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News From the Heart Rhythm Society| Volume 17, ISSUE 1, e220-e228, January 01, 2020

2019 HRS/EHRA/APHRS/LAHRS focused update to 2015 expert consensus statement on optimal implantable cardioverter-defibrillator programming and testing

  • Author Footnotes
    ∗ Representative of the Asia Pacific Heart Rhythm Society (APHRS)
    Martin K. Stiles
    Footnotes
    ∗ Representative of the Asia Pacific Heart Rhythm Society (APHRS)
    Affiliations
    Waikato Hospital, Hamilton, New Zealand
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  • Author Footnotes
    † Representative of the European Heart Rhythm Association (EHRA)
    Laurent Fauchier
    Footnotes
    † Representative of the European Heart Rhythm Association (EHRA)
    Affiliations
    Centre Hospitalier Universitaire Trousseau, Université François Rabelais, Tours, France
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  • Author Footnotes
    ‡ Representative of the Latin American Heart Rhythm Society (LAHRS)
    Carlos A. Morillo
    Footnotes
    ‡ Representative of the Latin American Heart Rhythm Society (LAHRS)
    Affiliations
    Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
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  • Author Footnotes
    § Representative of the Heart Rhythm Society (HRS)
    Bruce L. Wilkoff
    Footnotes
    § Representative of the Heart Rhythm Society (HRS)
    Affiliations
    Cleveland Clinic, Cleveland, Ohio
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  • Author Footnotes
    ∗ Representative of the Asia Pacific Heart Rhythm Society (APHRS)
    † Representative of the European Heart Rhythm Association (EHRA)
    ‡ Representative of the Latin American Heart Rhythm Society (LAHRS)
    § Representative of the Heart Rhythm Society (HRS)
Open AccessPublished:May 15, 2019DOI:https://doi.org/10.1016/j.hrthm.2019.02.034
2019 HRS/EHRA/APHRS/LAHRS focused update to 2015 expert consensus statement on optimal implantable cardioverter-defibrillator programming and testing
Previous ArticleSystematic review and meta-analysis of catheter ablation of ventricular tachycardia in ischemic heart disease

      Abstract

      The 2015 HRS/EHRA/APHRS/SOLAECE Expert Consensus Statement on Optimal Implantable Cardioverter-Defibrillator Programming and Testing provided guidance on bradycardia programming, tachycardia detection, tachycardia therapy, and defibrillation testing for implantable cardioverter-defibrillator (ICD) patient treatment. The 32 recommendations represented the consensus opinion of the writing group, graded by Class of Recommendation and Level of Evidence. In addition, Appendix B provided manufacturer-specific translations of these recommendations into clinical practice consistent with the recommendations within the parent document. In some instances, programming guided by quality evidence gained from studies performed in devices from some manufacturers was translated such that this programming was approximated in another manufacturer’s ICD programming settings. The authors found that the data, although not formally tested, were strong, consistent, and generalizable beyond the specific manufacturer and model of ICD. As expected, because these recommendations represented strategic choices to balance risks, there have been reports in which adverse outcomes were documented with ICDs programmed to Appendix B recommendations. The recommendations have been reviewed and updated to minimize such adverse events. Notably, patients who do not receive unnecessary ICD therapy are not aware of being spared potential harm, whereas patients in whom their ICD failed to treat life-threatening arrhythmias have their event recorded in detail. The revised recommendations employ the principle that the randomized trials and large registry data should guide programming more than anecdotal evidence. These recommendations should not replace the opinion of the treating physician who has considered the patient’s clinical status and desired outcome via a shared clinical decision-making process.

