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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The broadening of indications for treatment with an implantable cardioverter-defibrillator &#40;ICD&#41; to include patients at risk &#40;primary prevention&#41; has further increased the importance of limiting the incidence of device-related adverse events in order to preserve patients&#8217; quality of life&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Inappropriate delivery of ICD therapies triggered by supraventricular tachyarrhythmias &#40;SVT&#41; is a common problem&#44; occurring in 16&#8211;22&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Studies have shown that detection enhancements in dual-chamber ICDs are able to reduce inappropriate therapies due to SVT and associated adverse clinical outcomes&#46; However&#44; other studies have failed to find an improvement in rhythm classification or a reduction of shocks with the use of dual-chamber algorithms&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Recently&#44; more advanced detection algorithms have been proposed in order to reduce the number of inappropriate ICD therapies&#46; The PARAD and PARAD&#43; algorithms correctly identify ventricular tachycardia &#40;VT&#41; in more than 99&#37; of cases&#44; and slow VT &#40;150 bpm&#41; in 94&#37;&#46; Their specificity for SVT detection is particularly high &#40;92&#37;&#41;&#44; with 86&#37; of episodes of atrial fibrillation &#40;AF&#41; or atrial flutter being correctly classified&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> The PARAD&#43; algorithm&#44; which inhibits VT therapy when a long ventricular cycle is detected&#44; improves the performance of the PARAD algorithm in AF&#44; by increasing specificity for AF in the slow zone&#44; without decreasing sensitivity for VT&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The authors report the case of a patient with a dual-chamber ICD with the PARAD&#43; algorithm who presented sustained VT but no therapy was delivered&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Case report</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors report a case of a 68-year-old Caucasian male with a history of paroxysmal AF&#44; stroke and ischemic cardiomyopathy with severe left ventricular systolic dysfunction&#44; who had a dual-chamber ICD &#40;Paradym DR&#44; Sorin&#41; implanted after an episode of monomorphic VT in 2010&#46; In 2011 AF became permanent&#46; No therapies were delivered by the ICD&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">On December 31&#44; 2012 the patient suddenly complained of rapid and persistent palpitations&#44; dyspnea and dizziness&#46; The ECG revealed VT with a rate of 170 bpm &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; His blood pressure was 70&#47;45 mmHg&#46; An external shock was immediately delivered&#44; which successfully terminated the VT approximately two hours after the onset of palpitations&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Interrogation of the ICD revealed no abnormal sensing or pacing parameters&#46; Ventricular autosensing histograms revealed that all detected ventricular waves were well above the sensitivity threshold&#46; The ICD was programmed with four detection zones and corresponding therapies&#58; slow VT zone&#44; programmed at 462 ms for 100 consecutive cycles&#44; with no therapy &#40;monitoring zone&#41;&#59; VT zone&#44; programmed at 400 ms for 50 consecutive cycles&#44; with anti-tachycardia pacing &#40;ATP&#41; and shock&#59; a fast VT zone at 300 ms for 14 consecutive cycles&#44; with ATP and shock&#59; and finally a ventricular fibrillation &#40;VF&#41; zone at 250 ms&#46; The PARAD&#43; detection algorithm was activated&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the arrhythmia history stored in the device&#44; after the last follow-up on September 14&#44; 2012 there were 15 episodes&#44; but none was dated December 31&#44; 2012&#44; and none was labeled as VT&#46; The most recent episode was dated December 11&#44; 2012 and was labeled as SVT&#47;ST&#46; However&#44; the last 24-hour heart rate curve was consistent with the reported VT &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">On January 2nd 2013 VF was induced and correctly detected and terminated with a 20-J shock&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The patient was discharged after a change to the Stability&#43;&#47;Acceleration algorithm and a reduction in the VT zone to 30 cycles&#46; At three-month follow-up&#44; the patient remained asymptomatic and no events were recorded&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Why did the ICD not record an event or deliver a therapy&#63; Was the device functioning correctly&#63;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In order to answer these questions&#44; it is essential to understand the PARAD&#43; algorithm and how it determines the functioning of the ICD&#46; When a majority of RR intervals are detected within the VT zone&#44; both the PARAD and PARAD&#43; algorithms first examine ventricular stability&#46; If the rhythm is unstable&#44; AF is diagnosed and therapy is withheld&#46; If the rhythm is stable&#44; atrioventricular &#40;AV&#41; conduction is then analyzed&#46; If the rhythm is stable and A and V are dissociated&#44; VT is diagnosed by PARAD and therapy is delivered&#46; However&#44; if PARAD&#43; is activated&#44; the occurrence of long ventricular cycles is examined&#46; Each ventricular cycle is compared beat-to-beat to the mean tachycardia cycle length&#44; the average of the last four intervals shorter than or equal to the programmed tachycardia detection interval&#46; VT therapy is inhibited for 24 consecutive