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      Device rounds: T-wave oversensing: A cause of loss of cardiac resynchronization therapy

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          Abstract

          A CRT-D patient presented with loss of biventricular pacing associated with heart failure symptoms. The electrocardiogram showed sinus rhythm with alternating wide unpaced and narrower paced QRS complexes. Device interrogation showed T-wave oversensing on all paced biventricular beats, with the following sinus P-wave not tracked due to it falling in the post-ventricular atrial refractory period, leading to intrinsic conduction. Device reprogramming from true bipolar (RV tip to RV ring) sensing to integrated bipolar (RV tip to RV coil) resolved the problem without having to decrease sensitivity values, allowing biventricular pacing close to 100% to resume with improvement of symptoms. T-wave oversensing is a frequently recognised cause of inappropriate therapy in implantable cardioverter defibrillators, but less frequently as a cause of loss of biventricular pacing in CRT-Ds. We review the different non-invasive strategies to overcome this problem.

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          Most cited references13

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          Reasons for loss of cardiac resynchronization therapy pacing: insights from 32 844 patients.

          The efficacy of cardiac resynchronization therapy (CRT) is associated with the amount of CRT pacing delivered. The specific causes of CRT pacing loss and their relative frequencies remain poorly defined.
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            The association between biventricular pacing and cardiac resynchronization therapy-defibrillator efficacy when compared with implantable cardioverter defibrillator on outcomes and reverse remodelling.

            Previous studies on biventricular (BIV) pacing and cardiac resynchronization therapy-defibrillator (CRT-D) efficacy have used arbitrarily chosen BIV pacing percentages, and no study has employed implantable cardioverter defibrillator (ICD) patients as a control group.
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              Hyperkalemia induced T wave oversensing leading to loss of biventricular pacing and inappropriate ICD shocks.

              Inappropriate ICD shocks remain a common problem. Double counting of single ventricular events can occur with biventricular ICDs implanted before univentricular sensing was available. Often this is due to a tachyarrhythmia or loss of left ventricular capture. This report describes a patient who developed hyperkalemia during hemodialysis, received inappropriate ICD shocks and experienced loss of biventricular pacing due to T wave rather than QRS double counting. Oversensing was abolished by reducing the potassium content of the dialysis bath. This underscores the need for careful interpretation of saved electrograms to determine the cause for, and appropriate treatment of, device related problems.
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                Author and article information

                Contributors
                Journal
                Indian Pacing Electrophysiol J
                Indian Pacing Electrophysiol J
                Indian Pacing and Electrophysiology Journal
                Elsevier
                0972-6292
                16 November 2016
                Sep-Oct 2016
                16 November 2016
                : 16
                : 5
                : 175-178
                Affiliations
                [1]Department of Cardiology, University Hospitals of Geneva, Switzerland
                Author notes
                []Corresponding author. Department of Cardiology, University Hospitals of Geneva, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland.Department of CardiologyUniversity Hospitals of Geneva4 Rue Gabrielle-Perret-GentilGeneva1205Switzerland dayal.nicolas@ 123456gmail.com
                Article
                S0972-6292(16)31283-9
                10.1016/j.ipej.2016.11.009
                5153439
                b4293e69-57db-448e-879d-f7a3dfc75004
                Copyright © 2016, Indian Heart Rhythm Society. Production and hosting by Elsevier B.V.

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

                History
                : 11 May 2016
                : 5 November 2016
                : 6 November 2016
                Categories
                Device round

                Cardiovascular Medicine
                t-wave oversensing,cardiac resynchronisation therapy,loss of biventricular pacing

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