Eligibility of cardiac resynchronization therapy patients for subcutaneous implantable cardioverter defibrillators

  • Massimo GiammariaEmail author
  • Maria Teresa Lucciola
  • Claudia Amellone
  • Fabrizio Orlando
  • Giuseppe Mazzone
  • Sara Chiarenza
  • Mariolina Lovecchio
  • Sergio Valsecchi



Before subcutaneous implantable cardioverter defibrillator (S-ICD) implantation, the adequacy of sensing is required to be verified through surface ECG screening. Our objective was to determine whether S-ICD can be considered as a supplementary therapy in patients who are receiving biventricular (BIV) pacing.


We evaluated 48 patients with BIV devices to determine S-ICD candidacy during BIV, left ventricular (LV), right ventricular (RV) pacing, and intrinsic conduction (left bundle branch block—LBBB) by using an automated screening tool. Eligibility was defined by the presence of at least one appropriate vector in the supine and standing positions.


Eligibility was verified during BIV pacing in 34 (71%) patients. In patients screened-out, QRS duration was longer (p = 0.035) and ischemic cardiomyopathy was more frequent (p = 0.027). LV-only pacing was associated with a lower passing rate (46%) (p < 0.001 versus BIV). The LBBB QRS morphology during inhibited ventricular pacing was acceptable in 51% of patients. The QRS generated by RV pacing was acceptable in 25% of patients. In patients who passed the screening test during BIV, the QRS was not acceptable in 76% during RV pacing (i.e., accidental loss of LV capture). The concomitant adequacy during inhibited ventricular pacing (i.e., possible intrinsic conduction) was not assessed in 40% of patients.


S-ICD may be a supplemental therapy in the majority of CRT patients. Standard BIV pacing should be preferred to the LV-only pacing mode, as it is more frequently associated with adequacy of S-ICD sensing. Spontaneous LBBB and RV-paced QRS morphologies are frequently inadequate. Therefore, in patients selected for concomitant S-ICD and CRT implantation, accidental loss of LV capture or possible intrinsic conduction must be prevented.


ICD Subcutaneous Screening CRT Sudden death 



Implantable cardioverter-defibrillators


Subcutaneous ICD


Cardiac resynchronization therapy




Compliance with ethical standards

All patients provided written informed consent for data storage and analysis, as approved by the Institutional Review Board.

Conflict of interest

M. Lovecchio, S. Chiarenza and S. Valsecchi are employees of Boston Scientific, Inc. No other conflicts of interest exist.

