[Sandwiched between the single- and triple-chamber ICD: do we still need the dual-chamber ICD?]

Since it has been shown that adverse events are more frequent with dual-compared to single-chamber ICDs in patients with heart failure, and since the importance of prevention of unnecessary right ventricular pacing and the success of biventricular pacing have been demonstrated in numerous studies, the need for dual-chamber ICD systems has to be reassessed. The development of these systems was accompanied by expectations of improved hemodynamics in patients with bradycardia, a reduced incidence of atrial fibrillation, inappropriate therapies, and bradycardia-associated ventricular tachyarrhythmias. Single-chamber ICDs should be used restrictively and with great caution in patients with (sinus-) bradycardia and heart failure, since a relevant proportion of these patients is at risk of hemodynamic deterioration. Even if the proportion of patients with proven pacemaker syndrome is so small that it does not reach the level of statistical significance in large studies, a small percentage of patients with hemodynamic deterioration due to VVI pacing is still clinically (and economically) intolerable. Since the development of bradycardia or symptomatic chronotropic incompetence (e.g., due to amiodarone) is difficult to predict, it seems reasonable to use the indication for dualchamber systems liberally. However, the systematic prevention of unnecessary right ventricular pacing is crucial if dual-chamber ICDs are used. If advanced tachycardia discrimination algorithms and careful, individual programming are used, dual-chamber ICDs are superior in the prevention of inappropriate therapies. Additionally, dualchannel electrograms allow a more reliable interpretation of stored tachycardia episodes. In summary, dual-chamber systems represent a valuable improvement of ICD therapy but require thorough programming to convey their advantage.