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ICDs ascertain tachycardias imperfectly: An ICD-detected tachycardia may represent either a tachyarrhythmia (SVT or VT) or oversensing of nonarrhythmic electrical signals. ICDs additionally allocate tachycardias imperfectly: Accurate SVT episodes may be classified as VT or VF; and accurate VT may be classified as SVT. Stored ICD electrograms from detected SVT, VT, and VF episodes calm with agnate annotated markers (Fig. 1) accommodate the capital abstracts for interpreting the causes and outcomes of ICD shocks. Amount 2 summarizes the access to the assay of delivered ICD therapy. The aboriginal footfall is to actuate if assay was delivered in acknowledgment to oversensing or a accurate tachycardia.
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ICD leads and electrograms. The larboard console shows an ICD arrangement including left-pectoral alive can and RV lead. Adapted console shows telemetered electrograms. The dual-coil advance uses true-bipolar assay amid tip and arena electrodes. Adapted console shows telemetered high-voltage (shock), far-field (FF-VEGM) and sensing, near-field (NF-VEGM) electrograms with annotated markers. Arrows on Brand Access denotes timing of R after-effects sensed from true-bipolar electrogram. ICDs admeasurement all timing intervals from this electrogram and affectation them on the Brand Channel, which additionally indicates the ICD's allocation of anniversary atrial and ventricular accident by letter symbols. In this figure, VS indicates sensed ventricular contest in the atrium amount area and numbers announce RR intervals. The stored near-field, rate-sensing electrogram is a wide-band (unfiltered) arresting in Medtronic ICDs, but filtered in Guidant and St. Jude ICDs.
Analysis of ICD shocks. See text.
Inappropriate assay occurs in the absence of tachycardias because nonphysiological or nonarrhythmic, physiological signals are oversensed and detected as arrhythmias.[1,2] Nonphysiological signals usually are extracardiac. Physiological signals may be intracardiac (P, R, or T waves) or extracardiac (myopotentials). Oversensing presents adapted patterns of stored electrograms and associated markers. See Amount 3.
Types of oversensing constant in inappropriate apprehension of VT/VF. A–C appearance oversensing of physiological, intracardiac signals. D–F appearance oversensing of extracardiac signals. (A) P-wave oversensing in atrium accent from chip bipolar advance with distal braid abreast the tricuspid valve. (B) R-wave bifold counting during conducted AF in a biventricular-sensing ICD. (C) T-wave oversensing in accommodating with low-amplitude R beachcomber (note mV arrangement marker). (D) Electromagnetic arrest from a ability assignment has college amplitude on broadly spaced high-voltage electrogram than on carefully spaced accurate bipolar assay electrogram. (E) Diaphragmatic myopotential oversensing in a accommodating with an chip bipolar advance at the RV apex. Agenda that babble akin is constant, but oversensing does not action until automated accretion ascendancy increases the accretion sufficiently, about 600 ms afterwards the sensed R waves. (F) Advance breach babble after-effects in alternating assimilation of amplifier ambit denoted by arrow. RA = adapted atrium; RV = adapted ventricular assay electrogram; HV = high-voltage electrogram. Reprinted with permission from Swerdlow and Shivkumar.[58]
Intracardiac Signals. Ventricular oversensing of physiologic intracardiac signals after-effects in two detected ventricular electrograms for anniversary cardiac cycle, which may aftereffect in inappropriate apprehension of VT or VF.
T-Wave Oversensing. Oversensing of ad-lib T after-effects may account inappropriate apprehension of either VT or VF, depending on the sensed RT breach and programmed VF apprehension interval. T-wave oversensing is articular by alternating electrogram morphologies.[1] RR intervals usually alternate, but the consequence of alternation may be small.
R-wave bifold counting occurs if the continuance of the assay electrogram exceeds the ventricular blanking aeon of 120–140 ms, which is programmable abandoned in St. Jude ICDs. It may be affronted by sodium-channel-blocking drugs, decidedly at aerial affection rates, which access use-dependent sodium-channel blockade. It is decidedly accepted during VT or conducted supraventricular rhythms in Y-adapted or earlier biventricular ICDs that use continued bipolar assay amid the tips of the left-ventricular (LV) and right-ventricular (RV) electrodes.[3] See Amount 4 and Area IXA. Bifold counting of R after-effects after-effects in alternation of ventricular aeon lengths with an isoelectric breach amid sensed events, bearing a adapted "railroad track" arrangement of ventricular intervals on breach plots. See Amount 4 lower console and legend.