      Keywords

      Manufacturer-Specific Translation of ICD Programming Recommendations
      The manufacturer-specific programming settings/choices set forth below are based on a compilation of clinical expertise and clinical trial data as reported in the 2015 HRS/EHRA/APHRS/SOLAECE Expert Consensus Statement on Optimal Implantable Cardioverter-Defibrillator Programming and Testing, of which this Appendix B is a part. These recommended settings/choices represent a diligent and good faith effort on the part of the writing committee to translate the consensus statement recommendations to device settings/choices for the four specified clinical issues/implantable cardioverter-defibrillator (ICD) therapies where the writing committee considered that there was sufficient consensus and supporting data to make recommendations intended to improve the safety, morbidity, and mortality profile of patients with these clinical issues/ICD therapies. They are the recommendations of the writing committee only. They do not represent the position or recommendations of HRS, EHRA, LAHRS (formerly SOLAECE), or APHRS, nor are they the manufacturer’s nominal settings or the precise programming tested during clinical trials of these devices, nor are they necessarily the settings/choices that would be recommended by the manufacturer. These recommended settings/choices are not applicable in all circumstances. As stated in the Introduction to the consensus statement, “The care of individual patients must be provided in context of their specific clinical condition and the data available on that patient.” Each treating physician must carefully consider the circumstances of their individual patient and determine whether these recommended settings/choices are appropriate to their patient’s circumstances.
      ǂThe manufacturer-specific programming settings/choices set forth below are based on a compilation of clinical expertise and clinical trial data as reported in the 2015 HRS/EHRA/APHRS/SOLAECE Expert Consensus Statement on Optimal Implantable Cardioverter-Defibrillator Programming and Testing, of which this Appendix B is a part. These recommended settings/choices represent a diligent and good faith effort on the part of the writing committee to translate the consensus statement recommendations to device settings/choices for the four specified clinical issues/implantable cardioverter-defibrillator (ICD) therapies where the writing committee considered that there was sufficient consensus and supporting data to make recommendations intended to improve the safety, morbidity, and mortality profile of patients with these clinical issues/ICD therapies. They are the recommendations of the writing committee only. They do not represent the position or recommendations of HRS, EHRA, LAHRS (formerly SOLAECE), or APHRS, nor are they the manufacturer’s nominal settings or the precise programming tested during clinical trials of these devices, nor are they necessarily the settings/choices that would be recommended by the manufacturer. These recommended settings/choices are not applicable in all circumstances. As stated in the Introduction to the consensus statement, “The care of individual patients must be provided in context of their specific clinical condition and the data available on that patient.” Each treating physician must carefully consider the circumstances of their individual patient and determine whether these recommended settings/choices are appropriate to their patient’s circumstances.

      Abbott (Formerly St. Jude Medical)

      Tabled 1
      Brady

        Single Chamber

      • VVI 40bpm

        Dual Chamber

      • DDD, consider Ventricular Intrinsic Preference (VIP) ± rate response

        CRT

      • DDD ± rate response
      • Consider SyncAV* (if intact AV conduction) as appropriate
      Detection

        In patients with no VT history

      • VF:
        30 intervals*1, 240 or 250bpm*
      • VT2:
        30 intervals*1, 187bpm*
      • VT:
        Monitor, at user discretion

        In patients where VT CL is known

      • VF:
        30 intervals*1, 240 or 250bpm
      • VT2:
        30 intervals*1, 187bpm or 10–20bpm < VT rate*
      • VT:
        Therapy at 10–20bpm < VT rate or Monitor zone
      1 Fewer intervals to detect may be reasonable due to the possibility of VT straddling 2 zones that may result in “binning” to both zones, effectively doubling time to detect. Beats that fall out of zone sometimes reset counters so patients with poor sensing should also have fewer detection intervals considered.
      Therapy
      • VF:
        ATP While Charging, 8 pulses at 85% VT CL
      • All shocks: Maximum output (unless DFT guided)
      • Note: 1st shock 4–6J lower than full output
      • VT2:
        ATP, ≥1 bursts of 8 pulses at 85% VT CL
      • Scan step 10ms, Re-adaptive ON, Minimum CL 200ms
      • All shocks ON
      • VT:
        As for VT2, favoring more ATP2
      2 Rarely, hemodynamically stable slow VT can be treated without programming a back-up shock.
      SVT Discriminators3

        Single Chamber

      • Far-Field Morphology:  ON, 90%, 3 of 10
      • All others: “Passive”

        Dual Chamber/CRT-D

      • Far-Field Morphology: ON, 90%, 3 of 10
      • Arrhythmia onset:ON (default settings)
      • Interval Stability:ON (default settings)
      • If ALL
      • For CRT: Template Auto Update 30 days and Template Pacing Hysteresis ON
      •  or Far-Field Morphology Auto Update OFF
      • SVT Upper Limit:230bpm
      • SVT Discrimination Timeout: OFF
      • VT Therapy Timeout:OFF
      3 SVT Discriminators are not required in Complete Heart Block.
      Oversensing Rejection
      • Low Frequency Attenuation:ON
      • SecureSense RV Lead Noise Discrimination: ON

