Have we been programming our
defibrillators poorly?
Albert Y. Sun, MD
Assistant Professor of Medicine
Clinical Cardiac Ele...
Programming ICDs

War Games MGM 1983
All Rights Reserved, Duke Medicine 2007
Overview of Basic ICD Function
Device
Programming

Tachycardia
Detection

VT 170 bpm

Classification
Monitoring
SVT

VT/VF...
Case 1: 85 y/o Male with Afib, ICM, and a
Primary Prevention ICD

All Rights Reserved, Duke Medicine 2007
What to do next?

A.  No changes to programming,
increase beta blocker and/or
start anti-arrhythmic
B.  Change VF to >200 ...
A)  No changes to
programming, increase
beta blocker and/or start
anti-arrhythmic
B)  Change VF to >200 bpm
and increase N...
Irregular Cycle Length

All Rights Reserved, Duke Medicine 2007

A Lead not functioning –
Undersensing Afib
Inappropriate Shocks
45

39

40

33

35
30

26

25

21

20
15

17
12

% Inappropriate Shocks
% Appropriate Shocks

10
5
0
...
Inappropriate Implantable Cardioverter-Defibrillator Shocks in MADIT II: Frequency,
Mechanisms, Predictors, and Survival I...
Inappropriate Implantable Cardioverter-Defibrillator Shocks in MADIT II: Frequency,
Mechanisms, Predictors, and Survival I...
PREPARE

J Am Coll Cardiol 2008;52:541–50

All Rights Reserved, Duke Medicine 2007
MADIT-RIT
Cumulative Probability of First Inappropriate
Therapy by Treatment Group

Arm A
(Conventional)

Arm B
(High-rate...
ADVANCE III
Trial design: Patients undergoing ICD implantation were randomized to either prolonged
detection (30 of 40 int...
Results of the PainFree Rx II (Pacing Fast Ventricular Tachycardia Reduces Shock Therapies)
trial. The pie charts show ter...
Take Home Points From This Case
•  New Paradigm in Primary Prevention ICD
programming
–  Longer detect times - NID 30/40; ...
Case 2: 67M with Chronic Afib, NICM, CRT-D,
and worsening Heart Failure Symptoms
Pacing Summary
Mode

DDD

Lower Rate

60
...
A.  Increase Lower Rate
from 60 to 70
B.  Afib Ablation
C.  AV node ablation
D.  All are reasonable

What to do next?
Paci...
What to do next?
Pacing Summary
Mode

DDD

Lower Rate

60

Paced AV

130 ms

Mode Switch

171

Upper Track

120

Sensed AV...
Very low Bi-Ventricular pacing percentage
Pacing Summary
Mode

DDD

Lower Rate

60

Paced AV

130 ms

Mode Switch

171

Up...
Atrial Fibrillation Impacts Adherence to Heart Rhythm Society
Recommendations for Achieving High Bi-Ventricular Pacing Per...
Survival and Biventricular Pacing percentage

Patients with biventricular pacing percentage above 99.6% experienced a
24% ...
Take Home Points
•  Goal for BiV pacing >99%
–  Programming changes
–  Aggressive Afib control

All Rights Reserved, Duke ...
Case 3: 65 M with ICM EF 35%, Dual Chamber
Primary Prevention ICD with mild fatigue
Current programming:
DDD 50

80
60
AP-...
VT: NID 16, 167 bpm, ATP (Burst) x 1, 35J
x6
VF: NID 18/24, >188bpm, ATP during
Charging, 35J x 6
33%

11%

on

ng
e

T	
 ...
What to do next?
A)  Add VT monitor zone at
150 to catch VHR
B)  Change Therapy zone to
single zone VF 30/40 >200
bpm
C)  ...
% of the time

Chronotropic incompetence
100
90
80
70
60
50
40
30
20
10
0

PVCs/NSVT/Bigeminy
VS

VT: NID 16, 167 bpm,
ATP...
Overall Take Home Points
•  New Paradigm in Primary Prevention ICD
programming
–  Longer detect times - NID 30/40; VF 2.5 ...
Thank you for your time and thank you to the patients.