R-wave bifold counting in a accommodating with a Y-adapted cardiac resynchronization ICD and LBBB. Main panel: Atrial and continued bipolar ventricular electrograms are apparent with Brand Channels. The aboriginal two complexes appearance atrial-sensed, ventricular paced rhythm. The third atrial circuitous is abortive and initiates SVT faster than the programmed high tracking limit, constant in alternating R-wave bifold counting. Admit shows that the aboriginal basic of the ventricular electrogram represents RV activation and the added basic represents LV activation. Admit additionally illustrates altitude for inappropriate apprehension of SVT. The double-counted, RV-LV breach measures aural 20 ms of the ventricular blanking aeon of 120 ms (see Brand Channel) and is consistently classified in the VF zone. Inappropriate apprehension occurs back the breach represented by the solid band articulation (asterisk) in the high adapted admit is beneath than the VT apprehension interval. This breach represents the aberration amid the accurate SVT aeon breadth (CL, dotted band articulation in high adapted insert) and the double-counted RV-LV interval. For example, if the VT apprehension breach is 400 ms and the double-counted RV-LV breach is 140 ms, inappropriate apprehension occurs for any tachycardia aeon breadth beneath than 540 ms. AS = sensed atrial intervals; AR = atrial intervals in postventricular atrial adverse period; VS = breach sin atrium zone; FS = intervals in VF zone. High larboard panel: Artifice shows atrial intervals as accessible squares and ventricular intervals as bankrupt circles. The anterior accent is atrial sensed, ventricular paced with a aeon breadth of ~700 ms. At the access of SVT, there is an brusque abatement in atrial intervals. Sensed "ventricular intervals" alternate. Their sum equals the atrial interval. This "railroad track" arrangement of ventricular intervals additionally occurs with P-wave oversensing and may action with T-wave oversensing. A agnate "railroad track" arrangement of atrial intervals occurs with far-field R-wave oversensing on the atrial channel. See Amount 17.
P-wave oversensing may action if the distal braid of an chip bipolar advance is abutting to the tricuspid valve, and the sensed PR breach exceeds the ventricular blanking period. It is attenuate in adults with defibrillation leads abreast the RV apex, but may action in accouchement or in adults if the RV electrode dislodges or is positioned in the adjacent septum or arrival allocation of the RV. If P-wave oversensing occurs during a 1:1 rhythm, the considerations are agnate to those for R-wave bifold counting, provided the sensed PR or RP breach is beneath than the VF apprehension interval. However, oversensing of P after-effects as R after-effects can account inappropriate apprehension of VF during atrial fibrillation or atrial flutter, absolute of the ventricular rate.
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Far-field R-wave oversensing on the atrial channel, the analog of P-wave oversensing on the ventricular channel, shows a arrangement of alternating atrial aeon lengths with one faculty brand timed abutting to the ventricular electrogram. If amount and continuance belief for VT are fulfilled, far-field R-wave oversensing may abash SVT-VT discrimination. But it does not account inappropriate apprehension of VT if the ventricular amount is in the atrium zone.
Extracardiac Signals. The characteristic affection of oversensing extracardiac signals is backup of the isoelectric baseline with high-frequency babble that does not accept a connected accord to the cardiac cycle.[2]
External electromagnetic interference[1,2] Arresting amplitude is greater on the high-voltage electrogram recorded from broadly spaced electrodes than on the assay electrogram recorded from carefully spaced electrodes. The arrest arresting may be continuous. Clinical abstracts may advance a specific identifiable account of alien electromagnetic interference.
Lead/Connector Problems. Oversensing due to advance or adapter (header, adapter, or set-screw) problems is intermittent. Usually it occurs abandoned during a baby atom (<10%) of the cardiac aeon and generally saturates the amplifier. It may be bound to the assay electrogram and may be associated with postural changes. Often, the pacing-lead impedance is abnormal, advertence complete or fractional abeyance of the pace-sense circuit. However, aberrant impedance abstracts may be intermittent.
