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      Impact of a novel algorithm designed to reduce T-wave oversensing with the subcutaneous defibrillator in a patient with type I Brugada electrocardiogram

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          Abstract

          Introduction Key Teaching Points • Common complications in patients with Brugada syndrome are inappropriate shocks, mainly due to T-wave oversensing, caused by spontaneous electrocardiogram (ECG) variability, which increases the risk of false detection. • The morphology-based subcutaneous sensing approach of the subcutaneous implantable cardioverter-defibrillator (S-ICD) has been vulnerable to QRS/T-wave oversensing, which is the leading cause of inappropriate shocks with the S-ICD. • The SMART Pass algorithm enables a high-pass (9-Hz) filter for sensing and heart rate estimate. This algorithm seems to be particularly attractive for reducing inappropriate shocks in patients with dynamic ECG morphology changes, like in Brugada syndrome. • This patient case underscores the clinical value of S-ICD as an alternative solution for younger patients, who need multiple years of ICD therapy, for sudden cardiac death prophylaxis. Brugada syndrome (BrS) is an inherited disease associated with an increased risk of developing malignant ventricular arrhythmias. These can not only cause syncope but also lead to sudden cardiac death (SCD), which may be the first manifestation of the syndrome. The type I electrocardiogram (ECG) is typically characterized by ST-segment elevation of more than 2 mm (coved type) in at least one of the right precordial leads.1, 2 The most common gene mutation is associated with the SCN5A locus and found in 20%–25% of patients with BrS.3, 4 While implantable cardioverter-defibrillator (ICD) therapy is the main therapy in symptomatic patients, 5 a low arrhythmic event rate is often observed and the relatively high complication risk in mostly young patients who receive transvenous ICDs (TV-ICDs) should be taken into account when considering this approach. 6 Common complications in these patients are inappropriate shocks, 7 mainly due to T-wave oversensing, caused by spontaneous ECG variability, which increases the risk of false detection.8, 9 Despite its existing detection algorithms, the morphology-based subcutaneous sensing approach of the subcutaneous ICD (S-ICD) has been vulnerable to QRS/T-wave oversensing, which is the leading cause of inappropriate shocks with the S-ICD. 10 This phenomenon occurs more often in patients with spontaneous type I Brugada ECGs.5, 11, 12 Conversely, many of the system-related complications of TV-ICDs can be avoided by the S-ICD: with a device-related complication–free rate of 99% 13 and which is considered a favorable therapy, over TV-ICD therapy, in young patients. 14 Case report In 1998, a 37-year-old male patient with a family history of BrS (brother experienced resuscitated cardiac arrest and underwent ICD implantation), spontaneous type I ECG (Figure 1), and ventricular fibrillation induction during electrophysiology study was implanted with a single-chamber TV-ICD for the primary prevention of SCD. Figure 1 Surface electrocardiogram: observe the spontaneous marked ST-segment elevation in lead V1 in this patient. Electrical storm occurred in 2005 for which the patient received 10 appropriate ICD shocks and was subsequently treated with quinidine without arrhythmia relapse. In July 2015, the patient was diagnosed with a severe Staphylococcus aureus infection, including valvular endocarditis, septic pulmonary embolism, and cardiogenic shock. This was preceded by a problematic history over 12 years, including 3 device replacements, of which 2 were elective due to battery depletion. In addition, 2 right ventricular leads were replaced owing to mechanical lead failure. In total, there were 4 surgical interventions, including 1 successful lead extraction. After complete system extraction in July 2015, the patient was offered a wearable defibrillator while he remained under antibiotic treatment for 6 weeks to resolve his valvular endocarditis. Considering the considerable burden of complications in this still young patient, and despite a type I ST-segment elevation on the surface ECG (Figure 1), an EMBLEM S-ICD (model A209, Boston Scientific, SW 3.0.479) was implanted in September 2015. The implantation procedure was uneventful, with a successful defibrillation conversion test at 65 J. Two suitable sensing vectors (secondary and alternate) could be identified, albeit with borderline small signals of 0.4 mV or less. In the period between November 2015 and June 2016, there were 8 untreated and 1 treated episodes due to T-wave oversensing. These episodes typically occurred at heart rates above 90 beats/min. Furthermore, there was evidence of multiple events of inappropriately sensed but correctly discarded T waves by the morphology correlation and double detection algorithm of S-ICD. In June 2016, the device was upgraded with a new software version (SW 3.1.529), including the SMART Pass algorithm, which uses a digital high-pass (9-Hz) filter in the sensing circuit of the S-ICD to avoid cardiac oversensing. In the subsequent year, no episodes of T-wave oversensing or discarded T waves occurred, even during exercise-induced heart rates above 100 beats/min. Switching SMART Pass on clearly resulted in a reduction in discarded T waves, which are no longer sensed when the algorithm is active (Figure 2). Figure 2 A: Inappropriately sensed but correctly discarded T waves (black dots) with SMART Pass off. B: In the same patient, T waves are no longer sensed with SMART Pass on and with the same sensing vector (secondary configuration). S = ventricular sensing. Discussion With this case report of a patient with BrS and a dynamic type I ECG morphology, we sought to illustrate the impact of a novel algorithm (SMART Pass, Marlborough, MA) designed to avoid oversensing of the low-amplitude cardiac signals and demonstrate the suitability of S-ICD in these patients. The SMART Pass algorithm enables a high-pass (9-Hz) filter for sensing and heart rate estimate. The ECG for rhythm discrimination remains unchanged and continues to use the wide-band filtered ECG similar to previous generations. SMART Pass will be enabled with manual/automatic setup during a session (QRS voltage >0.5 mV) and will be automatically disabled for low amplitudes and slower rates. Conclusion This patient case underscores the clinical value of S-ICD as an alternative solution for younger patients, who need multiple years of ICD therapy, for SCD prophylaxis. The SMART Pass algorithm seems to be particularly attractive for reducing inappropriate shocks in patients with dynamic ECG morphology changes, like in BrS.