All Rights Reserved, Duke Medicine 2007
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SCD 2014: Have We Been Programming Defibrillators Poorly? New Information!

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SCD 2014: Have We Been Programming Defibrillators Poorly? New Information!

  1. 1. Have we been programming our defibrillators poorly? Albert Y. Sun, MD Assistant Professor of Medicine Clinical Cardiac Electrophysiology Duke University Medical Center albert.sun@duke.edu
  2. 2. Programming ICDs War Games MGM 1983 All Rights Reserved, Duke Medicine 2007
  3. 3. Overview of Basic ICD Function Device Programming Tachycardia Detection VT 170 bpm Classification Monitoring SVT VT/VF Withhold Therapies Therapy Spurious detection Withhold Therapies Redection Episode Termination No VT/VF Therapies Exhausted yes Adapted from Circulation: A and E, 10/2011 vol. 4 no. 5 778-790 All Rights Reserved, Duke Medicine 2007
  4. 4. Case 1: 85 y/o Male with Afib, ICM, and a Primary Prevention ICD All Rights Reserved, Duke Medicine 2007
  5. 5. What to do next? A.  No changes to programming, increase beta blocker and/or start anti-arrhythmic B.  Change VF to >200 bpm and increase NID to 30/40. C.  Turn on Discriminators (Stability and Onset) D.  B and C E.  B and C and medication changes F.  Other 54% 16% 16% 6% 8% All Rights Reserved, Duke Medicine 2007 Ch N o   c ha n ge s er th O an  to ge  pr  V og F r Tu  to am rn  > ...  o 20 n 0    D b is p m cr im  .. in . at or B s    a (. .. n d  C  a n B d    a m n ed d  C ic at io n ... 0%
  6. 6. A)  No changes to programming, increase beta blocker and/or start anti-arrhythmic B)  Change VF to >200 bpm and increase NID to 30/40. C)  Turn on Discriminators (Stability and Onset) D)  B and C E)  B and C and medication changes F)  Other All Rights Reserved, Duke Medicine 2007
  7. 7. Irregular Cycle Length All Rights Reserved, Duke Medicine 2007 A Lead not functioning – Undersensing Afib
  8. 8. Inappropriate Shocks 45 39 40 33 35 30 26 25 21 20 15 17 12 % Inappropriate Shocks % Appropriate Shocks 10 5 0 MADIT-II DEFINITE SCD-HefT Kadish A, Dyer A, Daubert JP, et al., N Engl J Med. 2004;350:2151-2158. Daubert JP, Zareba W, Cannom DS, et al., J Am Coll Cardiol. 2008;5:1357-1365. Poole JE, Johnson GW, Hellkamp AS, et al. N Engl J Med. September 4, 2008;359:1009-1017. All Rights Reserved, Duke Medicine 2007
  9. 9. Inappropriate Implantable Cardioverter-Defibrillator Shocks in MADIT II: Frequency, Mechanisms, Predictors, and Survival Impact HR for mortality of 2.29 (p = 0.02) Daubert, JP et al. J Am Coll Cardiol. 2008;51(14):1357-1365. doi:10.1016/j.jacc.2007.09.073 All Rights Reserved, Duke Medicine 2007
  10. 10. Inappropriate Implantable Cardioverter-Defibrillator Shocks in MADIT II: Frequency, Mechanisms, Predictors, and Survival Impact Ventricular Rate Precipitating Inappropriate Shock Daubert, JP et al. J Am Coll Cardiol. 2008;51(14):1357-1365. doi:10.1016/j.jacc.2007.09.073 All Rights Reserved, Duke Medicine 2007
  11. 11. PREPARE J Am Coll Cardiol 2008;52:541–50 All Rights Reserved, Duke Medicine 2007