Myopotential oversensing may abide for capricious fractions of the cardiac cycle. Diaphragmatic myopotentials are best arresting on the assay electrogram. Oversensing usually occurs afterwards continued diastolic intervals or afterwards ventricular paced contest back amplifier acuteness or accretion is maximal. It generally ends with a sensed R wave, which abruptly reduces sensitivity. In pacemaker-dependent patients, diaphragmatic oversensing causes inhibition of pacing, constant in assiduous oversensing and inappropriate apprehension of VF (Fig. 5). Clinically this may present as blackout from inhibition of pacing followed by an inappropriate shock. This is an barring to the aphorism that blackout above-mentioned to a shock indicates an adapted shock. It is best accepted in macho patients who accept chip bipolar leads in the RV acme with Guidant ICDs that advance Automated Accretion Control™.[4] Pectoral myopotentials are added arresting on a far-field electrogram that includes the ICD can rather than the near-field electrogram; because ICDs do not use this electrogram for rate-counting, oversensing of pectoral myopotentials does not usually account inappropriate detection. The best accepted barring occurs if the assay of the far-field electrogram is acclimated for SVT-VT bigotry during exercise-induced atrium tachycardia.
Oversensing of diaphragmatic myopotentials causes inhibition of bradycardia pacing and commitment of an inappropriate shock (not shown) in a pacemaker-dependent patient. High-frequency myopotentials accept greater amplitude on integrated-bipolar assay electrogram (RV tip–coil) than high-voltage electrogram (shock). VP-Sr = paced intervals; VS = intervals in atrium zone; VF = intervals in VF zone; Epsd = adventure start/end. Repositioning the advance abandoned the problem.
If assay is delivered in acknowledgment to a tachycardia, the added footfall is to actuate if the anterior accent detected as VT or VF is accurate VT/VF or SVT. Afterwards the anterior tachycardia is diagnosed, posttherapy tachycardias charge be diagnosed to actuate if they represent assiduity of the anterior arrhythmia or one of the four altered classes of arrhythmia: SVT afterwards assay of VT, a altered VT afterwards assay of VT, VT afterwards inappropriate assay of SVT (e.g., accessory proarrhythmia[5]), or a altered SVT afterwards inappropriate assay of SVT (e.g., atrial fibrillation afterwards inappropriate assay of atrium tachycardia).Figure 6 summarizes methods for allegory single-chamber and dual-chamber electrograms.
Method for assay of stored electrograms in dual-chamber ICDs (upper panel) and single-chamber ICDs (lower panel). Asterisks denote weaker criteria. TP = antitachycardia pacing; AFib = atrial fibrillation; AFlu = atrial flutter. See argument for details.
Analysis of Single-Chamber Electrograms. The morphology, abruptness of onset, and regularity of ventricular electrograms anatomy the foundation of single-chamber SVT-VT discrimination.
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Morphology. Electrogram assay should be analyzed from the all recorded channels, alluringly including a far-field dipole. SVT cannot be discriminated from VT absolutely application near-field electrograms in 5–10% of VTs.[6,7] A real-time, advertence electrogram of conducted baseline accent should be recorded to analyze assay with that of the stored electrogram. Ideally, it should be recorded in the aspect in which the adventure occurred.
The accent is classified as SVT if electrogram assay is compatible and identical to the atrium morphology. It is classified as VT if assay is compatible and audibly altered from the atrium morphology. This access necessarily classifies rate-related array annex block during SVT as VT. Afterwards shocks, electrogram assay is adulterated by postshock advance animosity and/or bounded electroporation. See Amount 7. Assay cannot be acclimated to discriminate VT from SVT until postshock electrogram baloney resolves.
Interval Stability. Characteristically, the ventricular accent is anyhow aberrant in atrial fibrillation and approved during monomorphic VT, but exceptions are important. Usually, atrial fibrillation is detected afield during advancing atrial fibrillation back the ventricular amount exceeds the programmed amount criterion. Thus, stored intervals are anyhow aberrant above-mentioned to and during detection. However, because RR intervals in atrial fibrillation are added approved at faster ventricular rates, breach adherence cannot anxiously discriminate atrial fibrillation from VT at ante aloft ~170/min.[8,9] Further, the conducted ventricular accent in atrial fibrillation may adjust at slower ante due to brief alignment of the atrial rhythm. During rapidly conducted atrial fibrillation, electrograms frequently authenticate attenuate beat-to-beat aberration in morphology, the intracardiac associate of rate-related aberrancy. In contrast, electrograms during VT tend to accept a added compatible morphology. However, amiodarone or blazon IC antiarrhythmic drugs may account monomorphic VT to become clearly aberrant or polymorphic VT to slow, causing aberrant intervals during accurate VT in the VT amount zone.[10,11]
Onset. Atrium tachycardia accelerates gradually and is consistently detected at the sinus-VT amount abuttals (Fig. 7). In contrast, the access of VT or paroxysmal SVT is brusque unless it originates during atrium tachycardia or SVT. However, if VT starts abruptly with an anterior amount beneath the programmed VT apprehension rate, the alpha of the stored electrogram does not almanac the access of the arrhythmia. Rather, it classifies the VT as SVT back it accelerates gradually beyond the programmed, sinus-VT amount boundary. In Medtronic ICDs, stored (flashback) intervals above-mentioned the stored electrogram may admittance actual assay of an abrupt-onset arrhythmia with an anterior amount slower than the VT apprehension amount (Fig. 8). In the absence of anamnesis intervals, the few aberrant of stored electrograms above-mentioned to anterior apprehension are bereft to accomplish a absolute assurance of a "gradual-onset" arrhythmia.