      Manufacturer-Specific Translation of ICD Programming Recommendations
      The manufacturer-specific programming settings/choices set forth below are based on a compilation of clinical expertise and clinical trial data as reported in the 2015 HRS/EHRA/APHRS/SOLAECE Expert Consensus Statement on Optimal Implantable Cardioverter-Defibrillator Programming and Testing, of which this Appendix B is a part. These recommended settings/choices represent a diligent and good faith effort on the part of the writing committee to translate the consensus statement recommendations to device settings/choices for the four specified clinical issues/implantable cardioverter-defibrillator (ICD) therapies where the writing committee considered that there was sufficient consensus and supporting data to make recommendations intended to improve the safety, morbidity, and mortality profile of patients with these clinical issues/ICD therapies. They are the recommendations of the writing committee only. They do not represent the position or recommendations of HRS, EHRA, LAHRS (formerly SOLAECE), or APHRS, nor are they the manufacturer’s nominal settings or the precise programming tested during clinical trials of these devices, nor are they necessarily the settings/choices that would be recommended by the manufacturer. These recommended settings/choices are not applicable in all circumstances. As stated in the Introduction to the consensus statement, “The care of individual patients must be provided in context of their specific clinical condition and the data available on that patient.” Each treating physician must carefully consider the circumstances of their individual patient and determine whether these recommended settings/choices are appropriate to their patient’s circumstances.
      ǂThe manufacturer-specific programming settings/choices set forth below are based on a compilation of clinical expertise and clinical trial data as reported in the 2015 HRS/EHRA/APHRS/SOLAECE Expert Consensus Statement on Optimal Implantable Cardioverter-Defibrillator Programming and Testing, of which this Appendix B is a part. These recommended settings/choices represent a diligent and good faith effort on the part of the writing committee to translate the consensus statement recommendations to device settings/choices for the four specified clinical issues/implantable cardioverter-defibrillator (ICD) therapies where the writing committee considered that there was sufficient consensus and supporting data to make recommendations intended to improve the safety, morbidity, and mortality profile of patients with these clinical issues/ICD therapies. They are the recommendations of the writing committee only. They do not represent the position or recommendations of HRS, EHRA, LAHRS (formerly SOLAECE), or APHRS, nor are they the manufacturer’s nominal settings or the precise programming tested during clinical trials of these devices, nor are they necessarily the settings/choices that would be recommended by the manufacturer. These recommended settings/choices are not applicable in all circumstances. As stated in the Introduction to the consensus statement, “The care of individual patients must be provided in context of their specific clinical condition and the data available on that patient.” Each treating physician must carefully consider the circumstances of their individual patient and determine whether these recommended settings/choices are appropriate to their patient’s circumstances.

      BIOTRONIK

      Tabled 1
      Brady

        Single Chamber

      • VVI 40bpm

        Dual Chamber

      • DDD, consider IRS Plus* / I OPT* ± Closed Loop Stimulation (CLS)* or
      • DDD with Vp Suppression* ± rate response

        CRT

      • DDD; optional DDD-CLS* or rate response* at user discretion
      Detection

        In patients with no VT history1

      • VF:
        30/40 intervals* (if programmable, otherwise 24/30), 231bpm*
      • VT2:
        30 intervals*, 188bpm*
      • VT1:
        Monitor zone* at user discretion

        In patients where VT CL is known

      • VF:
        24/30 intervals*, 231bpm*
      • VT2:
        30 intervals*, 188bpm* (or 10–20bpm < VT rate)
      • VT1:
        Therapy* at 10–20bpm < VT rate or Monitor zone* at user discretion
      1 SVT discriminators are linked to Detection Zones. An alternative configuration would be VF 250bpm, VT2 231bpm and VT1 188bpm with therapy (i.e., no Monitor zone) if >1 ATP attempt desired up to 250bpm.
      Therapy
      • VF:
        ATP One-Shot, 1 burst of 8 pulses at 88%2 CL*, full output shocks (unless DFT guided)
      • VT2:
        ATP ≥1 bursts* of 8 pulses* at 88%2 CL*, 10ms scan decrement*, All shocks ON
      • VT1:
        Monitor zone* or Therapy* as for VT2 (favoring more ATP)3
      2 If programmable, otherwise 85%.

      3 Rarely, hemodynamically stable slow VT can be treated without programming a back-up shock.
      SVT Discriminators4

        Single Chamber

      • MorphMatch5ON(*)
      • Onset6OFF
      • StabilityOFF*
      • Sustained VT Timer OFF

        Dual Chamber/CRT-D

      • SMARTON (at default settings or adapted to known VT)
      4 SVT Discriminators are not required in Complete Heart Block.

