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Prospective comparison of a conventional and an accelerated protocol for programmed ventricular stimulation in
F Morady1, A Kadish, M de Buitleir
1Division of Cardiology, University of Michigan Medical Center, Ann Arbor 48109-0022.
Insights
An accelerated programmed stimulation protocol significantly improves efficiency for inducing ventricular tachycardia (VT) by reducing steps and time. This method enhances specificity without compromising VT induction rates in patients with coronary artery disease.
Area of Science:
- Electrophysiology
- Cardiology
- Medical Device Technology
Background:
- Coronary artery disease (CAD) patients with ventricular tachycardia (VT) history require effective diagnostic protocols.
- Conventional programmed stimulation (PS) protocols may be time-consuming and less efficient.
Purpose of the Study:
- To compare the sensitivity, specificity, and efficiency of conventional versus accelerated PS protocols for VT induction.
- To evaluate the impact of accelerated PS on diagnostic yield and patient safety.
Main Methods:
- A comparative study involving 293 CAD patients with VT history.
- Two PS protocols were used: conventional (basic drive trains at 600/400 msec, apex) and accelerated (basic drive trains at 350/400/600 msec, apex and second site).
- Electrophysiological testing was conducted in baseline and drug-testing states.
Main Results:
- The accelerated protocol required significantly fewer steps (4.0 vs. 10.1) and less time (5.6 vs. 14.4 minutes) to induce monomorphic VT (p < 0.001).
- VT induction rates were comparable or improved with the accelerated protocol (89% vs. 92% for sustained VT in sustained VT history patients).
- The accelerated protocol showed a trend towards reduced induction of ventricular fibrillation or polymorphic VT (0.9% vs. 3.6%, p = 0.05).
Conclusions:
- The accelerated PS protocol, utilizing a 350 msec basic drive train and three extrastimuli, significantly enhances efficiency.
- This protocol reduces procedure time and steps by over 50% while maintaining or improving VT induction rates.
- Accelerated PS improves specificity and reduces adverse events during electrophysiological testing for VT.
Background:
This study compared the sensitivity, specificity, and efficiency of a "conventional" and "accelerated" programmed stimulation protocol in 293 patients with coronary artery disease who had a history of sustained or nonsustained monomorphic ventricular tachycardia (VT).
Methods And Results:
In the conventional protocol, one and two extrastimuli were introduced during sinus rhythm and during basic drive trains at cycle lengths of 600 and 400 msec at the right ventricular apex and then at the outflow tract or septum. In the accelerated protocol, one, two, and then three extrastimuli were introduced at each of three basic drive train cycle lengths (350, 400, and 600 msec) at the right ventricular apex; the procedure was repeated at a second right ventricular site. Six hundred thirty-four electrophysiological tests were performed using one of these two protocols either in the baseline state (293 tests) or during drug testing (341 tests). The yield of sustained, monomorphic VT was 89% with the conventional protocol and 92% with the accelerated protocol during baseline tests in patients who had a history of sustained VT (p = 0.05); 20% and 34%, respectively, during baseline tests in patients with a history of nonsustained VT (p = 0.06); and 70% and 77%, respectively, during drug testing (p = 0.2). To induce sustained, monomorphic VT, 10.1 +/- 5.0 (mean +/- SD) protocol steps and 14.4 +/- 8.7 minutes were required with the conventional protocol, compared with 4.0 +/- 3.7 steps and 5.6 +/- 6.1 minutes with the accelerated protocol (p less than 0.001 for each comparison). Among the tests in which sustained, monomorphic VT was induced, sustained polymorphic VT or ventricular fibrillation was induced more often with the conventional protocol (3.6%) than with the accelerated protocol (0.9%, p = 0.05).
Conclusions:
The efficiency of programmed stimulation can be improved by the early use of a basic drive train cycle length of 350 msec and three extrastimuli. Compared with a conventional stimulation protocol, the accelerated protocol used in this study reduces the number of protocol steps and duration of time required to induce monomorphic VT by an average of more than 50% and improves the specificity of programmed stimulation without impairing the yield of monomorphic VT.