society of Australia and New Zealand Position statement
2020, Heart Lung and CirculationResynchronization therapy and sudden death management in congenitally corrected transposition: Submitted by Damien Cullington, MBChB (hons), MD, MRCP, FESC
2018, Arrhythmias in Adult Congenital Heart Disease: A Case-Based ApproachPacing and Defibrillation Use in Pediatric Patients
2016, Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy
Medtronic supports Pediatric Cardiac Electrophysiology Fellowship Training in the Thomas P. Graham Jr. Division of Pediatric Cardiology at Vanderbilt through an unrestricted grant. None of the authors receive any direct support from industry, nor was this study funded by industry.