      5 MorphMatch is recommended for patients with narrow QRS complexes and sufficient far-field amplitude. Otherwise, Onset 20% and Stability 48ms is a recommended alternative.

      6 If Onset is programmed ON, the performance of this discriminator is enhanced with a Monitoring Zone enabled.
      Others
      • Lead Integrity check ON (if available)
      • HomeMonitoringON* (if available)

      Manufacturer-Specific Translation of ICD Programming Recommendations
      The manufacturer-specific programming settings/choices set forth below are based on a compilation of clinical expertise and clinical trial data as reported in the 2015 HRS/EHRA/APHRS/SOLAECE Expert Consensus Statement on Optimal Implantable Cardioverter-Defibrillator Programming and Testing, of which this Appendix B is a part. These recommended settings/choices represent a diligent and good faith effort on the part of the writing committee to translate the consensus statement recommendations to device settings/choices for the four specified clinical issues/implantable cardioverter-defibrillator (ICD) therapies where the writing committee considered that there was sufficient consensus and supporting data to make recommendations intended to improve the safety, morbidity, and mortality profile of patients with these clinical issues/ICD therapies. They are the recommendations of the writing committee only. They do not represent the position or recommendations of HRS, EHRA, LAHRS (formerly SOLAECE), or APHRS, nor are they the manufacturer’s nominal settings or the precise programming tested during clinical trials of these devices, nor are they necessarily the settings/choices that would be recommended by the manufacturer. These recommended settings/choices are not applicable in all circumstances. As stated in the Introduction to the consensus statement, “The care of individual patients must be provided in context of their specific clinical condition and the data available on that patient.” Each treating physician must carefully consider the circumstances of their individual patient and determine whether these recommended settings/choices are appropriate to their patient’s circumstances.
      ǂThe manufacturer-specific programming settings/choices set forth below are based on a compilation of clinical expertise and clinical trial data as reported in the 2015 HRS/EHRA/APHRS/SOLAECE Expert Consensus Statement on Optimal Implantable Cardioverter-Defibrillator Programming and Testing, of which this Appendix B is a part. These recommended settings/choices represent a diligent and good faith effort on the part of the writing committee to translate the consensus statement recommendations to device settings/choices for the four specified clinical issues/implantable cardioverter-defibrillator (ICD) therapies where the writing committee considered that there was sufficient consensus and supporting data to make recommendations intended to improve the safety, morbidity, and mortality profile of patients with these clinical issues/ICD therapies. They are the recommendations of the writing committee only. They do not represent the position or recommendations of HRS, EHRA, LAHRS (formerly SOLAECE), or APHRS, nor are they the manufacturer’s nominal settings or the precise programming tested during clinical trials of these devices, nor are they necessarily the settings/choices that would be recommended by the manufacturer. These recommended settings/choices are not applicable in all circumstances. As stated in the Introduction to the consensus statement, “The care of individual patients must be provided in context of their specific clinical condition and the data available on that patient.” Each treating physician must carefully consider the circumstances of their individual patient and determine whether these recommended settings/choices are appropriate to their patient’s circumstances.

      Boston Scientific

      Tabled 1
      Brady

        Single Chamber

      • VVI, 40bpm*

        Dual Chamber

      • DDD, consider RYTHMIQ* or AV Search +* ± rate response

        CRT

      • DDD ± rate response
      • Consider Smart Delay optimization of AV delays
      Detection

        In patients with no VT history

      • Option 1 – delayed therapy
      • VF:
        8 of 10 intervals plus 5-second duration*, 250bpm*
      • VT:
        8 of 10 intervals plus 12-second duration*, 185bpm*
      • VT-1:
        Monitor, at user discretion
      • Option 2 – high-rate therapy
      • VF:
        8 of 10 intervals plus 2.5-second duration*, 200bpm*
      • VT-1:
        Monitor, at user discretion

        In patients where VT cycle length is known

      • VF:
        5-second duration*, 250bpm*
      • VT:
        12-second duration*, 185bpm* or 10–20bpm < VT rate
      • VT-1:
        Monitor Zone or Therapy at ≥12-second duration*, 10–20bpm < VT rate
      Therapy
      • VF:
        QuickConvert ON to 300bpm* (if available)
      • All shocks: Maximum output (unless DFT guided)
      • VT:
        ATP-1: Scan, ≥1 bursts, 8 pulses* at 84%* coupling interval and cycle
      • length (Minimum 200ms*), 10ms decrement*
      • ATP-2: OFF*
      • All shocks: ON
      • VT-1:
        As for VT, favoring more ATP1
      1 Rarely, hemodynamically stable slow VT can be treated without programming a back-up shock.
      SVT Discriminators2