cycles after each ventricular interval longer than this average plus a programmable increment&#44; set at a nominal value of 172 ms&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The maximum storage of the Sorin Paradym DR ICD is 15 episodes&#46; At the time the ICD was interrogated on January 1&#44; 2013&#44; the device memory was full&#46; In such circumstances&#44; according to priorities for storage of episodes&#44; the device continues to record sustained episodes only&#46; So&#44; from the device&#39;s point of view &#40;according to the discrimination algorithms and the programmed settings&#41; no sustained ventricular arrhythmia occurred after December 11&#44; 2012&#46; This means that during the episode none of the programmed numbers of consecutive cycles was reached&#44; either for the slow VT zone &#40;100 consecutive cycles&#41;&#44; or for the VT zone &#40;50 consecutive cycles&#41;&#44; or for the fast VT&#47;VF zone &#40;14 consecutive cycles&#41;&#44; probably due to changes in the rhythm majorities&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">When the last stored episodes were analyzed&#44; episodes correctly classified as SVT were noted&#44; corresponding to AF episodes with rapid ventricular rate&#46; However&#44; in the last episode stored the intracardiac electrograms &#40;IEGMs&#41; and the tachograph &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41; revealed a period suggestive of VT &#40;based on rhythm stability and on the ventricular IEGM&#41;&#46; During this period&#44; the device successively alternated the rhythm classification between SVT&#47;ST and ventricular tachycardia with long cycle length &#40;VTLC&#41;&#44; based on AV association&#46; As seen above&#44; once the rhythm is classified as stable &#40;meaning that in nominal settings at least 75&#37; of the last eight RR intervals are within a 65-ms stability window&#41;&#44; AV conduction is analyzed&#46; The rhythm is considered associated when at least 75&#37; of the total PR intervals from the eight last RR intervals fall in the 65-ms stability window&#46; In the episode described&#44; the device successively alternated the AV association from stable and not associated &#40;VTLC diagnosis&#41; to N&#58;1 association &#40;SVT diagnosis&#41; and 1&#58;1 association &#40;classified as SVT or VT by PARAD&#43;&#44; depending on additional acceleration criteria&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Thus&#44; in the case reported&#44; the most probable hypothesis is that due to simultaneous occurrence of VT and AF rhythms&#44; the ongoing rhythm classification &#40;based on AV association&#41; alternated between SVT&#47;ST majority and VT&#47;VTLC majority&#44; and so the programmed VT cycle number was never reached and therapy was consecutively delayed&#46; Also&#44; since there were already 15 episodes stored in the device&#39;s arrhythmia history&#44; no event was recorded&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Since the patient had permanent AF it was decided to change the algorithm criterion to &#8220;Stability&#43;&#47;Acceleration&#8221;&#46; This criterion is based on ventricular intervals only&#59; the algorithm does not take PR association into account&#44; and therefore there is no risk of not treating a VT due to changing PR association&#46; However&#44; it does not take into account the origin of the acceleration&#44; so there is a risk of misclassifying an SVT with 1&#58;1 conduction in the ventricle as VT&#44; which could lead to the delivery of inappropriate therapies&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">We cannot say with certainty what would happen if the VT zone were programmed for less than 50 consecutive cycles&#44; but the risk of not delivering appropriate therapy would certainly be lower&#46; However&#44; recent studies have reported fewer inappropriate shocks using a duration of 30 cycles for VT&#44; with no increase in the incidence of syncope or death&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> and in the MADIT-RIT trial &#40;in which AF patients were excluded&#41;&#44; a 60-second delay &#40;VT zone 170&#8211;199 bpm&#41; before initiation of therapy had a overall result superior to conventional programming&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Due to the reported event we decreased the number of consecutive cycles to 30&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">To our knowledge this is the first case report worldwide of failure to deliver a shock in a dual-chamber ICD due to the PARAD&#43; algorithm&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Physicians&#8217; knowledge of the algorithms of the different models and manufacturers is necessarily imperfect&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In patients with permanent or long-term persistent AF with a dual-chamber ICD using the PARAD&#43; algorithm&#44; discrimination should be based only on the ventricular channel&#44; in order to avoid problems with detection and subsequent failure to deliver therapy&#46; In patients with paroxysmal or persistent recurrent AF the risk of not delivering VT therapy must be weighed against the risk of delivering inappropriate therapy&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Protection of human and animal subjects</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Confidentiality of data</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Right to privacy and informed consent</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Authorship</span><p id="par0125" class="elsevierStylePara elsevierViewall">RC and IJ were major contributors in writing the manuscript&#46; All authors read and approved the final manuscript&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interests to declare&#46;</p></span></span>"
