Sensing and Tachyarrhythmia Detection Problems in Implantable Cardioverter Defibrillators

Sensing of cardiac activity and detection of tachyarrhythmias in implantable cardioverter defibrillators (ICDs) are complex functions and errors occur. Sources of sensing-detection errors include the variable nature of intracardiac electrograms, the occasional inability of automatically adjusting signal amplifiers to cope with this variability, problems with sensing leads, inappropriate programming, and limitations of tachyarrhythmia detection algorithms, which are optimized to avoid underdetection of ventricular tachyarrhythmias. Current ICDs vary considerably in details of sensing and detection function, programmability, and diagnostic data, so that a through knowledge of each device is necessary to diagnose and correct these problems. Stored intracardiac electrograms and/or marker channels available in most of these devices have contributed much to our understanding of sensing-detection errors. Undersensing of individual signals, most frequently due to signal variability and/or inability of the amplifier to adjust adequately, can lead to delay or failure of tachyarrhythmia detection. Delay or failure of tachyarrhythmia detection can also occur if algorithms to enhance specificity, such as sudden onset or rate stability, are utilized. Oversensing of T waves or noise can lead to false detection; however, the most common cause of false detection is the inability of current detection algorithms to distinguish supraventricular from ventricular tachyarrhythmias. New algorithms that incorporate atrial sensing, electrogram morphology analysis, or hemodynamic monitoring may result in improved detection accuracy of ICDs in the future.