        ICD

      • RhythmID: ON

        CRT-D

      • Onset/Stability: ON or RhythmID: ON*
      • Sustained Rate Duration (SRD): OFF*
      • SVT Discriminators apply only up to 230bpm
      2 SVT Discriminators are not required in Complete Heart Block.
      Oversensing Rejection
      • Nonphysiological Signal Detected: ON (Latitude)
      Others
      • Turn on “Beep When Out-of-Range” Daily Lead Measurements*
      • RV Pacing Impedance Abrupt Change alert ON (Latitude)
      • Single Chamber: Consider %RV pacing alert ON (Latitude)
      • Dual Chamber: Consider %RV pacing alert in non-AVB patients ON (Latitude)
      • CRT-D: Consider CRT % pacing alert ON (Latitude)
      SUBCUTANEOUS ICD

      Settings:
      • Shock Zone: ≥230bpm
      • Conditional Zone: ≥200bpm or 10–20bpm < VT CL (if known)
      • Consider post-shock pacing ON

      Manufacturer-Specific Translation of ICD Programming Recommendations
      The manufacturer-specific programming settings/choices set forth below are based on a compilation of clinical expertise and clinical trial data as reported in the 2015 HRS/EHRA/APHRS/SOLAECE Expert Consensus Statement on Optimal Implantable Cardioverter-Defibrillator Programming and Testing, of which this Appendix B is a part. These recommended settings/choices represent a diligent and good faith effort on the part of the writing committee to translate the consensus statement recommendations to device settings/choices for the four specified clinical issues/implantable cardioverter-defibrillator (ICD) therapies where the writing committee considered that there was sufficient consensus and supporting data to make recommendations intended to improve the safety, morbidity, and mortality profile of patients with these clinical issues/ICD therapies. They are the recommendations of the writing committee only. They do not represent the position or recommendations of HRS, EHRA, LAHRS (formerly SOLAECE), or APHRS, nor are they the manufacturer’s nominal settings or the precise programming tested during clinical trials of these devices, nor are they necessarily the settings/choices that would be recommended by the manufacturer. These recommended settings/choices are not applicable in all circumstances. As stated in the Introduction to the consensus statement, “The care of individual patients must be provided in context of their specific clinical condition and the data available on that patient.” Each treating physician must carefully consider the circumstances of their individual patient and determine whether these recommended settings/choices are appropriate to their patient’s circumstances.
      ǂThe manufacturer-specific programming settings/choices set forth below are based on a compilation of clinical expertise and clinical trial data as reported in the 2015 HRS/EHRA/APHRS/SOLAECE Expert Consensus Statement on Optimal Implantable Cardioverter-Defibrillator Programming and Testing, of which this Appendix B is a part. These recommended settings/choices represent a diligent and good faith effort on the part of the writing committee to translate the consensus statement recommendations to device settings/choices for the four specified clinical issues/implantable cardioverter-defibrillator (ICD) therapies where the writing committee considered that there was sufficient consensus and supporting data to make recommendations intended to improve the safety, morbidity, and mortality profile of patients with these clinical issues/ICD therapies. They are the recommendations of the writing committee only. They do not represent the position or recommendations of HRS, EHRA, LAHRS (formerly SOLAECE), or APHRS, nor are they the manufacturer’s nominal settings or the precise programming tested during clinical trials of these devices, nor are they necessarily the settings/choices that would be recommended by the manufacturer. These recommended settings/choices are not applicable in all circumstances. As stated in the Introduction to the consensus statement, “The care of individual patients must be provided in context of their specific clinical condition and the data available on that patient.” Each treating physician must carefully consider the circumstances of their individual patient and determine whether these recommended settings/choices are appropriate to their patient’s circumstances.

      Medtronic

      Tabled 1
      Brady

        Single Chamber

      • VVI 40bpm

        Dual Chamber

      • DDD, consider Managed Ventricular Pacing (MVP; AAI↔DDD) ± rate response

        CRT

      • DDD ± rate response
      • Patient with intact AV conduction and LBBB—Consider Adaptive BiV & LV*
      Detection

        In patients with no VT history

      • VF:
        30/40 intervals, 188bpm
      • FVT:
        OFF1
      • VT:
        OFF
      • VT Monitor:
        User discretion

        In patients where VT CL is known

      • VF:
        30/40 intervals, 188bpm
      • FVT:
        OFF1
      • VT:
        24* intervals2, 10–20bpm < VT rate
      • VT Monitor:
        User discretion
      1 Use of ATP Before/During Charging in the VF zone achieves similar functionality as use of the FVT zone. Multi-zone programming using FVT may allow tiered ATP therapy.

