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Alternans of the ventricular electrogram in patients with an implanted cardioverter-defibrillator

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Abstract
Background: The occurrence and significance of alternans of the ventricular electrogram (VEGM) in patients with an implanted cardioverter-defibrillator (ICD) has been rarely reported. Objectives and Methods: This report describes our observations of VEGM alternans documented in nine patients with an ICD (seven new cases and two previously published cases for comparison). Results: We found seven new cases of near-field VEGM alternans and added two of our previously reported examples. Catecholaminergic polymorphic ventricular tachycardia (CPVT) was diagnosed in one patient based on ICD recordings. Alternans occurred during ventricular tachycardia (VT) in eight patients. A fast sinus tachycardia could not be ruled out in one patient. Stable cycle length alternans was found in five patients. QRS alternans of the left ventricular (LV) electrogram (EGM) was recorded in all five patients who had a device for cardiac resynchronization therapy capable of sensing by the LV channel. These five cases exhibited corresponding alternans of the right ventricular (RV) EGM in three cases, none in one patient, and a questionable recording in another. Alternans of the far-field (FF) VEGM occurred simultaneously with RV EGM alternans in all four patients whose device provided an FF tracing. Conclusion: Ventricular alternans may be more common than realized in ICD patients with VT. The correlation of VEGM alternans with the surface electrocardiogram remains unknown. Although QRS alternans itself as an electrical pattern is generally benign, its cause may not be, as illustrated in our patient with CPVT. Furthermore, associated cycle length alternans or undersensing of the smaller alternans component may complicate ICD therapy.
Keywords
cycle length alternans, ventricular tachycardia, implantable cardioverter-defibrillator, electrical alternans, catecholaminergic polymorphic ventricular tachycardia, bidirectional ventricular tachycardia, NARROW QRS TACHYCARDIA, ELECTRICAL ALTERNANS, COMPLEX TACHYCARDIA, CARDIAC ALTERNANS, MECHANISM, ICD

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Chicago
Barold, S Serge, Andreas Kucher, Antoine de Meester, and Roland Stroobandt. 2015. “Alternans of the Ventricular Electrogram in Patients with an Implanted Cardioverter-defibrillator.” Pace-pacing and Clinical Electrophysiology 38 (12): 1470–1480.
APA
Barold, S. S., Kucher, A., de Meester, A., & Stroobandt, R. (2015). Alternans of the ventricular electrogram in patients with an implanted cardioverter-defibrillator. PACE-PACING AND CLINICAL ELECTROPHYSIOLOGY, 38(12), 1470–1480.
Vancouver
1.
Barold SS, Kucher A, de Meester A, Stroobandt R. Alternans of the ventricular electrogram in patients with an implanted cardioverter-defibrillator. PACE-PACING AND CLINICAL ELECTROPHYSIOLOGY. 2015;38(12):1470–80.
MLA
Barold, S Serge, Andreas Kucher, Antoine de Meester, et al. “Alternans of the Ventricular Electrogram in Patients with an Implanted Cardioverter-defibrillator.” PACE-PACING AND CLINICAL ELECTROPHYSIOLOGY 38.12 (2015): 1470–1480. Print.
@article{6971962,
  abstract     = {Background: The occurrence and significance of alternans of the ventricular electrogram (VEGM) in patients with an implanted cardioverter-defibrillator (ICD) has been rarely reported. 
Objectives and Methods: This report describes our observations of VEGM alternans documented in nine patients with an ICD (seven new cases and two previously published cases for comparison). 
Results: We found seven new cases of near-field VEGM alternans and added two of our previously reported examples. Catecholaminergic polymorphic ventricular tachycardia (CPVT) was diagnosed in one patient based on ICD recordings. Alternans occurred during ventricular tachycardia (VT) in eight patients. A fast sinus tachycardia could not be ruled out in one patient. Stable cycle length alternans was found in five patients. QRS alternans of the left ventricular (LV) electrogram (EGM) was recorded in all five patients who had a device for cardiac resynchronization therapy capable of sensing by the LV channel. These five cases exhibited corresponding alternans of the right ventricular (RV) EGM in three cases, none in one patient, and a questionable recording in another. Alternans of the far-field (FF) VEGM occurred simultaneously with RV EGM alternans in all four patients whose device provided an FF tracing. 
Conclusion: Ventricular alternans may be more common than realized in ICD patients with VT. The correlation of VEGM alternans with the surface electrocardiogram remains unknown. Although QRS alternans itself as an electrical pattern is generally benign, its cause may not be, as illustrated in our patient with CPVT. Furthermore, associated cycle length alternans or undersensing of the smaller alternans component may complicate ICD therapy.},
  author       = {Barold, S Serge and Kucher, Andreas and de Meester, Antoine and Stroobandt, Roland},
  issn         = {0147-8389},
  journal      = {PACE-PACING AND CLINICAL ELECTROPHYSIOLOGY},
  keyword      = {cycle length alternans,ventricular tachycardia,implantable cardioverter-defibrillator,electrical alternans,catecholaminergic polymorphic ventricular tachycardia,bidirectional ventricular tachycardia,NARROW QRS TACHYCARDIA,ELECTRICAL ALTERNANS,COMPLEX TACHYCARDIA,CARDIAC ALTERNANS,MECHANISM,ICD},
  language     = {eng},
  number       = {12},
  pages        = {1470--1480},
  title        = {Alternans of the ventricular electrogram in patients with an implanted cardioverter-defibrillator},
  url          = {http://dx.doi.org/10.1111/pace.12758},
  volume       = {38},
  year         = {2015},
}

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