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JAMA Cardiology Clinical Challenge
July 17, 2019

A 44-Year-Old Woman With Dilated Cardiomyopathy

Author Affiliations
  • 1Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson
JAMA Cardiol. 2019;4(8):825-826. doi:10.1001/jamacardio.2019.1146

A 44-year-old woman with dilated cardiomyopathy while receiving maximally tolerated guideline-directed medical therapy presented after ventricular fibrillation arrest and subsequently underwent an uneventful implant of a subcutaneous cardioverter defibrillator (S-ICD; EMBLEM, version A219; Boston Scientific) for secondary prevention. The device was programmed with a conditional shock zone of 200 beats per minute and a shock zone of 230 beats per minute. Postprocedure chest radiography results showed appropriate device placement. Postimplant interrogation results showed appropriate device function. The patient was discharged the day after implant. Two weeks later, she presented to the emergency department (ED) after receiving several shocks from the device during the early morning, waking her up from sleeping. There were no reported symptoms associated with shortness of breath, chest pain, or syncope. Physical examination results revealed no signs of decompensated heart failure. Device interrogation results showed shock therapies delivered postimplant on days 3, 5, 6, and 10. The surface electrogram from the events, recorded at a paper speed of 25 millimeters per second and an amplitude of 2.5 mm/mvV) is shown in Figure 1. Repeated chest radiography at the ED showed appropriate device location, lead pin, and an absence of subcutaneous air trapping at the proximal and distal sense electrodes.