Safety and Diagnostic Yield of Noninvasive Ventricular Stimulation Performed Via Tiered Therapy Implantable Defibrillators

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Abstract
Extensive electrophysiological testing is critical for the effective utilization of sophisticated tachycardia detection and termination algorithms available in tiered therapy ICDs. To evaluate the safety and diagnostic yield of electrophysiological testing via noninvasive ventricular stimulation, we performed 294 electrophysiological studies in 154 patients (age 65 +/- 10; left ventricular ejection fraction 0.36 +/- 0.15) with tiered therapy ICDs. Stimulation was performed under methohexital anesthesia. A total of 918 sustained ventricular tachyarrhythmias were induced (3.1 +/- 2.5 per procedure): monomorphic VT, 550; ventricular flutter, 74; and VF, 246. The results of invasive and noninvasive programmed stimulation were compared for 79 patients who had both studies under similar treatment. Overall concordance was 83%, and did not differ significantly between patients who had the noninvasive stimulation via epicardial or endocardial pacing leads. VF could be induced in 206 of 257 studies (82%), and it was less likely to be induced in patients on amiodarone (74% vs 85%; P = 0.02), or beta blockers (55% vs 83%; P = 0.017). No patient presented a serious complication. Minor complications occurred during 39 studies: transient laryngospasm in 1, unintended delivery of an ICD shock to a conscious patient in 4; induction of sustained atrial fibrillation in 8; need for external rescue defibrillation shocks in 13; and delivery of inappropriate shocks for supraventricular rhythms in 14 studies. Noninvasive ventricular stimulation performed under methohexital anesthesia is safe. Its diagnostic yield compares favorably with that of conventional electrophysiological studies. VF can be induced in a majority of patients. There is good correlation between invasive and noninvasive programmed stimulation for induction of VT. Noninvasive ventricular stimulation may emerge as standard procedure for the initial programming and follow-up of ICDs.

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