Device-detected and device-terminated supraventricular tachycardia with use remote monitoring of ICD in the emergency department

Abstract

Atrial fibrillation (AF) and atrial flutter (AFL) are common arrhythmias in patients with heart failure (HF) implantable cardioverter-defibrillators (ICDs), and may trigger device therapies or prompt emergent management. Early electrical cardioversion (ECV) in the emergency department (ED) may terminate these episodes effectively, particularly when onset is documented and presentation is within 24 hours. This timeframe allows also for omission of transesophageal echocardiography to exclude presence of intracardiac thrombi according to current guidelines. However, data are scarce on outcomes of ECV in ICD-detectable AF/AFL episodes in the ED setting.

Methods

We have retrospectively identified patients who have been requested to report to our emergency department due to device-detected atrial arrhythmia via ICD remote monitoring and were called by our remote-monitoring team.

Results

Six male patients (aged 57–82 years) have been admitted to emergency department of our tertiary care center within the 6 months period. All episodes occurred within 24 hours of onset and were managed with device-guided electrical cardioversion in deep sedation. Baseline heart rates ranged from 70 to 150/min, with irregular ventricular response in three patients. Systolic blood pressure at presentation varied between 98 and 154 mmHg. All patients had structural heart disease with reduced LVEF (17–38%) and chronic heart failure; five had ischaemic cardiomyopathy. Anticoagulation consisted predominantly of apixaban, except for one patient on acenocoumarol (due to history of prosthetic heart valve).

Electrical cardioversion using the ICD system was successful in almost all cases, with delivered energies ranging from 20 J to 40 J; one patient required additional external 200 J shock. Sedation was performed using remimazolam (with or without fentanyl) in most cases. All anaesthetic procedures were conducted by intervention anaesthetic team. No neurological deficit has been observed and all of the patients were discharged home after 1-2h of observation.

During follow-up (from 1 to 7 months), five of six patients experienced arrhythmia recurrence: two within days to months, and three after 1–7 months. One patient remained recurrence-free throughout the observation period.

Conclusion(s)

Prompt emergency department evaluation combined with ICD-based remote monitoring enabled identification and rapid management of recent-onset AF/AFL. Device-guided electrical cardioversion proved feasible, well tolerated, and acutely effective in nearly all patients, with no periprocedural complications and short post-procedure observation time. Although arrhythmia recurrence during follow-up was common—reflecting the advanced structural heart disease burden—this approach supports the utility of ICD remote monitoring to streamline early rhythm control strategies, reduce unnecessary hospitalization, and facilitate timely intervention in appropriately selected patients.graphical abstractFor image description, please refer to the figure legend and surrounding text.