Supplementary Online Content€¦ · SC ICD Acute RCA thrombus. Cardiomegaly, cirrhosis, COPD Extended VF with undersensing leading to a delay in interval counts that delayed therapy

©2015AmericanMedicalAssociation.Allrightsreserved.

Supplementary Online Content

Tseng ZH, Hayward RM, Clark NM, et al. Sudden death in patients with cardiac implantable electronic devices. JAMA Intern Med. Published online June 22, 2015. doi:10.1001/jamainternmed.2015.2641. eTable. Details of Investigation for SCDs With Cardiovascular Implantable Electronic Devices eFigure 1. Case 5 eFigure 2. Case 1 eFigure 3. Case 2 eFigure 4. Case 3 eFigure 5. Case 4 eFigure 6. Case 15 eFigure 7. Case 18 eFigure 8. Case 19 eFigure 9. Case 20 eFigure 10. Case 21 This supplementary material has been provided by the authors to give readers additional information about their work.

Downloaded From: https://jamanetwork.com/ by a Non-Human Traffic (NHT) User on 04/24/2021


eTable 1. Details of Investigation for SCDs with Cardiovascular Implantable Electronic Devices

Case Patient Details Device Autopsy Findings Device Interrogation Terminal Rhythm Adjudicated COD Device Concern

1 70♂ with CHB, AF DC PPM No MI or other acute COD Sudden battery depletion from 2.62V (5 weeks prior to death) to 2.17V (day of death). See eFigure 2.

Presumed profound bradycardia/asystole Arrhythmic Yes (Battery; Hardware

failure)

2 42♂ with CHB, HCM, syncope DC PPM Hypertrophic CM with 3.0 cm

septum. No acute MI Normal PPM function with VF at time of death. See eFigure 3. VF Arrhythmic Yes (ICD was indicated at time of PPM; Improper

device selection)

3

77♀ with sick sinus syndrome, advanced AV block, CAD s/p MI, CVA,

Alzheimer's dz

DC PPM No MI; acute bronchopneumonia No VT/VF. Rapid rise in RV lead impedance (650‐>1620 ohms) 1wk prior to death concerning for lead fracture. See eFigure 4. PEA Pneumonia Yes (RV lead; Possible

hardware failure)

4 60♂ with CHB, AF DC PPM

Rectal adenocarcinoma, cardiomegaly, 30% LAD stenosis, and severe myocardial fibrosis. No MI or acute COD

Increase in RV lead impedance 2 days prior to death. PMVT/VF at the time of death. See eFigure 5. PMVT/VF Arrhythmic Yes (RV lead; Hardware

failure)

5 26♂ with 2nd deg. HB, L‐TGA s/p mechanical TVR DC PPM Massive pulmonary hemorrhage Normal PPM function w/o recorded events at time of death. See eFigure

1. PEA Massive pulmonary hemorrhage No

6 87♀ with 2nd deg. HB, AF, CAD s/p MI DC PPM Intracranial hemorrhage Acute increase in RV lead impedance (380‐>1340 ohms) post‐mortem. AF w/ RVR ‐>Asystole Intracranial

hemorrhage No

7 98♀ with CHB, AF DC PPM Pulmonary edema and scar from remote MI but no acute MI Normal PPM function w/o recorded events at the time of death. PEA (AS‐VP)

Cardiac (heart failure), non‐arrhythmic

No

8 70♂ with sinus node dysfunction DC PPM Scar from remote MI. No acute MI

or other COD Normal PPM function with VF at the time of death. VF Arrhythmic No

9 84♂ with CHB, AF DC PPM No acute cause of death No electrograms recorded (device was ERI), but intervals suggest VF. VF Arrhythmic No

10 56♂ with CHB, CHF DC PPM Dilated CM w/o MI or other acute COD Normal PPM function. Device at ERI, full interrogation not possible. Unknown Arrhythmic No

11 88♀ with AF and bradycardia DC PPM Blunt force injuries of head/neck

w/ CAD Normal PPM function. AF with RVR at time of death. AF with RVR Occult trauma No

