Noise detection during bradycardia pacing with a hybrid nonthoracotomy implantable cardioverter defibrillator system: Incidence and clinical significance

The purpose of this study was to prospectively evaluate the incidence of noise detection during bradycardia pacing by an FDA approved hybrid nonthoracotomy ICD system. An illustrative case report which prompted this investigation is provided. Backup bradycardia pacing by tiered therapy cardioverter defibrillators has been useful in preventing postshock bradycardia and occasionally for chronic rate support in bradycardic patients. Unexplained "noise" detected by real-time telemetry has been previously described during bradycardia pacing by a device utilizing automatic gain control for sensing. Eighteen patients were prospectively evaluated for noise detection during ventricular pacing by the ICD. Real-time telemetry was analyzed with each patient: (1) supine, (2) supine with deep inspiration/expiration, (3) supine during Valsalva, and (4) during a change in position from supine to sitting. Analysis of pacing threshold and lead impedance was made in each patient. Eleven of 18 patients had noise detected on real-time telemetry during bradycardia pacing. In 10 patients this was noted during deep inspiration/expiration, in 2 during Valsalva maneuver, and in 5 with position change. There was no evidence in any patient of lead malfunction nor any difference in pacing threshold or lead impedance bet-treen patients with noise detected versus those without it. Noise detection by an approved hybrid ICD system is common and may be due to the automatic gain control which maximizes sensitivity during bradycardia pacing. This may lead to clinically significant even ts, with both suppression of bradycardia pacing and triggering of tachycardia therapy in the absence of ventricular tachyarrhythmias in pacemaker-dependent patients.