Ethical approval

The study was approved by the Local Ethics Committee.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, et al. 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: the task force for the Management of Patients with ventricular arrhythmias and the prevention of sudden cardiac death of the European Society of Cardiology (ESC)endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Europace. 2015;17:1601–87.Google Scholar
  2. 2.
    Weiss R, Knight BP, Gold MR, Leon AR, Herre JM, Hood M, et al. Safety and efficacy of a totally subcutaneous implantable-cardioverter defibrillator. Circulation. 2013;128:944–53.CrossRefGoogle Scholar
  3. 3.
    Lee DS, Krahn AD, Healey JS, Birnie D, Crystal E, Dorian P, et al. Evaluation of early complications related to De novo cardioverter defibrillator implantation insights from the Ontario ICD database. J Am Coll Cardiol. 2010;55:774–82.CrossRefGoogle Scholar
  4. 4.
    Reynolds MR, Cohen DJ, Kugelmass AD, et al. The frequency and incremental cost of major complications among medicare beneficiaries receiving implantable cardioverter-defibrillators. J Am Coll Cardiol. 2006;47:2493–7.CrossRefGoogle Scholar
  5. 5.
    Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. AHA/ACC/HRS guideline for Management of Patients with Ventricular Arrhythmias and the prevention of sudden cardiac death: executive summary: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society. Heart Rhythm. 2017;(2017 Oct 30)Google Scholar
  6. 6.
    Boersma L, Barr C, Knops R, Theuns D, Eckardt L, Neuzil P, et al. Implant and midterm outcomes of the subcutaneous implantable cardioverter-defibrillator registry: the EFFORTLESS study. J Am Coll Cardiol. 2017;70:830–41.CrossRefGoogle Scholar
  7. 7.
    Poole JE, Gleva MJ, Mela T, Chung MK, Uslan DZ, Borge R, et al. Complication rates associated with pacemaker or implantable cardioverter-defibrillator generator replacements and upgrade procedures: results from the REPLACE registry. Circulation. 2010;122:1553–61.CrossRefGoogle Scholar
  8. 8.
    Haugaa KH, Tilz R, Boveda S, Dobreanu D, Sciaraffia E, Mansourati J, et al. Implantable cardioverter defibrillator use for primary prevention in ischaemic and non-ischaemic heart disease-indications in the post-DANISH trial era: results of the European heart rhythm association survey. Europace. 2017;19:660–4.CrossRefGoogle Scholar
  9. 9.
    Perego GB, Chianca R, Facchini M, Frattola A, Balla E, Zucchi S, et al. Simultaneous vs. sequential biventricular pacing in dilated cardiomyopathy: an acute hemodynamic study. Eur J Heart Fail. 2003;5:305–13.CrossRefGoogle Scholar
  10. 10.
    Olde Nordkamp LR, Warnaars JL, Kooiman KM, et al. Which patients are not suitable for a subcutaneous ICD: incidence and predictors of failed QRS-T-wave morphology screening. J Cardiovasc Electrophysiol. 2014;25:494–9.CrossRefGoogle Scholar
  11. 11.
    Randles DA, Hawkins NM, Shaw M, Patwala AY, Pettit SJ, Wright DJ. How many patients fulfil the surface electrocardiogram criteria for subcutaneous implantable cardioverter-defibrillator implantation? Europace. 2014;16:1015–21.CrossRefGoogle Scholar
  12. 12.
    Groh CA, Sharma S, Pelchovitz DJ, Bhave PD, Rhyner J, Verma N, et al. Use of an electrocardiographic screening tool to determine candidacy for a subcutaneous implantable cardioverter-defibrillator. Heart Rhythm. 2014;11:1361–6.CrossRefGoogle Scholar
  13. 13.
    Ip JE, Wu MS, Kennel PJ, et al. Eligibility of pacemaker patients for subcutaneous implantable cardioverter defibrillators. J Cardiovasc Electrophysiol. 2017;28:544–8.CrossRefGoogle Scholar
  14. 14.
    Theuns DA, Burke M, Allavatam V, et al. AB05–01: evaluation of a high pass filter designed to reduce oversensing in the S-ICD (abstr.). Heart Rhythm. 2016;13:S10–1.CrossRefGoogle Scholar
  15. 15.
    Olde Nordkamp LR, Brouwer TF, Barr C, et al. Inappropriate shocks in the subcutaneous ICD: incidence, predictors and management. Int J Cardiol. 2015;195:126–33.CrossRefGoogle Scholar
  16. 16.
    Willcox ME, Prutkin JM, Bardy GH. Recent developments in the subcutaneous ICD. Trends Cardiovasc Med. 2016;26:526–35.CrossRefGoogle Scholar
  17. 17.
    Hernández-Madrid A, Facchin D, Klepfer RN, Ghosh S, Matía R, Moreno J, et al. Device pacing diagnostics overestimate effective cardiac resynchronization therapy pacing results of the hOLter for efficacy analysis of CRT (OLÉ CRT) study. Heart Rhythm. 2017;14:541–7.CrossRefGoogle Scholar
  18. 18.
    Okamura H, McLeod CJ, DeSimone CV, et al. Right parasternal lead placement increases eligibility for subcutaneous implantable cardioverter defibrillator therapy in adults with congenital heart disease. Circ J. 2016;80:1328–35.CrossRefGoogle Scholar
  19. 19.
    Santini L, Pappalardo A, Schirripa V, Danisi N, Forleo GB, Ammirati F. Oversensing of an unexpected atrial flutter. A new tool to improve detection of supraventricular arrhythmias in subcutaneous implantable cardioverter-defibrillators. HeartRhythm Case Rep. 2017;3:286–8.CrossRefGoogle Scholar
  20. 20.
    Tjong FV, Brouwer TF, Smeding L, et al. Combined leadless pacemaker and subcutaneous implantable defibrillator therapy: feasibility, safety, and performance. Europace. 2016;18:1740–7.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Massimo Giammaria
    • 1
    Email author
  • Maria Teresa Lucciola
    • 1
  • Claudia Amellone
    • 1
  • Fabrizio Orlando
    • 1
  • Giuseppe Mazzone
    • 1
  • Sara Chiarenza
    • 2
  • Mariolina Lovecchio
    • 2
  • Sergio Valsecchi
    • 2
  1. 1.Maria Vittoria HospitalTurinItaly
  2. 2.Boston Scientific ItalyMilanItaly

Personalised recommendations