Programming optimization is crucial for minimizing inappropriate shocks in patients with Brugada syndrome with a subcutaneous implantable cardioverter-defibrillator

This commentary refers to ‘Subcutaneous implantable cardiac defibrillator in Brugada syndrome: a prospective multicentre study’ by J.-B. Gourraud et al., https://doi.org/10.1093/eurheartj/ehaf743 and the discussion piece ‘Inappropriate shocks in Brugada syndrome: a matter of data capture rather than programming?’, by V. Probst and J.B. Gourraud, https://doi.org/10.1093/eurheartj/ehag008. We read with great interest the article ‘Subcutaneous implantable cardiac defibrillator in Brugada syndrome: a prospective multicentre study’ by Gourraud et al.1 and congratulate the authors for addressing a clinically challenging topic. Their work reports several important findings: an appropriate shock rate of 2.9% per year over a median follow-up of 36 months, with all spontaneous arrhythmias successfully terminated at first shock, and an acceptable device-related complication rate of 5.6% per year—albeit with a relatively high mean rate of inappropriate shocks (5.26% per year). We believe that certain aspects, not fully detailed in the manuscript, may have contributed to this elevated rate of inappropriate interventions. Although the authors state that device programming followed predefined settings—conditional zone at 220 b.p.m., ventricular fibrillation zone at 240 b.p.m., and SMART Pass enabled—the paper lacks detailed information on actual programming within the cohort, particularly among patients with inappropriate shocks. The only explicit data provided is that SMART Pass was active in just 66% of patients. Since the T-wave oversensing was the most frequent cause of inappropriate therapy, it would be relevant to clarify how many such events occurred in patients without SMART Pass or with suboptimal programming.