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(Circulation. 2008;118:2122-2129.)
© 2008 American Heart Association, Inc.

Arrhythmia/Electrophysiology

Downloadable Algorithm to Reduce Inappropriate Shocks Caused by Fractures of Implantable Cardioverter-Defibrillator Leads

Charles D. Swerdlow, MD; Bruce D. Gunderson, MS; Kevin T. Ousdigian, MS; Athula Abeyratne, PhD; Robert W. Stadler, PhD; Jeffrey M. Gillberg, MS; Amisha S. Patel, MS; Kenneth A. Ellenbogen, MD

From the Department of Cardiology Cedars–Sinai Medical Center, Los Angeles, Calif (C.D.S.); Medtronic, Inc, Mounds View, Minn (B.D.G., K.T.O., A.A., R.W.S., J.G., A.P.); and Division of Cardiology, Medical College of Virginia/Virginia Commonwealth University, Richmond (K.A.E.).

Correspondence to Charles D. Swerdlow, MD, Cedars-Sinai Medical Towers, 8635 W Third St, Suite 1190 W, Los Angeles, CA 90048. E-mail swerdlow{at}ucla.edu

Received June 9, 2008; accepted September 8, 2008.

Background— The primary method for monitoring implantable cardioverter-defibrillator lead integrity is periodic measurement of impedance. Sprint Fidelis leads are prone to pace-sense lead fractures, which commonly present as inappropriate shocks caused by oversensing.

Methods and Results— We developed and tested an algorithm to enhance early identification of lead fractures and to reduce inappropriate shocks. This lead-integrity algorithm, which can be downloaded into presently implanted implantable cardioverter-defibrillators, alerts the patient and/or physician when triggered by either oversensing or excessive increases in impedance. To reduce inappropriate shocks, the lead-integrity algorithm increases the number of intervals to detect (NID) ventricular fibrillation when triggered. The lead-integrity algorithm was tested on data from 15 970 patients with Fidelis leads (including 121 with clinically diagnosed fractures) and 95 other fractured leads confirmed by analysis of returned product. The effect of the NID on inappropriate shocks was tested in 92 patients with 927 shocks caused by lead fracture. Increasing the NID reduced inappropriate shocks (P<0.0001). The lead-integrity algorithm provided at least a 3-day warning of inappropriate shocks in 76% (95% CI, 66 to 84) of patients versus 55% (95% CI, 43 to 64) for optimal impedance monitoring (P=0.007). Its positive predictive value was 72% for lead fractures and 81% for lead fractures or header-connector problems requiring surgical intervention. The false-positive rate was 1 per 372 patient-years of monitoring.

Conclusions— A lead-integrity algorithm developed for download into existing implantable cardioverter-defibrillators increases short-term warning of inappropriate shocks in patients with lead fractures and reduces the likelihood of inappropriate shocks. It is the first downloadable RAMware to enhance the performance of nominally functioning implantable cardioverter-defibrillators and the first implantable cardioverter-defibrillator monitoring feature that triggers real-time changes in ventricular fibrillation detection parameters to reduce inappropriate shocks.

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