Case 2 Multiple Morphologies in a Single Episode

Patient: 49-year-old man with old infarction, left ventricular ejection fraction 0.28, no evident heart failure, and history of atrial flutter.

Index arrhythmia: sustained monomorphic ventricular tachycardia, cycle length 290 ms. Remained inducible on sotalol, what was continued (1993).

Complaint: frequent shocks within the first six months.

Electrogram

Electrogram

ICD pulse generator: Ventak 1715 (CPI, later Guidant, USA). Shock delivered between RV coil and subcutaneous array with SVC coil - DFT 15 J.

Electrogram interpretation

Shock-lead electrograms. In the first strip ATP (burst) is delivered for a narrow QRS complex tachycardia with TCL of 360 ms, resulting in a polymorphic wide QRS tachycardia, ending in a regular wide QRS complex tachycardia with TCL of 240 ms. In the second strip, this wide QRS complex tachycardia is treated with a 34 J shock, resulting in an illegible rhythm strip, transitioning to an irregular, narrow complex rhythm, which again is given a biphasic 34 J shocked in strip 3, resulting in no definite electrogram changes, except for repolarization disturbances.

Diagnosis: the initiating arrhythmia is atrial flutter with 2:1 atrioventricular conduction; the final strip shows atrial fibrillation. With the available information no definite diagnosis can be made for the wide QRS tachycardia in strips 1 and 2.

Single Chamber Devices

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