Can an Implantable Cardioverter-Defibrillator (ICD) treat atrial tachycardia (AT)/atrial fibrillation (AF) with burst pacing+/ramp pacing?

From the Guidelines

Yes, an Implantable Cardioverter Defibrillator (ICD) can treat atrial tachycardia (AT) and atrial fibrillation (AF) using burst+ or ramp pacing therapies, as supported by the 2008 ACC/AHA/HRS guidelines for device-based therapy of cardiac rhythm abnormalities 1.

Key Points

• ICDs with atrial leads can deliver specialized pacing algorithms to terminate atrial arrhythmias, including burst+ and ramp pacing therapies.
• These therapies work by interrupting the reentrant circuit or overwhelming the arrhythmogenic focus, allowing the normal sinus node to regain control of the heart rhythm.
• The effectiveness of these therapies varies between patients, with success rates generally between 30-70% depending on the specific arrhythmia mechanism, as noted in the 2008 ACC/AHA guidelines for the management of adults with congenital heart disease 1.
• Programming should be individualized based on the patient's specific arrhythmia characteristics, and these therapies are most effective for organized atrial tachycardias rather than chaotic atrial fibrillation.

Considerations

• Not all ICDs have atrial therapies, and this feature is typically found in dual-chamber or biventricular ICDs with atrial leads.
• The use of burst+ or ramp pacing therapies should be carefully considered in patients with robust AV conduction, as they may accelerate the atrial rate.
• Newer-generation ICDs equipped with algorithms for both atrial tachycardia and VT detection and treatment, including atrial antitachycardia pacing and low-energy shocks for atrial tachycardia, have also been used successfully in a small number of patients with recurrent IART, as reported in the 2008 ACC/AHA guidelines for the management of adults with congenital heart disease 1.

From the Research

ICD Treatment for AT/AF with Burst+/Ramp

• ICDs can treat atrial tachycardia (AT) and atrial fibrillation (AF) using burst+/ramp pacing therapies 2, 3, 4.
• The efficacy of these pacing therapies varies depending on the type of arrhythmia and the cycle length of the arrhythmia 2, 3, 4.
• Burst+ and Ramp pacing therapies have been shown to be effective in terminating AT episodes, with Ramp therapy being more effective for AT episodes with longer cycle lengths 4.
• The efficacy of pacing therapies for AF is generally lower than for AT, but still significant 2, 3.
• The use of ICDs with pacing therapies can reduce the time required for AT/AF termination and improve quality of life for patients 2, 4.

Efficacy of Burst+/Ramp Pacing Therapies

• Burst+ pacing therapy terminated 44% of AT episodes in one study 4.
• Ramp pacing therapy terminated 53% of AT episodes in the same study, and was more effective for AT episodes with longer cycle lengths 4.
• The efficacy of pacing therapies for AF was lower, with Burst+ terminating 26% of AF episodes in one study 3.
• The median time from pacing to AT/AF termination was 1.1 minute for pacing successes in one study 2.

Clinical Implications

• ICDs with pacing therapies can be an effective treatment option for patients with AT/AF 2, 3, 4.
• The choice of pacing therapy and the programming of the ICD should be individualized based on the patient's specific needs and the characteristics of their arrhythmia 2, 3, 4.
• Further studies are needed to fully understand the clinical implications of ICD treatment for AT/AF with burst+/ramp pacing therapies 4.