Inappropriate subcutaneous implantable cardioverter-defibrillator shocks due to T-wave oversensing can be prevented: implications for management

Background: Inappropriate shocks (IASs) complicate implantable cardioverter-defibrillator (ICD) therapy. The management of IASs in patients with a subcutaneous ICD (S-ICD) differs from that in patients with a conventional ICD because of different sensing algorithms and programming options.

Objective: To describe the management of IASs in patients with an S-ICD.

Methods: Patients were implanted with an S-ICD between February 2009 and July 2012. The prevalence data and clinical determinants of IASs were prospectively collected. In the case of T-wave oversensing (TWOS), an exercise test was performed, and all possible sensing vectors were screened for TWOS. The absence of TWOS defined a suitable vector.

Results: Eleven of 69 patients (54% men; mean age 39 ± 14 years; 73% primary prevention) received IASs after 8.9 ± 10 months of implantation (10.8% annual incidence rate). In 8 cases, TWOS caused IASs. Seven of these IASs occurred during exercise and 1 during atrial fibrillation with a high ventricular rate. To manage TWOS, in 7 of 8 patients the sensing vector was changed and in 5 of 8 patients the (un)conditional zone was changed. Hereafter, IASs recurred in 3 of 8 patients, in 2 because of programming errors. Hence, after reprogramming, we observed no IASs in 87.5% of the patients with TWOS during a follow-up of 14.1 ± 13 months.

Conclusions: IASs due to TWOS in the S-ICD can be managed by reprogramming the sensing vector and/or the therapy zones of the device using a template acquired during exercise. Exercise-optimized programming can reduce future IASs, and standard exercise testing shortly after the implantation of an S-ICD may be considered in patients at an increased risk for TWOS.