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Desafio

What is the Diagnosis?

Qual o Diagnóstico?

Jose Mario Baggio1,*; Joubert Ariel Pereira Mosquera1; Luis Gustavo Ferreira Gomes1; Wagner Luis Gali1; Alvaro Valentim Lima Sarabanda1

DOI: 10.24207/jac.v32i1.998_PT

FIGURES

Citation: Baggio Junior JM, Mosquera JAP, Gomes LGF, Gali WL, Sarabanda AVL. What is the Diagnosis?. Arq Bras Cardiol 32(1):52. doi:10.24207/jac.v32i1.998_PT
 

CASE PRESENTATION

Patient YB, 50 years old, female, with hypothyroidism, severe left ventricular dysfunction, uncompressed left ventricle and poorly tolerated ventricular tachycardia, submitted to implantation of a dual chamber implantable cardioverter defibrillator (ICD) in February 2012 (generator Secura DR Medtronic, 4076 Medtronic atrial electrode, and Sprint Quattro 6947 Medtronic ventricular electrode). Returns asymptomatic nine months after the implant for routine evaluation.

The initial interrogation evidenced electrophysiological measures. The device alert highlighted 700 episodes of short VV (intervals between QRS complex senses less than 200 ms) (Fig. 1). These episodes usually represent electrode noise, excessive sensitivity (double QRS count or cross-sensitivity of atrial events in the ventricle) or electromagnetic interference.

The telemetry of the device revealed episodes of cross-sensitivity through the ventricular channel of both sensed and stimulated atrial events (Fig 2). Such behavior is not usual in devices with correctly positioned bipolar electrodes. On chest radiography (Fig. 3), it was possible to confirm the adequate positioning of the atrial, ventricular and shock-spring electrodes.

However, after careful evaluation of the programming, it was observed that the ventricular sensitivity was programmed in a tip to coil, which increases the detection antenna and the possibility of cross-sensitivity, once the detection field becomes larger (Fig. 4). Thus, it was decided to program the sensitivity of the ventricle in bipolar, correcting the sensitivity dysfunction that motivated the short VV alarm. This correction is important because, given sinus tachycardia, this behavior could cause an inappropriate shock.

 

ANSWER

In patients with ICDs and low sensitivity thresholds (<5 mV), the increase of the detection antenna by programming, converting the operation of a true bipolar electrode into integrated bipolar, is an important resource. However, it should be noted that by increasing the detection antenna of these devices, patients are exposed to a greater risk of excessive sensitivity of cardiac and non-cardiac events that occur outside the ventricles.

 

REFERENCES

Ellenbogen KA, Wilkoff BL, Kay GN, Lau CP, Auricchio A. Clinical cardiac pacing defibrillation, and resynchronization therapy. 5a ed. Philadelphia: Elsevier; 2017. https://doi.org/10.1016/c2014-0-01314-7
Barold SS, Stroobandt X, Sinnaeve AF. Cardiac pacemakers step by step. Chichester: Wiley-Blackwell; 2004.

© Todos os Direitos Reservados 2019 - Departamento de Estimulação Cardíaca Artificial da Sociedade Brasileira de Cirurgia Cardiovascular