      2 Consecutive count in VT zone; hence, lower NID as per PainFree SST data.
      Therapy
      • VF:
        ATP Before* Charging; ChargeSaver ON All shocks: Full output shocks (unless DFT guided)
      • VT (if ON):
        Rx1: ATP, ≥1 bursts of 8 pulses at 88% VT CL, 10ms Decrement
      • Rx2-6: All Shocks ON3
      3 Rarely, hemodynamically stable slow VT can be treated without programming a back-up shock.
      SVT Discriminators4

        Single Chamber

      • Wavelet:ON
      • Limit:260ms (230bpm)
      • Stability:OFF
      • Onset:OFF

        Dual Chamber/CRT-D

      • PR Logic:ON (Other 1:1 OFF until lead stabilized at ∼3 months)
      • Wavelet:ON (if available)
      • SVT Limit:260ms (230bpm)
      • Stability:OFF
      • Onset:OFF
      4 SVT Discriminators are not required in Complete Heart Block.
      Oversensing Rejection
      • Lead Integrity Alert: ON
      • T-wave Oversensing: ON (if available)
      • RV Lead Noise:ON* without timeout (if available)

      Manufacturer-Specific Translation of ICD Programming Recommendations
      The manufacturer-specific programming settings/choices set forth below are based on a compilation of clinical expertise and clinical trial data as reported in the 2015 HRS/EHRA/APHRS/SOLAECE Expert Consensus Statement on Optimal Implantable Cardioverter-Defibrillator Programming and Testing, of which this Appendix B is a part. These recommended settings/choices represent a diligent and good faith effort on the part of the writing committee to translate the consensus statement recommendations to device settings/choices for the four specified clinical issues/implantable cardioverter-defibrillator (ICD) therapies where the writing committee considered that there was sufficient consensus and supporting data to make recommendations intended to improve the safety, morbidity, and mortality profile of patients with these clinical issues/ICD therapies. They are the recommendations of the writing committee only. They do not represent the position or recommendations of HRS, EHRA, LAHRS (formerly SOLAECE), or APHRS, nor are they the manufacturer’s nominal settings or the precise programming tested during clinical trials of these devices, nor are they necessarily the settings/choices that would be recommended by the manufacturer. These recommended settings/choices are not applicable in all circumstances. As stated in the Introduction to the consensus statement, “The care of individual patients must be provided in context of their specific clinical condition and the data available on that patient.” Each treating physician must carefully consider the circumstances of their individual patient and determine whether these recommended settings/choices are appropriate to their patient’s circumstances.
      ǂThe manufacturer-specific programming settings/choices set forth below are based on a compilation of clinical expertise and clinical trial data as reported in the 2015 HRS/EHRA/APHRS/SOLAECE Expert Consensus Statement on Optimal Implantable Cardioverter-Defibrillator Programming and Testing, of which this Appendix B is a part. These recommended settings/choices represent a diligent and good faith effort on the part of the writing committee to translate the consensus statement recommendations to device settings/choices for the four specified clinical issues/implantable cardioverter-defibrillator (ICD) therapies where the writing committee considered that there was sufficient consensus and supporting data to make recommendations intended to improve the safety, morbidity, and mortality profile of patients with these clinical issues/ICD therapies. They are the recommendations of the writing committee only. They do not represent the position or recommendations of HRS, EHRA, LAHRS (formerly SOLAECE), or APHRS, nor are they the manufacturer’s nominal settings or the precise programming tested during clinical trials of these devices, nor are they necessarily the settings/choices that would be recommended by the manufacturer. These recommended settings/choices are not applicable in all circumstances. As stated in the Introduction to the consensus statement, “The care of individual patients must be provided in context of their specific clinical condition and the data available on that patient.” Each treating physician must carefully consider the circumstances of their individual patient and determine whether these recommended settings/choices are appropriate to their patient’s circumstances.

