Key result
Integrating ECG, device tracings, and EP findings helps prevent ICD misclassification of 2:1 V-A tachycardias.
This case highlights the importance of integrating surface ECG, device tracings, and electrophysiological findings to correctly diagnose and treat complex tachycardias, avoiding misclassification by device algorithms.
Multimodal confirmation essential before acting on ICD-detected 2:1 VA tachycardias; hypothesis-generating for enhanced device discrimination algorithms.
We report a 52-year-old man with coronary artery disease, reduced left ventricular ejection fraction, and a cardiac resynchronization therapy–defibrillator (CRT-D), admitted to the emergency department for palpitations. Surface ECG showed a wide-complex tachycardia with a 2:1 ventricular-to-atrial (V:A) relationship. Device interrogation revealed episodes detected in the ventricular tachycardia monitor zone, according to the atrioventricular discrimination algorithms. Detailed analysis of surface ECG and device intracardiac electrograms was performed, followed by an electrophysiological study and catheter ablation of the responsible circuit of the tachycardia. This case illustrates the diagnostic complexity and differential diagnosis of tachycardias presenting with a 2:1 V:A relationship and highlights the importance of integrating surface ECG, device tracings, and electrophysiological findings to correctly identify the underlying mechanism, to avoid misclassification by device algorithms, and to treat the arrhythmia effectively.
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Micari et al. (2026) studied this question. Tachycardias with a 2:1 ventricular-to-atrial relationship require integrating surface ECG, device tracings, and electrophysiological findings to prevent misclassification by ICD algorithms.
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