  12. 12. MADIT-RIT Cumulative Probability of First Inappropriate Therapy by Treatment Group Arm A (Conventional) Arm B (High-rate) Arm C (Duration-delay) Zone 1: Zone 1: Zone 1: >170 bpm, 2.5s delay 170 bpm >170 bpm, 60s delay ATP + Shock Monitor only ATP + Shock Zone 2: Zone 2: Zone 2: >200 bpm, 1s delay >200 bpm, 2.5s delay >200 bpm, 12s delay Quick Convert ATP Shock Quick Convert ATP Shock ATP + Shock Zone 3 : >250 bpm, 2.5s delay Quick Convert ATP + Shock Reduction in all-cause mortality (high- rate therapy vs. conventional therapy) HR 0.45; 95% CI, 0.24 to 0.85; P=0.01 Moss, A et al. N Engl J Med 2012;367:2275-83. All Rights Reserved, Duke Medicine 2007
  13. 13. ADVANCE III Trial design: Patients undergoing ICD implantation were randomized to either prolonged detection (30 of 40 intervals) or routine programming (18 of 24 intervals). Patients were followed for 1 year. /100 Patient-Years 100 67 50 42 0 Primary endpoint (p < 0.001) Longinterval (n = 948) Standardinterval (n = 954) Gasparini M, et al. JAMA 2013;309:1903-11 All Rights Reserved, Duke Medicine 2007
  14. 14. Results of the PainFree Rx II (Pacing Fast Ventricular Tachycardia Reduces Shock Therapies) trial. The pie charts show terminating therapy for FVT episodes in each arm. Koneru J et al. Circ Arrhythm Electrophysiol 2011;4:778-790 Copyright © American Heart Association, Inc. All rights reserved. All Rights Reserved, Duke Medicine 2007
  15. 15. Take Home Points From This Case •  New Paradigm in Primary Prevention ICD programming –  Longer detect times - NID 30/40; VF 2.5 + secs –  Higher Rate Therapy zones VF>200, •  Utilize Discriminators •  Utilize ATP even for Fast VT All Rights Reserved, Duke Medicine 2007
  16. 16. Case 2: 67M with Chronic Afib, NICM, CRT-D, and worsening Heart Failure Symptoms Pacing Summary Mode DDD Lower Rate 60 Paced AV 130 ms Mode Switch 171 Upper Track 120 Sensed AV 100 ms Upper Sensor 120 Afib Burden 100% AS 100% VP 61% VS 39% All Rights Reserved, Duke Medicine 2007 Relevant Meds: •  Toprol XL 200 BID •  Digoxin 0.125 Daily •  Lisinopril 40 Daily •  Spironolactone 25 Daily •  Lasix 40 BID •  Amiodarone 200 Daily
  17. 17. A.  Increase Lower Rate from 60 to 70 B.  Afib Ablation C.  AV node ablation D.  All are reasonable What to do next? Pacing Summary Mode DDD Lower Rate 60 Paced AV 130 ms Mode Switch 171 Upper Track 12 0 Sensed AV 100 ms Upper Sensor 12 0 Afib Burden 41% 44% 100% AS 100% VP 6% 9% 61% A. VS All Rights Reserved, Duke Medicine 2007 39% B. C. D.
  18. 18. What to do next? Pacing Summary Mode DDD Lower Rate 60 Paced AV 130 ms Mode Switch 171 Upper Track 120 Sensed AV 100 ms Upper Sensor 120 Afib Burden 100% AS 100% VP 61% VS 39% All Rights Reserved, Duke Medicine 2007 A)  Increase Lower Rate from 60 to 70 B)  Afib Ablation C)  AV node ablation D)  All are reasonable
  19. 19. Very low Bi-Ventricular pacing percentage Pacing Summary Mode DDD Lower Rate 60 Paced AV 130 ms Mode Switch 171 Upper Track 120 Sensed AV 100 ms Upper Sensor 120 Afib with RVR Afib Burden 100% AS 100% VP 61% VS 39% All Rights Reserved, Duke Medicine 2007