12 77♂ with CHB, AF, CAD s/p MI, CHF DC PPM No MI. Acute lung inflammation

due to pneumonia Normal PPM function. NSVT ‐‐>

Idioventricular rhythm

Pneumonia No

13 87♂ with tachy‐brady syndrome DC PPM No MI or other acute COD. 50%

LAD stenosis Normal PPM function with VF at time of death. VF Arrhythmic No

14 77♂ with CHB, CAD, idiopathic CM CRT‐P N/A No device interrogation. VF recorded by paramedics. VF Arrhythmic No

15 78♂ with Dilated CM DC ICD Massive subarachnoid hemorrhage, cardiomegaly (heart 760g)

VF documented at time of death (likely secondary to subarachnoid hemorrhage). See eFigure 6. VF Subarachnoid

hemorrhage No

16 76♂ with Ischemic CM, AF, CAD DC ICD Scar from remote MI and CM but

no acute MI or other COD

Episodes of VF during EMS rescue were not recorded by device and required external shocks for rescue. Delay to shock due to ATP programming in the VF zone. See Figure 2.

VF Arrhythmic Yes (VF episodes missed; Programming and Device

algorithm issue)

17 70♂ with Ischemic CM, CHF CRT‐D CM without acute MI or other

COD VF undersensed with device interpreting return to sinus rhythm (no shock delivered). See Figure 3. VF Arrhythmic Yes (VF undersensing; Device

algorithm issue)

18 74♂ with CAD s/p MI, ischemic CM, AF, VT DC ICD Scar from remote MI and 99% LAD

stenosis but no acute MI

VF with undersensing. 40 VF and 2 VT episodes identified and 17/42 shocks aborted due to undersensing. The second event showed significant undersensing with a significant delay in therapy. See eFigure 7.

VF Arrhythmic Yes (VF undersensing)



19 54♀ with dilated CM, ESRD on HD DC ICD N/A

VT that was undersensed. This was treated with ATP but wavering VT cycle length resulted in a delayed shock. VT degraded into fine VF that was undersensed. Patient left in VF/VT and device stopped recording and was unable to detect after that point. See eFigure 8.

VF Arrhythmic Yes (VT undersensing)

20 71♂ with AF, CAD, ischemic CM SC ICD Acute RCA thrombus.

Cardiomegaly, cirrhosis, COPD Extended VF with undersensing leading to a delay in interval counts that delayed therapy. See eFigure 9. VF Arrhythmic

Yes (VF undersensing, Programming and Device

algorithm issue)

21 80♂ with ischemic CM, CAD, CHF CRT‐D N/A

VF storm with 4 shocks and multiple rounds of ATP. Final event shows VT but device did not rescue due to programming of tachycardia zone. See eFigure 10.

VT Arrhythmic Yes (VT slower than VT zone; Programming)

22 80♂ with Ischemic CM, AF DC ICD Hypertensive heart disease, COPD

VF with successful defibrillation x 3 followed by RV lead noise and increase in lead impedance with 4th shock suggesting lead fracture. See Figure 4.

VF Arrhythmic Yes (Lead fracture; Hardware failure)

AF ‐ atrial fibrillation, CAD ‐ coronary artery disease, CHB ‐ complete heart block, CHF ‐ congestive heart failure, CM – cardiomyopathy, COD – cause of death, CRT‐P ‐ cardiac resynchronization therapy pacemaker, CRT‐D ‐ cardiac resynchronization therapy defibrillator, DC ‐ dual chamber, MI ‐ myocardial infarction, PEA ‐ pulseless electrical activity, PPM ‐ permanent pacemaker, RV ‐ right ventricle, RVR ‐ rapid ventricular response, SC ‐ single chamber, VF ‐ ventricular fibrillation, VT ‐ ventricular tachycardia



eFigure1(Case5).Left:Post‐mortemdeviceinterrogationshowingnoventricularhighrateepisodes.Right:H&Esectionoflung(12.5X)demonstratingdilatedbronchialveins(arrows)andhemosiderin‐ladenmacrophages(arrowheads).ReprintedwithpermissionfromHaywardRM,UrsellPC,FosterE,TsengZH.SuddendeathduetononarrhythmiccauseinapatientwithL‐TGA.AnnNoninvasiveElectrocardiol.2014;19(3):293‐297.