Proarrhythmia acquired by inappropriate shock for atrium tachycardia during rate-only detection. (A) The top larboard archetype shows electrograms recorded from high-voltage leads (HVA-HVB) during atrium rhythm. The top adapted archetype shows the anterior stored electrogram from the advised tachycardia. The electrograms in these two panels are about identical, advertence that advised arrhythmia is SVT. The electrogram during tachycardia is brusque at the best amplitude of 8 mV. The lower panels are "flashback interval" plots of the RR-interval aeon lengths above-mentioned to rate-only apprehension of VF, which occurs at the adapted ancillary of anniversary panel. The breach cardinal above-mentioned to apprehension is advised on the abscissa, and the agnate breach is advised on the ordinate. The lower larboard console shows 2000 RR intervals above-mentioned to detection. A tachycardia is present throughout. Shortly afterwards the 400th interval, the accent accelerates gradually in a address archetypal of atrium tachycardia and decreases beneath the programmed VF apprehension breach of 340 ms. The lower adapted console shows this bit-by-bit dispatch on an broadcast calibration during the aftermost 100 intervals above-mentioned to detection. Cycle-length abstracts are truncated to the abutting 10 ms. (B) Stored electrogram during assay of the tachycardia detected in Console A. The aboriginal VF shock (VF Rx 1) after-effects in addition of the electrogram afterwards change in the aeon breadth of 330 ms. This is apparently due to shock-induced adapted array annex block which was accurate in this accommodating at electrophysiologic testing. The archetype is alternate at the end of the aboriginal band and connected thereafter. Shocks 2, 3, and 4 resulted in no change in amount or electrogram morphology. On the added line, the fifth VF shock (VF Rx 5) induces VT with aeon breadth 280 ms, admitting adapted synchronization to the base of the R wave. The sixth VF shock (VF Rx 6) accelerates the VT to aeon breadth 210 ms. This accent terminates spontaneously 21 aberrant later, and atrium tachycardia with a advanced electrogram resumes (asterisk). No added shocks were delivered during these 21 aberrant because the best cardinal of therapies per area is six in this ICD. The accommodating appear that during action he accomplished assorted shocks followed by syncope. The programmed shock backbone was 24 J for the aboriginal shock and 34 J for consecutive shocks. Reprinted with permission from Swerdlow.[59]
Underdetection of VT and undersensing of VF. The lower console is a "flashback interval" artifice of RR-intervals aeon lengths above-mentioned to apprehension of VF, which occurs at the adapted ancillary of anniversary panel. The breach cardinal above-mentioned to apprehension is advised on the abscissa, and the agnate breach is advised on the ordinate. Horizontal curve announce the VT apprehension breach (TDI) of 400 ms and VF apprehension breach (FDI) of 320 ms. Shortly afterwards the 500th breach above-mentioned detection, approved tachycardia begins abruptly. The connected aeon breadth indicates reliable sensing. This VT is not detected admitting reliable assay because the aeon breadth is > the programmed TDI. VT persists for 3.7 min until about breach 280 above-mentioned to detection, back sensed intervals become awful variable. This indicates decline of the accent to VF with undersensing that delays detection. During VT and VF, atrial anamnesis intervals (not shown) adumbrated lower amount absolute bradycardia pacing at 40 beats/min (1500 ms). The high console shows stored atrial and far-field ventricular electrograms anon above-mentioned to apprehension with atrial and ventricular Brand Channels. Specific undersensed electrograms cannot be articular because the amount assay electrogram was not recorded. However, long-sensed RR intervals catastrophe with VS markers announce undersensing and accord to continued breach in high panel. "VF Assay 1 Defib" at lower adapted (arrow) denotes apprehension of VF.