      MicroPort CRM (Formerly LivaNova and Sorin Group)

      Tabled 1
      Brady

        Single Chamber

      • VVI 40bpm*

        Dual Chamber

      • SafeR (AAI↔DDD) ± rate response, consider DDD* in complete heart block

        CRT

      • DDD ± rate response, consider weekly AV + VV SonR optimization ON1
      1 Requires SonRtip atrial lead with integrated hemodynamic sensor.
      Detection

        In patients with no VT history

      • VF:
        20 cycle* + 6/8 majority >255bpm*
      • FVT:
        20 cycle* + 6/8 majority 230bpm
      • VT:
        20 or 30 cycle* + 6/8 majority 185bpm
      • Slow VT:
        Monitor zone at user discretion

        In patients where VT CL is known

      • VF:
        20 cycle* + 6/8 majority >255bpm*
      • FVT:
        20 cycle*+ 6/8 majority 230bpm
      • VT:
        ≥20 cycle* + 6/8 majority 185bpm (or 10–20bpm < VT rate)
      • Slow VT:
        Monitor zone at user discretion
      Therapy
      • VF:
        6 x 42J*
      • FVT:
        If stable2: 1 x ATP (Burst @ 85% x 8 beats) then 6 x 42J* (unless DFT guided)
      • If unstable: 6 x 42J* (unless DFT guided)
      • VT:
        ≥1 x ATP (Burst + Scan @ 85% x 8 beats; Scan 8ms) then all Shocks ON*3
      2 Satisfaction of stability (nominal value = 30ms) in the Fast VT zone will not prevent therapy but rather activate programmable burst pacing prior to shock therapy.

      3 Rarely, hemodynamically stable slow VT can be treated without programming a back-up shock.
      SVT Discriminators4

        Single Chamber

      • Single button programming; Stability+/Acc
      • Rate, Stability, Degree of Onset, VT long cycle search
      • Nominal settings: Onset 19%, Stability 65ms (Slow VT, VT); Long cycle extension 10 cycles; Long cycle gap 170ms

        Dual Chamber/CRT-D

      • Single button programming; PARAD+
      • Rate, Stability, AV association analysis, Degree and Chamber of Onset, VT long cycle search
      • Nominal settings: Onset 25%, Stability 65ms (Slow VT, VT); Long cycle extension 10 cycles; Long cycle gap 170ms
      4 SVT Discriminators are not required in Complete Heart Block.
      Oversensing Rejection
      • Daily check Lead impedance ON*
      • Daily check Lead coil continuity ON*
      • Daily check V oversensing alerts ON*
      • T-wave filtering and noise detection are hardcoded in firmware

      Appendix

      Appendix 1Author disclosure table
      Writing group memberEmploymentHonoraria/Speaking/ConsultingSpeakers’ bureauResearch
      Research and fellowship support are classed as programmatic support. Sources of programmatic support are disclosed but are not regarded as a relevant relationship with industry for writing group members or reviewers.
      		Fellowship support
      Research and fellowship support are classed as programmatic support. Sources of programmatic support are disclosed but are not regarded as a relevant relationship with industry for writing group members or reviewers.
      		Ownership/Partnership/Principal/Majority stockholderStock or stock optionsIntellectual property/RoyaltiesOther
      Martin K. Stiles, MBChB, PhD, FHRS (Chair)Waikato Hospital, Hamilton, New ZealandNoneNoneNoneNoneNoneNoneNoneNone
      Laurent Fauchier, MD, PhDCentre Hospitalier Universitaire Trousseau, Université François Rabelais, Tours, France1: BMS/Pfizer;

      1: Boehringer Ingelheim;

      1: Medtronic;

      1: Novartis;

      2: Bayer HealthCare      		NoneNoneNoneNoneNoneNoneNone
      Carlos A. Morillo, MD, FHRSLibin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada1: Abbott;

      1: Bayer;

      1: BMS/Pfizer;

      1: Medtronic;

      1: Servier      		NoneNoneNoneNoneNoneNoneNone
      Bruce L. Wilkoff, MD, FHRS, CCDSCleveland Clinic, Cleveland, Ohio1: Abbott Vascular;

      2: Medtronic;

