Skip to main content


Swipe om te navigeren naar een ander artikel

17-05-2017 | Rhythm Puzzle - Answer | Uitgave 11/2017 Open Access

Netherlands Heart Journal 11/2017

Appropriate or inappropriate ICD shock; what is the post-shock rhythm?

Netherlands Heart Journal > Uitgave 11/2017
B. M. van Gelder, B. ter Burg, F. A. L. E. Bracke


At first sight, this may seem an appropriate shock for ventricular fibrillation, followed by conversion to sinus rhythm. However, the abrupt change in morphology of the RV electrogram with extreme short fibrillation sense (FS) intervals below 200 ms is not suggestive of ventricular fibrillation. The intervals are also comparable with the atrial sense (AS) and atrial sensing in the blanking period (Ab) intervals in the atrial channel. These observations suggest that the sensed arrhythmia in the ventricular channel is not ventricular fibrillation, but sensing of atrial fibrillation. This observation can only be explained by a displacement of the ventricular lead towards the right atrium. Review of the X‑rays, which at implant showed a normal RV apical position of the shock lead (Fig.  1, left panel), showed migration of the lead into the right atrium in the post-shock X‑ray (Fig.  1, right panel). It is therefore clear that the shock therapy was inappropriate.
The post-shock right atrial electrogram showed the simultaneous termination of atrial fibrillation, which suggests ventricular pacing. However, the ventricular pace pulse is actually stimulating the atrium. This is proven by the coinciding atrial activation on the atrial lead (Fig.  2).
The effective atrial stimulation from the ventricular pace pulse is a further confirmation of the ventricular lead dislocation. The far-field R wave signal in the atrial channel indicates subsequent antegrade conduction to the ventricle (Fig.  2).

Conflict of interest

B.M. van Gelder provides training and education for St Jude Medical, the Netherlands and is clinical advisor for LivaNova, France. B. ter Burg and F.A.L.E. Bracke: no conflicts of interest declared.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Onze productaanbevelingen

Netherlands Heart Journal

Het Netherlands Heart Journal wordt uitgegeven in samenwerking met de Nederlandse Vereniging voor Cardiologie en de Nederlandse Hartstichting. Het tijdschrift is Engelstalig en wordt gratis beschikbaa ...

Over dit artikel

Andere artikelen Uitgave 11/2017

Netherlands Heart Journal 11/2017 Naar de uitgave

Editor’s Comment

Resuscitation on the pitch