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Original Articles

A Randomized Study to Compare Ramp Versus Burst Antitachycardia Pacing Therapies to Treat Fast Ventricular Tachyarrhythmias in Patients With Implantable Cardioverter Defibrillators

The PITAGORA ICD Trial

Michele M. Gulizia, MD; Leandro Piraino, MD; Marino Scherillo, MD; Calogero Puntrello, MD; Calogero Vasco, MD; Maria Carmela Scianaro, MD; Franco Mascia, MD; Orazio Pensabene, MD; Salvatore Giglia, MD; Giacomo Chiarandà, MD; Ignazio Vaccaro, MD; Salvatore Mangiameli, MD; Dario Corrao, MS; Elisabetta Santi, MS; Andrea Grammatico, PhD on behalf of PITAGORA ICD Study Investigators

From the Garibaldi-Nesima Hospital (M.M.G.), Catania; Civico e Benfratelli Hospital (L.P.), Palermo; Rummo Hospital (M.S.), Benevento; S. Antonio Abate Hospital (C.P.), Trapani; Umberto I Hospital (C.V.), Enna; Perrino Hospital (M.C.S.), Brindisi; S. Sebastiano Hospital (F.M.), Caserta; Villa Sofia Hospital (O.P.), Palermo; S. Elia Hospital (S.G.), Caltanisetta; Moscatello Hospital (G.C.), Augusta; S. Giovanni di Dio Hospital (I.V.), Agrigento; Garibaldi Hospital (S.M.), Catania; and Medtronic Italy Clinical Department (D.C., E.S., A.G.), Rome, Italy.

Correspondence to Michele M. Gulizia, MD, Cardiology Department, Garibaldi-Nesima Hospital, Catania, Italy. E-mail michele.gulizia{at}tin.it

Received July 3, 2008; accepted January 7, 2009.

Background— In patients with implantable cardioverter-defibrillators (ICDs), antitachycardia pacing (ATP) is highly effective in terminating fast ventricular tachycardias (FVTs) and lowers the use of high-energy shocks, without increasing the risk of arrhythmia acceleration or syncope.

Methods and Results— The aim of the PITAGORA ICD trial was to randomly compare 2 ATP strategies (88% coupling interval burst versus 91% coupling interval ramp, both 8 pulses) in terms of ATP efficacy, arrhythmia acceleration, and syncope. Two hundred six ICD patients (83% male, 67±11 years) were enrolled. FVT episodes with cycle lengths between 240 and 320 ms were treated by 1 ATP sequence and, in the event of failure, by shocks. Over a median follow-up of 36 months, 829 spontaneous ventricular tachyarrhythmia episodes were detected in 79 patients. Episode review identified 595 episodes as true ventricular arrhythmias in 72 patients; devices classified 111 (18.7%) episodes as VF, 216 (36.3%) as FVT, and 268 (45.0%) as VT. Fifty-six patients had 214 treated FVT episodes—2 FVTs self-terminated before ATP release; 44 (79%) of these had at least 1 effective ATP intervention, and 34 (61%) were spared ICD shocks. Burst terminated 100 of 133 (75.2%) FVT episodes, whereas ramp terminated 44 of 81 (54.3%; P=0.015). Acceleration occurred in 9 of 214 (4.2%) FVT episodes treated: 6 episodes in 3 ramp patients and 3 episodes in 3 burst patients. Two patients—1 in each group—suffered 1 syncopal event associated to a nonterminated FVT episode.

Conclusions— Burst is significantly more efficacious than ramp in terminating FVT episodes. As the first therapy for FVT episodes, ATP carries a low risk of acceleration or syncopal events.

Key Words: reentry • shock • burst • tachycardia • implantable cardioverter defibrillator

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CLINICAL PERSPECTIVE

Related Article

A Randomized Study to Compare Ramp Versus Burst Antitachycardia Pacing Therapies to Treat Fast Ventricular Tachyarrhythmias in Patients With Implantable Cardioverter Defibrillators: The PITAGORA ICD Trial

Michele M. Gulizia, Leandro Piraino, Marino Scherillo, Calogero Puntrello, Calogero Vasco, Maria Carmela Scianaro, Franco Mascia, Orazio Pensabene, Salvatore Giglia, Giacomo Chiarandà, Ignazio Vaccaro, Salvatore Mangiameli, Dario Corrao, Elisabetta Santi, Andrea Grammatico on behalf of PITAGORA ICD Study Investigators
Circ Arrhythm Electrophysiol 2009 2: 146-153. [Abstract] [Full Text] [PDF]