Analysis of Dual-Chamber Electrograms. Assay of atrial and ventricular ante and atrio-ventricular (AV) relationships are the foundations of dual-chamber accent analysis. If the ventricular amount exceeds the atrial rate, the assay is VT. If the atrial amount exceeds the ventricular rate, rapidly conducted atrial fibrillation or agitate charge be acclaimed from VT during atrial arrhythmia.
Tachycardias with 1:1 AV Relationship. In tachycardias with 1:1 AV association, brief AV block permits the assay of SVT; brief VA block permits the assay of VT. The all-inclusive majority of tachycardias with 1:1 AV accord are SVT, primarily atrium tachycardia. VT with 1:1 VA advice accounts for beneath than 10% of VTs detected by ICDs in best studies.[12,13] The arch appropriate appearance amid SVT and VT with 1:1 AV accord accommodate assay of the ventricular electrogram, alcove of onset, and acknowledgment to ventricular antitachycardia pacing (Fig. 9). Atrial tachycardia usually begins with a abbreviate PP breach followed by a abbreviate RR interval, admitting VT usually begins with a abbreviate RR interval. A few beats of AV breach may action until 1:1 ventriculoatrial advice stabilizes. In atrium tachycardia, the atrial accent accelerates gradually with an about abiding PR interval.
Appropriate assay for VT with 1:1 VA conduction. Bipolar atrial electrogram (RA), dual-chamber Brand Channel, and rate-sensing (RV) electrogram are shown. Asterisk denotes access of VT during atrium tachycardia, articular by brusque dispatch of ventricular amount and change in electrogram assay afterwards change in atrial rate. Assay discriminator requires 5 of 8 bout array ≥60% to abstain therapy. During atrium tachycardia, array exhausted 60%. (Five are 100%) During VT, best array are beneath than 60%. Check marks aloft Brand Access announce that assay algorithm classifies beats as supraventricular. "X" marks announce beats classified as VT morphology. The VT aeon breadth is moderately irregular. Changes in VV breach announce those in AA interval. Ventricular antitachycardia pacing (ATP) at adapted of lower console after-effects in brief VA block afterwards dispatch of the atrial amount followed by 1:1 VA conduction. The abreast accompanying atrial and ventricular activation during tachycardia is added archetypal of archetypal (antegrade-slow, retrograde-fast) AV nodal reentrant tachycardia than VT, but the abridgement of the AV breach at the access of tachycardia is inconsistent with this diagnosis. Pacing-induced VA block afterwards dispatch of the atrial amount is additionally aberrant in AV nodal reentry. "Trigger" in lower console indicates apprehension of VT. "D =" at access of ATP indicates that atrial amount = ventricular rate. "S" denotes intervals breach the "Sinus" area best than the VT apprehension breach of 400 ms. "T" denotes intervals in VT zone. DDI = approach switch. Time band is in section.
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Tachycardias with Atrial Amount > Ventricular Rate. Once far-field R after-effects are differentiated from atrial electrograms, conducted atrial fibrillation or atrial agitate (Fig. 10) charge be acclaimed from VT during atrial arrhythmia (Fig. 11). Best VT during paroxysmal atrial fibrillation is fast abundant to be classified in the VF zone.[14] The single-chamber belief of aberrant ventricular assay and approved ventricular amount are best accessible for diagnosing VT during atrial fibrillation. Conducted atrial agitate may be diagnosed in the attendance of aberrant ventricular assay if constant 2:1 AV affiliation or Mobitz 1 AV block is present. VT during atrial agitate is diagnosed based on aberrant assay and AV dissociation.
Inappropriate apprehension of rapidly conducted atrial fibrillation. Adherence and assay algorithms are accumulated with "ANY" in this St. Jude ICD so that VT is diagnosed if either discriminator classifies accent as VT. Adherence algorithm afield classifies accent because ventricular aeon lengths regularize. Assay algorithm accurately classifies accent as SVT. The accent would accept been classified accurately if the assay discriminator abandoned had been programmed. "F" markers announce ventricular intervals in VF (Fib) zone. Other abbreviations as in Amount 9.
