ICD lead fracture - step-by-step evaluation and management case

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A patient with ICD lead fracture was admitted with multiple inappropriate shocks and ventricular asystole episodes. The ICD system was comprehensively evaluated, reprogrammed, the patient underwent new P/S lead implantation. Lead integrity alert function, inadvertent CS placement of defibrillation lead, subclavian crush, conservative-to-aggressive options of ICD lead fracture management are presented.

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  • Types of oversensing resulting in inappropriate detection of VT/VF. A–C show oversensing of physiological, intracardiac signals. D–F show oversensing of extracardiac signals. (A) P-wave oversensing in sinus rhythm from integrated bipolar lead with distal coil near the tricuspid valve. (B) R-wave double counting during conducted AF in a biventricular-sensing ICD. (C) T-wave oversensing in patient with low-amplitude R wave (note mV calibration marker). (D) Electromagnetic interference from a power drill has higher amplitude on widely spaced high-voltage electrogram than on closely spaced true bipolar sensing electrogram. (E) Diaphragmatic myopotential oversensing in a patient with an integrated bipolar lead at the RV apex. Note that noise level is constant, but oversensing does not occur until automatic gain control increases the gain sufficiently, about 600 ms after the sensed R waves. (F) Lead fracture noise results in intermittent saturation of amplifier range denoted by arrow. RA = right atrium; RV = right ventricular sensing electrogram; HV = high-voltage electrogram.
  • ICD lead fracture - step-by-step evaluation and management case

    1. 1. A case of comprehensive step-by- step evaluation and management of inappropriate shocks
    2. 2. History • 44 years old male • Rheumatoid arthritis; III0 AV block, sustained VT, cardiac arrest (2008) • s/p CAG (2008, NS), dual-chamber ICD implant (2008, Virtuoso DR, Linox TD 65/16, CapSure® SP Novus), ICD generator change (09.2012, Maximo II DR) • Beta-blocker self–discontinued • Parasyncope, hypotension, ventricular asystole episodes, multiple shocks, hearable device tones after mulberry climbing, • Severe bradycardia episodes on prehospital ECGs, no tachyarrhythmia
    3. 3. Clinical magnets
    4. 4. “Learn to use what you have got, and you won't need what you have not.” -- Phileas Fogg
    5. 5. Atip-to-Aring Can-to-SVCcoil RVtip-to-RVring RVtip-to-RVcoil
    6. 6. True bipolar sensing (tip-to-RVring) Integrated bipolar sensing (tip-to-RVcoil)

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