eFigure2(Case1).Top: PPM interrogation 5 weeks prior to death shows estimated battery longevity of 6 months and > 95% ventricular pacing. The patient’s PVC burden was at least 3%, which accounted for most of the non-paced ventricular beats and underlying rhythm at device check was sinus bradycardia with complete heart block and a slow junctional escape. The patient’s ventricular pacing threshold at this this time was 2.5V with a pulse width of 0.4 ms. Bottom: Pacemaker interrogation within 1 day after death demonstrates excessive voltage decrease of 0.46 V consistent with rapid battery depletion and no ventricular high rate episodes.



eFigure3(Case2).Top:Atrialmarkerchannel.Middle:Ventricularmarkerchannel.Bottom:Intervals.VFatthetimeofdeath.ICDisaIIarecommendationin2008ACC/AHA/HRSGuidelinesforHCMpatientswithunexplainedsyncopeandseptalthickness>30mm.ThispatientdiedofVFwithaPPMinplace.



eFigure4(Case3).Postmortem PPM interrogation demonstrating a rapid substantial increase in atrial and ventricular lead impedances that was first detected 2 days prior to death. The patient died suddenly on January 13, 2012. The intrinsic R-wave was measured at 5.5 mV on the day prior to death, suggesting intrinsic ventricular activity. However, lead fracture can be intermittent and the sensing could have been due to junctional or ventricular escape beats. Atrial lead impedance also increased, raising the possibility of changes due to acidosis or electrolyte disturbances, but atrial lead impedance normalized on the day of death. In this case, although pneumonia was found on autopsy and occult pneumonia was adjudicated as the COD, right ventricular lead fracture or a global pacemaker problem resulting in profound bradycardia or asystole could not be excluded as a contributor to sudden death.



eFigure5(Case4).Top:Increaseinventricularleadimpedance2dayspriortodeath(thepatientdiedsuddenlyon11/3/13).Bottom:VentricularelectrogramshowsPMVT/VFatthetimeofdeath.NoacuteCODwasfoundonautopsy.TheleadmalfunctionmayhaveleddirectlytoVT/VFviapause‐dependentmechanismcausedbyinconsistentventricularcaptureorRonTphenomenonduetoundersensing.



eFigure6(Case15).78MwithdilatedCMandVFdocumentedatthetimeofdeathwhichwasrecognizedandtreatedbytheICD(Left).VFwasduetohemorrhageintherightinsularcortex(Right)leadingtoarrhythmia(neurocardiogenicVF).





eFigure 7 (Case 18). The patient had 40 VF and 2 VT episodes identified and 17 of 42 shocks aborted due to undersensing. Top: atrial electrogram. Middle: ventricular electrogram. Bottom: device markers. Strips are continuous. This event shows a return to sinus (*) after the previous shock due to undersensing of VF (arrowheads). This resulted in a significant delay in therapy.



eFigure8(Case19).Top:atrialelectrogram.Middle:ventricularelectrogram.Bottom:Shockelectrogram.After3unsuccessfulATPattempts,thepatientwasinVT/VF.UndersensingresultedinawaveringVTcyclelengthanddiversionofcharging(*).ThedeviceredetectedVFanddeliveredashock,butundersensingresultedinadelaytotherapyof12.2seconds(A).Ultimately,thepatientwasleftinVFthatthedevicewasunabletodetectandstoppedrecording(B).Thepatient’sfinalrecordedrhythm,whichshowedundersensingofVF.IntervalsshowvaryingcyclelengthswaveringinandoutofVTzone(C).



eFigure 9 (Case 20). Top and Middle Strips (continuous): Extended VF event with undersensing (arrowheads) that delays therapy. In addition, ATP delays shock therapy. Less than 1 minute later, the patient had multiple additional episodes of VT/VF requiring defibrillation. Bottom Strip: 4 minutes later, the final rhythm recorded by the device was VF with no further shocks delivered. Autopsy showed acute RCA thrombus. Cumulative delays to shock may have resulted in refractoriness of VF and further opportunity for undersensing.



eFigure10(Case21).Top: atrial electrogram. Middle: ventricular electrogram. Bottom: device markers. After 4 shocks and multiple rounds of ATP, the patient is left in VT (mean cycle length 447 msec) but the device did not rescue due to the programming of the tachycardia zone (VT detection zone >166 bpm or <360 msec).


Documents

Supplementary Online Content€¦ · SC ICD Acute RCA thrombus. Cardiomegaly, cirrhosis, COPD Extended VF with undersensing leading to a delay in interval counts that delayed therapy