      2: Philips      		NoneNoneNoneNoneNoneNoneNone
      Number value: 0 = $0; 1 = ≤ $10,000; 2 = > $10,000 to ≤ $25,000; 3 = > $25,000 to ≤ $50,000; 4 = > $50,000 to ≤ $100,000; 5 = > $100,000.
      ∗ Research and fellowship support are classed as programmatic support. Sources of programmatic support are disclosed but are not regarded as a relevant relationship with industry for writing group members or reviewers.
      Appendix 2Reviewer disclosure table
      Peer reviewerEmploymentHonoraria/Speaking/ConsultingSpeakers’ bureauResearch
      Research and fellowship support are classed as programmatic support. Sources of programmatic support are disclosed but are not regarded as a relevant relationship with industry for writing group members or reviewers.
      		Fellowship support
      Research and fellowship support are classed as programmatic support. Sources of programmatic support are disclosed but are not regarded as a relevant relationship with industry for writing group members or reviewers.
      		Ownership/Partnership/Principal/Majority stockholderStock or stock optionsIntellectual property/RoyaltiesOther
      Serge Boveda, MD, PhDCardiology Department, Clinique Pasteur, Toulouse, France1: Boston Scientific;

      1: Medtronic;

      1: MicroPort      		NoneNoneNoneNoneNoneNoneNone
      Michael R. Gold, MD, PhD, FHRSMedical University of South Carolina, Charleston, South Carolina1: Abbott Vascular;

      1: EBR Systems;

      1: Medtronic;

      2: Boston Scientific      		NoneNoneNoneNoneNoneNone1: ABIM
      Roberto Keegan, MDHospital Privado del Sur and Hospital Español, Bahia Blanca, ArgentinaNoneNoneNoneNoneNoneNoneNoneNone
      Valentina Kutyifa, MD, PhD, FHRS, FESC, FACCUniversity of Rochester Medical Center, Rochester, New York; Adjunct Position at Semmelweis University Heart Center, Budapest, Hungary1: Biotronik;

      1: ZOLL Medical Corporation      		None5: Biotronik;

      5: Boston Scientific;

      5: ZOLL Medical Corporation      		NoneNoneNoneNoneNone
      Chu-Pak Lau, MD, FHRS, CCDSThe University of Hong Kong, Hong Kong, Hong KongNoneNoneNoneNoneNoneNoneNoneNone
      Mark A. McGuire, MBBS, PhDHeart Rhythm Centre, Newtown, Australia1: MedtronicNoneNoneNoneNoneNoneNoneNone
      Siva K. Mulpuru, MD, FHRS, CCDSMayo Clinic Arizona, Phoenix, ArizonaNone0: MedtronicNoneNoneNoneNoneNoneNone
      David J. Slotwiner, MD, FHRSWeill Cornell Medical College, New York, New YorkNoneNoneNoneNoneNoneNoneNoneNone
      William Uribe, MD, MBA, FHRSCES Cardiología, Medellin, Colombia1: Abbot Laboratories;

      1: Pfizer      		NoneNoneNoneNoneNoneNoneNone
      Number value: 0 = $0; 1 = ≤ $10,000; 2 = > $10,000 to ≤ $25,000; 3 = > $25,000 to ≤ $50,000; 4 = > $50,000 to ≤ $100,000; 5 = > $100,000.
      ABIM = American Board of Internal Medicine.
      ∗ Research and fellowship support are classed as programmatic support. Sources of programmatic support are disclosed but are not regarded as a relevant relationship with industry for writing group members or reviewers.

      Article Info

      Publication History

      Published online: May 15, 2019

      Footnotes

      Document Reviewers: Serge Boveda, MD, PhD; Michael R. Gold, MD, PhD, FHRS; Roberto Keegan, MD; Valentina Kutyifa, MD, PhD, FHRS, FESC, FACC; Chu-Pak Lau, MD, FHRS, CCDS; Mark A. McGuire, MBBS, PhD; Siva K. Mulpuru, MD, FHRS, CCDS; David J. Slotwiner, MD, FHRS; William Uribe, MD, MBA, FHRS

      Developed in partnership with and endorsed by the European Heart Rhythm Association (EHRA), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS).

      For copies of this document, please contact the Elsevier Inc. Reprint Department ( [email protected] ). Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the Heart Rhythm Society. Instructions for obtaining permission are located at https://www.elsevier.com/about/our-business/policies/copyright/permissions.

      This article has been copublished in Europace and the Journal of Arrhythmia.

      Correspondence: Heart Rhythm Society, 1325 G Street NW, Suite 400, Washington, DC 20005. E-mail address: [email protected] .

      Identification

      DOI: https://doi.org/10.1016/j.hrthm.2019.02.034

      Copyright

      © 2019 The Heart Rhythm Society; the European Heart Rhythm Association, a registered branch of the European Society of Cardiology; the Asia Pacific Heart Rhythm Society; and the Latin American Heart Rhythm Society. Published by Elsevier Inc./Oxford University Press/Wiley. This article is published under the Creative Commons CC-BY license.

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