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References

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Device Diagnostics: Interval Tables, Event Counters, Interval Plots, Markers, Electrograms, and New Features

Summary

Diagnostic data of a pulse generator and the patient are now available, offering an array of alphanumerical data. When considering an arrhythmia, data can be clarified with numerical information (intervals), displayed in lists or tables. Event counters can provide information on all kind of events or interventions. Tachograms (or interval plots) display intervals versus time. Electrograms can be taken with different techniques from different channels. Physiological data can be obtained using sensors. All this information can be sent to the patient file, and even become available on the Web for the treating physician.

The ICD contains comprehensive data storage capabilities which offer the physician a possibility to improve patient care. Diagnostic data provide information regarding the function and activity of the pulse generator, which includes information on the battery, the hardware and software, including the lead and the lead-myocardial interface. The ICD has the capability of providing data on arrhythmia occurrence, the cycle length, and date and time of occurrence, with stored electrograms of the events. By examining these data, the physician can determine whether the arrhythmia was a true arrhythmia and whether therapy was appropriate. He can correlate the arrhythmic event with the presence or absence of symptoms and speculate on the electrophysiologic mechanism of the arrhythmia.

Multiple variables may affect the performance of arrhythmia detection by the ICD and one must be familiar with the programmed discrimination algorithms and the various modes of presenting stored diagnostic data. In this chapter, we will discuss the value and limitations of different modes of stored diagnostic information on cardiac arrhythmias.

Interval Tables and Event Counters

The first-generation ICDs provided event counters, displaying device-delivered shocks. The precise diagnosis of the arrhythmia which triggered device therapy and the 'appropriateness' of such therapy was based on the clinical history of the patient, the presence or absence of hemodynamically significant symptoms, or concomitant ECG monitoring. That uncertainty remained present in a large number of events is clear.

The second-generation ICDs stored and showed numerical RR intervals in tables, with or without device activity markers. This stored information allowed analysis of the rate of the arrhythmia preceding and following ICD therapy. Differentiation of arrhythmias was based on the regularity of RR intervals. Irregular intervals suggested atrial fibrillation, while regular intervals could indicate sinus tachycardia, atrial flutter, or atrial tachycardia as well as ventricular tachycardia. As was known from clinical observations, even monomorphic ventricular tachycardia may demonstrate irregular intervals at its onset, which makes it difficult to differentiate it from atrial fibrillation with this kind of information. Further, the detected intervals may include appropriately detected intervals or inappropriately detected or oversensed events due to intracardiac or extracardiac signals. As a consequence, arrhythmia diagnosis based on RR intervals alone remains associated with uncertainty[1].

Figure 3.1. Example of an episode text and the corresponding interval table displaying the RR intervals preceding and following device therapy for ventricular tachycardia (VT). After the first attempt of antitachycardia pacing (ATP), the device redetected RR intervals in the tachycardia detection zone. These RR intervals confirmed redetection of VT and triggered the next attempt with ATP to terminate VT. The episode text does not give details of the delivered attempts of ATP.

Figure 3.1. Example of an episode text and the corresponding interval table displaying the RR intervals preceding and following device therapy for ventricular tachycardia (VT). After the first attempt of antitachycardia pacing (ATP), the device redetected RR intervals in the tachycardia detection zone. These RR intervals confirmed redetection of VT and triggered the next attempt with ATP to terminate VT. The episode text does not give details of the delivered attempts of ATP.

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