  20. 20. Atrial Fibrillation Impacts Adherence to Heart Rhythm Society Recommendations for Achieving High Bi-Ventricular Pacing Percentage in US Clinics Multivariate analysis in Persistent AF patients Variable Odds Ratio (95% CI) Mean ventricular rate during 0.56  (0.44-­‐0.70)   AF % Patients with LR 1.07  (1.04  to   programmed ≥ 70 BPM 1.11)   P Value <  0.001   <  0.001   Atwater BD, Ousdigian KS, Sun AY, Koehler JL, Deering TL. AHA 2013 All Rights Reserved, Duke Medicine 2007
  21. 21. Survival and Biventricular Pacing percentage Patients with biventricular pacing percentage above 99.6% experienced a 24% reduction in mortality compared with the other quartile groups (hazard ratio = 0.76, P =0.001). Hayes, D et al Heart Rhythm 2011;8:1469 –1475 All Rights Reserved, Duke Medicine 2007
  22. 22. Take Home Points •  Goal for BiV pacing >99% –  Programming changes –  Aggressive Afib control All Rights Reserved, Duke Medicine 2007
  23. 23. Case 3: 65 M with ICM EF 35%, Dual Chamber Primary Prevention ICD with mild fatigue Current programming: DDD 50 80 60 AP-VS 40 AP-VP 20 0 <40 60 80 100 120 140 160 180 >200 % of the time 100 VT: NID 16, 167 bpm, ATP (Burst) x 1, 35J x6 VF: NID 18/24, >188bpm, ATP during Charging, 35J x 6 Ventricular Rate Interrogation with no Ventricular High rate events All Rights Reserved, Duke Medicine 2007
  24. 24. VT: NID 16, 167 bpm, ATP (Burst) x 1, 35J x6 VF: NID 18/24, >188bpm, ATP during Charging, 35J x 6 33% 11% on ng e T   m Ch a dd  V 0% th e r 0% O 0% A All Rights Reserved, Duke Medicine 2007 33% 22% ito A.  Add VT monitor zone at 150 to catch VHR B.  Change Therapy zone to single zone VF 30/40 >200 bpm C.  Change Pacing mode to DDDR 60 D.  Change Pacing mode to DDDR 60 E.  A and B F.  All of the above G.  Other Current programming: DDD 50 r  z   Ch The one  a an r a ge py t  ..  z .   Ch Pac on an in e  t ge g  m o  . ..  P ac o d e in g    to. m . od . e   to ... A A  a ll   of nd  th  B e   ab ov e What to do next?
  25. 25. What to do next? A)  Add VT monitor zone at 150 to catch VHR B)  Change Therapy zone to single zone VF 30/40 >200 bpm C)  Change Pacing mode to DDDR 60 D)  Increase Beta Blocker E)  A and B F)  All of the above G)  Other All Rights Reserved, Duke Medicine 2007 Current programming: DDD 50 VT: NID 16, 167 bpm, ATP (Burst) x 1, 35J x6 VF: NID 18/24, >188bpm, ATP during Charging, 35J x6
  26. 26. % of the time Chronotropic incompetence 100 90 80 70 60 50 40 30 20 10 0 PVCs/NSVT/Bigeminy VS VT: NID 16, 167 bpm, ATP (Burst) x 1, 35J x6 VP VF: NID 18/24, >188bpm, ATP during Charging, 35J x 6 Ventricular Rate All Rights Reserved, Duke Medicine 2007 Current programming: DDD 50
  27. 27. Overall Take Home Points •  New Paradigm in Primary Prevention ICD programming –  Longer detect times - NID 30/40; VF 2.5 + secs –  Higher Rate Therapy zones VF>200, •  Utilize Discriminators •  Uitlize ATP even for Fast VT •  Goal for BiV pacing >99% –  Programming changes –  Aggressive Afib control •  Not all VT needs to be treated. All Rights Reserved, Duke Medicine 2007
  28. 28. Thank you for your time and thank you to the patients. All Rights Reserved, Duke Medicine 2007

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