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            0 => "Dual-chamber"
            1 => "Implantable cardioverter-defibrillator"
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            3 => "PARAD&#43; algorithm"
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            0 => "Dupla-camara"
            1 => "Cardioversor-desfibrilhador implant&#225;vel"
            2 => "Fibrilha&#231;&#227;o auricular"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Inappropriate implantable cardioverter-defibrillator &#40;ICD&#41; therapies due to supraventricular tachyarrhythmia &#40;SVT&#41; are a common problem&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The authors report this case to warn of a possible detection problem and subsequent failure of deliver appropriate therapy in patients with atrial fibrillation &#40;AF&#41; and a dual-chamber ICD using the PARAD&#43; algorithm&#46; To our knowledge this is the first reported case of failure to deliver a shock in a dual-chamber ICD due to the PARAD&#43; algorithm&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The authors present a case of a 68-year-old Caucasian man with permanent AF and a dual-chamber Sorin Paradym ICD with the PARAD&#43; algorithm&#44; who presented an episode of sustained ventricular tachycardia &#40;VT&#41;&#46; The ICD did not store the event and did not delivery a therapy&#44; although the heart rate curve was consistent with an episode of VT&#46; No evidence of system dysfunction was found&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Due to simultaneous occurrence of VT and AF rhythms and alternation in rhythm classification by the PARAD&#43; algorithm the number of cycles needed to diagnose VT was not achieved and no therapy was delivered&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In patients with permanent or long-term persistent AF with a dual-chamber ICD using the PARAD&#43; algorithm&#44; discrimination should be based only on the ventricular channel&#46; In patients with paroxysmal or persistent recurrent AF the risk of not delivering VT therapy must be weighed against the risk of inappropriate therapy&#46;</p></span>"
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        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introdu&#231;&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">as terapias inapropriadas de um cardioversor-desfibrilhador implant&#225;vel &#40;CDI&#41; devido a taquiarritmias supraventriculares &#40;TSV&#41; s&#227;o ainda um problema comum&#46;</p><p id="spar1010" class="elsevierStyleSimplePara elsevierViewall">Os autores relatam este caso de modo a alertar um poss&#237;vel problema de dete&#231;&#227;o e subsequente falha na entrega de terapia apropriada em pacientes com CDI de dupla-c&#226;mara e fibrilha&#231;&#227;o auricular &#40;FA&#41; com o algoritmo PARAD&#43;&#46; Ao nosso conhecimento&#44; trata-se do primeiro caso reportado de falha na entrega de choque num CDI de dupla-c&#226;mara&#44; devido ao algoritmo PARAD&#43;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Caso cl&#237;nico</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">os autores relatam um caso de um homem de 68 anos de idade&#44; caucasiano&#44; com FA permanente&#44; portador de um CDI de dupla-c&#226;mara Paradym Sorin com o algoritmo PARAD&#43;&#44; que apresentou um epis&#243;dio de taquicardia ventricular &#40;TV&#41; mantida&#46; O CDI n&#227;o armazenou o epis&#243;dio e n&#227;o administrou qualquer terapia&#44; apesar de a curva da frequ&#234;ncia card&#237;aca ser consistente com um epis&#243;dio de TV&#46; N&#227;o foi encontrada nenhuma evid&#234;ncia de disfun&#231;&#227;o do sistema&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclus&#227;o</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Devido &#224; ocorr&#234;ncia simult&#226;nea de ritmos de TV e FA e &#224; altern&#226;ncia na classifica&#231;&#227;o de ritmo pelo algoritmo PARAD&#43;&#44; n&#227;o foi alcan&#231;ada a persist&#234;ncia programada para a dete&#231;&#227;o de TV e a terapia n&#227;o foi administrada&#46;</p><p id="spar2010" class="elsevierStyleSimplePara elsevierViewall">Em pacientes com FA persistente de longa dura&#231;&#227;o&#47;permanente com CDI de dupla c&#226;mara com algoritmo PARAD&#43;&#44; a discrimina&#231;&#227;o deve ser baseada apenas no canal ventricular&#46; Em pacientes com FA parox&#237;stica&#47;persistente recorrente o risco de n&#227;o entrega de terapia para a TV deve ser balan&#231;ado com o risco de terapia inapropriada&#46;</p></span>"
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "F&#46; Hintringer"
                            1 => "M&#46; Deibl"
                            2 => "T&#46; Berger"
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                    0 => array:2 [
                      "doi" => "10.1111/j.1540-8159.2004.00568.x"
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                        "paginaInicial" => "976"
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                      "titulo" => "Dual-chamber implantable cardioverter-defibrillator selection is associated with increased complication rates and mortality among patients enrolled in the NCDR implantable cardioverter-defibrillator registry"
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                            0 => "T&#46;A&#46; Dewland"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                          "etal" => true
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                            0 => "F&#46; Anselme"
                            1 => "R&#46; Mletzko"
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