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          Most cited references 12

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          Risk stratification in Brugada syndrome: results of the PRELUDE (PRogrammed ELectrical stimUlation preDictive valuE) registry.

          The PRELUDE (PRogrammed ELectrical stimUlation preDictive valuE) prospective registry was designed to assess the predictive accuracy of sustained ventricular tachycardia/ventricular fibrillation (VTs/VF) inducibility and to identify additional predictors of arrhythmic events in Brugada syndrome patients without history of VT/VF. Brugada syndrome is a genetic disease associated with increased risk of sudden cardiac death. Even though its value has been questioned, inducibility of VTs/VF is widely used to select candidates to receive a prophylactic implantable defibrillator, and its accuracy has never been addressed in prospective studies with homogeneous enrolling criteria. Patients with a spontaneous or drug-induced type I electrocardiogram (ECG) and without history of cardiac arrest were enrolled. The registry included 308 consecutive individuals (247 men, 80%; median age 44 years, range 18 to 72 years). Programmed electrical stimulation was performed at enrollment, and patients were followed-up every 6 months. During a median follow-up of 34 months, 14 arrhythmic events (4.5%) occurred (13 appropriate shocks of the implantable defibrillator, and 1 cardiac arrest). Programmed electrical stimulation performed with a uniform and pre-specified protocol induced ventricular tachyarrhythmias in 40% of patients: arrhythmia inducibility was not a predictor of events at follow-up (9 of 14 events occurred in noninducible patients). History of syncope and spontaneous type I ECG (hazard ratio [HR]: 4.20), ventricular refractory period <200 ms (HR: 3.91), and QRS fragmentation (HR: 4.94) were significant predictors of arrhythmias. Our data show that VT/VF inducibility is unable to identify high-risk patients, whereas the presence of a spontaneous type I ECG, history of syncope, ventricular effective refractory period <200 ms, and QRS fragmentation seem useful to identify candidates for prophylactic implantable cardioverter defibrillator. Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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            Outcome after implantation of a cardioverter-defibrillator in patients with Brugada syndrome: a multicenter study-part 2.

            Implantable cardioverter-defibrillator indications in Brugada syndrome remain controversial, especially in asymptomatic patients. Previous outcome data are limited by relatively small numbers of patients or short follow-up durations. We report the outcome of patients with Brugada syndrome implanted with an implantable cardioverter-defibrillator in a large multicenter registry.
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              SCN 5A Genetic Polymorphisms Associated With Increased Defibrillator Shocks in Brugada Syndrome

              Background Brugada syndrome (BrS) is an inherited primary arrhythmia disorder leading to sudden cardiac arrest. SCN5A, encoding the α‐subunit of the cardiac sodium channel (Nav1.5), is the most common pathogenic gene of BrS. An implantable cardioverter defibrillator (ICD) is the standard treatment for secondary prevention. This study aimed to evaluate association of the SCN5A variant with this cardiac conduction disturbance and appropriate ICD shock therapy in Thai symptomatic BrS patients with ICD implants. Methods and Results Symptomatic BrS patients diagnosed at university hospital were enrolled from 2008 to 2011. The primary outcome of the study was an appropriate ICD shock defined as having non‐pacing‐associated ICD shock after the occurrence of ventricular tachycardia or ventricular fibrillation. Associations between SCN5A polymorphisms, cardiac conduction disturbance, and potential confounding factors associated with appropriate ICD shock therapy were analyzed. All 40 symptomatic BrS patients (median age, 43 years) with ICD implantations were followed for 24 months. There were 16 patients (40%) who had the appropriate ICD shock therapy after ICD treatment. An independent factor associated with appropriate ICD shock therapy was SCN5A‐R1193Q with an adjusted hazard ratio of 10.550 (95% CI, 1.631–68.232). Conclusions SCN5A‐R1193Q is associated with cardiac conduction disturbances. It may be a genetic marker associated with ventricular arrhythmia leading to appropriate ICD shock therapy in symptomatic BrS patients with ICD treatment. Because of the small sample size of study population and the appropriate ICD shock outcome, further large studies are needed to confirm the results of this study.
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                Author and article information

                Contributors
                Journal
                HeartRhythm Case Rep
                HeartRhythm Case Rep
                HeartRhythm Case Reports
                Elsevier
                2214-0271
                21 November 2017
                January 2018
                21 November 2017
                : 4
                : 1
                : 31-33
                Affiliations
                []Cardiac Arrhythmias Management, Cardiology Department, Clinique Pasteur, Toulouse, France
                []Boston Scientific Europe, Paris, France
                Author notes
                [] Address reprint requests and correspondence: Dr Serge Boveda, Cardiac Arrhythmias Management, Cardiology Department, Clinique Pasteur, 45, Avenue de Lombez, 31076 Toulouse, France.Cardiac Arrhythmias ManagementCardiology Department, Clinique Pasteur, 45, Avenue de Lombez31076 ToulouseFrance sboveda@ 123456clinique-pasteur.com
                Article
                S2214-0271(17)30199-9
                10.1016/j.hrcr.2017.11.009
                5775447
                © 2017 Heart Rhythm Society. Published by Elsevier Inc.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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                Clinical Problem Solving

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