Underdetection of ventricular fibrillation despite ICD testing and high sinus R wave

Apart from monitoring shock efficacy, proof of flawless detection of induced ventricular fibrillation (VF) is a decisive argument in favor of implantable cardioverter defibrillator (ICD) testing. On the other hand, it has been observed that undersensing of VF is extremely rare with good sensing of the intrinsic R wave of  ≥ 5-7 mV. The case presented here shows limitations in both argumentations: Neither optimal R wave sensing during sinus rhythm nor repeated ICD testing could rule out or predict multiple erroneous detections of clinical VF episodes. This must be taken into consideration in the current discussion on the necessity of defibrillation testing. Further optimization of sensing technology should be a focus in the development of modern ICD systems so as to improve the safety and efficacy of ICD therapy.