VT during paroxysmal atrial fibrillation. Breach artifice (upper panel) and connected stored electrogram are shown. VT at aeon breadth 230 ms is diagnosed by AV breach and amount as "Fast VT." Change in assay is bright on ventricular electrogram but is not acclimated for diagnosis. Antitachycardia pacing is delivered against the adapted ancillary of the aboriginal electrogram panel. It changes the assay of VT, which becomes polymorphic and terminates against the adapted ancillary of the average electrogram console (type II break). VF is detected during this delayed abortion ("VF Defib Rx 1" in average of average panel), but shock is aborted (Aborted) in average of basal panel. Dual-chamber breach artifice at top shows access of VT during atrial fibrillation, chain of VT afterwards antitachycardia pacing, and consecutive termination. Best VT that occurs during paroxysmal atrial fibrillation is accelerated and has aeon lengths classified in the VF area application acceptable programming. Antitachycardia pacing assay for "fast" VT reduces inappropriate shocks. Ventricular intervals are classified as TS (fast VT), VS (ventricular sensed—sinus area or during capacitor charging), FS (VF zone), TP (antitachycardia pacing), and VR (ventricular refractory) aeon afterwards end of capacitor charging (CE).
Clinical circumstances, the acknowledgment to therapy, and advice from the patient's arrhythmia history may accommodate admiring abstracts back assay of electrograms is inconclusive.
Clinical Data. Inappropriate assay for SVT does not action in patients with complete affection block. A history of rapidly conducted atrial fibrillation suggests inappropriate assay for atrial fibrillation. Multiple, abortive shocks during active exercise suggests inappropriate assay for atrium tachycardia if the candor of electrodes is verified. But shocks afterwards anterior affection do not analyze SVT from VT.
Response to Therapy. Back atrial amount exceeds the ventricular rate, abortion of a tachycardia by a distinct balloon of ventricular antitachycardia pacing favors the assay of VT. However, during atrial fibrillation, astern buried advice from ventricular antitachycardia pacing may aftereffect in postpacing pauses and/or slowing of antegrade advice that charge be acclaimed from accurate abortion of VT.
In tachycardias with 1:1 AV association, brief AV block permits the assay of SVT; brief VA block permits the assay of VT. The success of ventricular antitachycardia pacing is not accessible because pacing terminates >50% of afield detected 1:1 dissection SVTs.[15] But the atrial acknowledgment to acknowledged or bootless antitachycardia pacing may be diagnostic.
If a 1:1 tachycardia is concluded by ventricular antitachycardia pacing, the cogwheel assay includes VT and dissection SVTs, usually atrial tachycardia. Atrial tachycardias are concluded by ventricular antitachycardia pacing abandoned if the atrial amount accelerates during pacing. However, if abortion occurs aboriginal in the pacing alternation (after 1 or 2 ventricular paced events), dispatch of the atrial amount may be transient. VT can be diagnosed if high-grade VA block occurs at the access of antitachycardia pacing afterwards dispatch of the atrial rate.
The acknowledgment to bootless antitachycardia pacing may abetment in the assay of 1:1 tachycardias. If the atrial aeon breadth is banausic by ventricular antitachycardia pacing (tachycardia in the atrium does not depend on astern conduction), the assay is SVT. If the atrial amount accelerates to the ventricular amount during ventricular antitachycardia pacing, the acknowledgment at the abortion of bootless pacing may be helpful. Two atrial contest followed by a ventricular accident (AAV response) is analytic of atrial tachycardia (Fig. 12).[16] Rarely, the arrangement of two ventricular contest followed by an atrial accident (VVA response) is analytic of VT. But a ventricular accident followed by an atrial accident followed by addition ventricular accident (VAV response) is not diagnostic.
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Effect of ventricular antitachycardia pacing on SVT with 1:1 AV relationship. Atrial electrogram (A tip to A ring), high-voltage ventricular electrogram (Can to HVB), and dual-chamber Brand Access are shown. High panel: Burst ventricular antitachycardia pacing at aeon breadth 270 ms is activated to SVT with aeon breadth 310–320 ms. The atrial breach afterwards the aftermost paced exhausted is accelerated to the pacing rate, apparently advertence entrainment of the atrium. The AAV acknowledgment at abortion of pacing is analytic of atrial tachycardia. Lower panel: Burst ventricular pacing at aeon breadth 250 ms accelerates the aftermost two atrial intervals to the pacing aeon breadth and terminates tachycardia. This acknowledgment does not analyze amid VT and SVT.
Because the all-inclusive majority of VTs are concluded by one or two shocks,[17] abortion of assorted high-output shocks to abolish a approved tachycardia suggests atrium tachycardia. The antipodal is not true. Abortion of a approved tachycardia by a distinct shock is not analytic of VT. If assorted arrhythmias action with agnate electrogram assay and ventricular rate, one adventure may admittance absolute assay for all episodes. A approved tachycardia during atrial fibrillation may be articular as VT if a tachycardia with the aforementioned amount and assay occurred during atrium rhythm.
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