A fatal device-device interaction between a wearable automated defibrillator and a unipolar ventricular pacemaker.
We report a fatal device-device interaction between a wearable automated defibrillator (WAD; LifeVest - LifeCor, Inc., Pittsburgh, PA, USA) and a unipolar pacemaker that occurred in an 18-year-old patient listed for cardiac transplantation due to his failing Fontan. The patient developed ventricular tachycardia that was initially detected by the WAD. However, large unipolar pacing artifacts and specific WAD arrhythmia detection algorithms caused the WAD to revert to nonrecognition of the arrhythmia, which lead to the patient's death. We identify likely causes of the failure and suggest methods of preventing such occurrences in the future.
LaPage
Martin J
MJ
Washington University School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, St. Louis, Missouri 63110, USA. lapage_m@kids.wustl.edu
Canter
Charles E
CE
Rhee
Edward K
EK
D000293:Adolescent; D047548:Defibrillators / Q000009:adverse effects*; D004868:Equipment Failure; D017809:Fatal Outcome; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000009:adverse effects* / Q000295:instrumentation* / Q000517:prevention & control; D010138:Pacemaker, Artificial / Q000009:adverse effects*; D017180:Tachycardia, Ventricular / Q000209:etiology*