Postpacing Interval During Right Ventricular Overdrive Pacing to Discriminate Supraventricular from Ventricular tachycardia

INTRODUCTION: Failure to differentiate supraventricular from ventricular arrhythmias is the most frequent cause of inappropriate implantable cardioverter-defibrillator (ICD) therapies. We hypothesized that the postpacing interval (PPI) after overdrive right ventricular pacing may differentiate ventricular (VT) from supraventricular tachycardia (SVT) such as sinus tachycardia, atrial flutter and atrial tachycardia. This hypothesis is based on the entrainment maneuver. Reentrant tachycardia circuit for VTs would haveshorter distance to RV apex than SVTs have, and the conduction time between a ventricular pacing site and the tachycardia origin is expected to be shorter in VTs than in SVTs. METHODS: 220episodes from 38 patients with single chamber ICDs that RV overdrive pacing could not terminate or change the tachycardia cycle length (TCL) were retrospectively reviewed. Episodes were classified as VTs (n=115) and SVTs (n=105). TCLs, PPIs and PPI-TCL were compared between groups. RESULTS: The cycle length of VTs was shorter than SVTs (320.6±30.3 vs 366.5±40 ms, p=0.001). PPI and PPI-TCL of VTs were shorter than SVTs (504.7±128.3 vs 689.2±121.8 ms, p=0.001, 184±103 vs 322.6±106.6 ms, p=0.001; respectively). ROC curve analysis demonstrated a 525 ms cut-off value for PPI has 89% sensitivity and 57.4% specificity to predict inappropriate ICD therapies due to SVTs (AUC:0.852). Similarly, A PPI-TCL <195 ms favored VT as a diagnosis rather than SVT with a 90% sensitivity, and 51% specificity (AUC:0.838). CONCLUSION: Analyzing of PPI during overdrive pacing from RV apex may discriminate supraventricular from ventricular tachycardia. This criterion may have a potential role in implantable devices that use a single ventricular lead.