# Modern physiological approach to inappropriate ICD shocks due to atrial fibrillation with very fast ventricular response. A case report

## TL;DR

A patient with a heart condition and an ICD received inappropriate shocks due to a fast heart rate, which was solved using a new pacing method and ablation.

## Contribution

Proposes a cost-effective solution using left bundle branch area pacing and ablation for inappropriate ICD shocks in patients with fast-conducting atrial fibrillation.

## Key findings

- Atrioventricular node ablation and left bundle branch area pacing successfully prevented inappropriate shocks.
- The patient's left ventricular function improved after the procedure.
- This approach avoids the need for additional expensive devices like dual-chamber or CRT-D implants.

## Abstract

Fast-conducting atrial fibrillation misinterpreted as ventricular tachycardia is the leading cause for inappropriate shocks in patients with implantable cardiac defibrillators (ICD). These inappropriate shocks are associated with significant morbidity and mortality and cause great discomfort and stress.

We report the case of a patient with ischemic cardiomyopathy, permanent atrial fibrillation, and a single-chamber DF-1 ICD implanted for the primary prevention of sudden cardiac death, who presented for multiple inappropriate internal shocks due to very fast-conducting atrial fibrillation, which was mislabeled as ventricular fibrillation by the ICD. Since the patient was under maximal atrioventricular nodal blocking medical therapy (beta-blockers and digitalis) and we didn`t find any reversible causes for the heart rate acceleration, we opted for rate control with atrioventricular node ablation. To counteract the risk of pacing-induced cardiomyopathy in this patient who would become totally pacemaker-dependent, we successfully performed left bundle branch area pacing. Because the patient`s ICD had a DF-1 connection and the battery had a long life remaining, we connected the physiological pacing lead to the IS-1 sense-pace port of the ICD. The 6-month follow-up showed an improvement in left ventricular function with no more inappropriate shocks.

Left bundle branch area pacing and atrioventricular node ablation in patients with an implantable single-chamber DF-1 defibrillator and fast-conducting permanent atrial fibrillation is a cost-efficient and very effective method to prevent and treat inappropriate shocks, avoiding the use of an additional dual-chamber or CRT-D device.