Tracing 1: Episode corresponding to palpitations on exertion
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Interpretation
- PR synchronised sinus rhythm in the sinus zone during exercise at about 120/min;
- The rhythm hovers around the lower boundary of the Slow VT zone;
- The sinus rhythm, which is stable, gradually enters the Slow VT zone, and is therefore diagnosed as SVT/ST,
- this, repetitively;
- The rhythm returns under the Slow VT zone and is diagnosed as Slow Rhythm (SR).
Comments
- In the operational sequence of the algorithm, all begins with the rate that must be in a programmed tachycardia zone. The rhythm rate must be stable, a basic condition to pursue further in the analysis. The degree of stability is defined by the programmed value. In this example, it is necessary that 75% of 8 sliding cycles in the VT zone fit within a 65 ms range: in this instance, the rhythm is continuously stable.
- Next, the PR association must be validated, which is the case in this example. The PR association is of the 1:1 type, and the analysis continues.
- The acceleration was gradual since the acceleration of entry in the VT zone was less than 25% from one cycle to the next.
- The conclusion is therefore sinus tachycardia.
- In the details of annotation nĀ°1, we can see from time to time that the stability is fulfilled, the PR association is of the 1:1 type, and that there has been no acceleration on entry into the Slow VT zone. The system performs this type of analysis on a continuous basis except for the initial acceleration until the rhythm returns to Slow.
- When the rhythm returns to Slow, the analysis reports the return of 6 Slow cycles.
This information is obtained by clicking on the analysis button of the EGM screen of the episode, and enables understanding the criteria that the discrimination algorithm has validated to reach its diagnosis.
This system works very well if a VT begins with a sudden acceleration meeting the programmed acceleration criteria. If a dissociated VT begins on exertion, the analysis of PR stability will allow confirming the dissociation and thus the VT, even if the acceleration criterion is not fulfilled (indeed, the acceleration criterion intervenes only after analysis of the association and is taken into account only if the association is 1:1). It is conversely quite different if a 1:1 VT begins with exertion while the sinus rate is fast, but the VT rate with retrograde 1:1 conduction is not. In this case, the acceleration criterion may not be validated and, hence, the VT not detected. Since the acceleration criterion is programmable, it is necessary to calculate the rate differences between the sinus rhythm and the tachycardia in order to program an appropriate acceleration value. Thereafter, it is advisable to have the patient perform a sudden exercise to verify that this new acceleration threshold value is not exceeded by the acceleration of the sinus rhythm on this sudden exercise.
For a dissociated VT on exertion, the acceleration criterion does not enter into account in PARAD+.
Message
A stable tachycardia, with 1:1 conduction, and progressive acceleration, is a priori an exercise sinus tachycardia.
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Question 1 of 1
1. Question
Patient
A 67-year-old man implanted for resuscitated VF-related sudden death, due to ischemic heart disease with history of infarction. PARADYM DR model due to sinus bradycardia with beta-blockers. Routine consultation. Ā Asymptomatic patient.
Programming
Three zones are programmed:
- a Slow VT zone between 125 and 170/min, without therapies, monitoring zone,
- a VT zone between 170 and 200/min with 3 bursts, then 4 ramps, then 6 x 42 J,
- a VF zone with 6 x 42 J.
Tachogram
EGM
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