Combined Atrial and Ventricular Antitachycardia Pacing as a Novel Method of Rhythm Discrimination

BACKGROUND: Inappropriate and unnecessary implantable cardioverter-defibrillator shocks continue to be highly prevalent. METHODS AND RESULTS: We prospectively evaluated a new algorithm for discriminating supraventricular (SVT) and ventricular (VT) tachycardias with 1:1 atrioventricular association that is based on the response of the arrhythmia to simultaneous or convergent dual-chamber antitachycardia pacing. Patients undergoing dual-chamber cardioverter-defibrillator implantation were randomized to the simultaneous atrioventricular and convergent atrioventricular arms with crossover at 3 months. Sixty-three patients had 1407 1:1 antitachycardia pacing sequences suitable for analysis (1381 1:1 SVT episodes in 32 patients and 26 1:1 VT episodes in 6 patients). Antitachycardia pacing terminated 66 of 1381 SVT (5%; generalized estimating equations adjusted, 23.8%) and 20 of 26 VT (77%; generalized estimating equation adjusted, 68.6%) episodes. After the exclusion of sinus tachycardia, the new software terminated 40 of 57 (70%; generalized estimating equation adjusted, 70.2%) SVT episodes. The new algorithm terminated or correctly classified 1379 of 1381 SVT sequences for an overall specificity of 99.9% (generalized estimating equation adjusted, 99.8%) and 23 of 26 VT for an overall sensitivity of 88.5% (generalized estimating equation adjusted, 82.1%). There were no statistically significant differences between the simultaneous and the convergent atrioventricular antitachycardia pacing sequences in their ability to confirm VT or reject SVT. No significant proarrhythmias were noted. CONCLUSIONS: We describe here a new pacing algorithm in dual-chamber defibrillators that can terminate arrhythmias or discriminate between 1:1 SVT and VT if the arrhythmia persists. Testing this new algorithm in larger patient populations is warranted. CLINICAL TRIAL REGISTRATION INFORMATION- URL: http://ftp.resource.org/gpo.gov/register/2007/2007_15297.pdf. IDE No. G060230.