Defibrillation electrode configurations developed from cardiac mapping that combine biphasic shocks with sequential timing

Extended charge banking model of dual path shocks for implantable cardioverter defibrillators

Background

Single path defibrillation shock methods have been improved through the use of the Charge Banking Model of defibrillation, which predicts the response of the heart to shocks as a simple resistor-capacitor (RC) circuit. While dual path defibrillation configurations have significantly reduced defibrillation thresholds, improvements to dual path defibrillation techniques have been limited to experimental observations without a practical model to aid in improving dual path defibrillation techniques.

Methods

The Charge Banking Model has been extended into a new Extended Charge Banking Model of defibrillation that represents small sections of the heart as separate RC circuits, uses a weighting factor based on published defibrillation shock field gradient measures, and implements a critical mass criteria to predict the relative efficacy of single and dual path defibrillation shocks.

Results

The new model reproduced the results from several published experimental protocols that demonstrated the relative efficacy of dual path defibrillation shocks. The model predicts that time between phases or pulses of dual path defibrillation shock configurations should be minimized to maximize shock efficacy.

Discussion

Through this approach the Extended Charge Banking Model predictions may be used to improve dual path and multi-pulse defibrillation techniques, which have been shown experimentally to lower defibrillation thresholds substantially. The new model may be a useful tool to help in further improving dual path and multiple pulse defibrillation techniques by predicting optimal pulse durations and shock timing parameters.

Programmable arbitrary waveform generator for internal defibrillation research

A programmable arbitrary waveform generator for creation of experimental defibrillation shocks is described. The system is capable of delivering shocks for internal defibrillation via 10 channels at 1000 Volts and 30 Amps. A microcontroller driven system that can receive waveform commands from a laptop was designed to be able to deliver shocks to any combination of electrodes. Waveforms are controllable down to 100 microsecond intervals and each channel is capable of serving as anode or cathode. This system can be used to verify predictions for defibrillation waveform efficacy as predicted by modeling efforts or to test new experimental waveforms tuned to parameters from an individual subject.

Effect of Rapid Biphasic Shock Subpulse Switching on Ventricular Defibrillation Thresholds

INTRODUCTION

The aim of this study was to demonstrate that significant reductions in defibrillation threshold (DFT) can be achieved by rapidly switching defibrillation pulses within an overall biphasic envelope between multiple endovascular electrode sets.

METHODS AND RESULTS

Defibrillation electrodes were implanted in four locations in nine anesthetized swine (41.7 +/- 8.7 kg). Electrodes were implanted into the right ventricular apex (RV), the superior vena cava (SVC), over the left pectoral region as a "hot can" (Can), and within the middle cardiac vein on the posterior left ventricular (LV) surface. The 50% DFT (level for which 50% of delivered shocks successfully defibrillated) for control shocks (7-ms first phase, 0.5-ms interpulse period, 4-ms second phase, RV- --> SVC+ + Can+) were determined to have energy of 20.5 +/- 5.5 J (mean +/- SD). Mean 50% DFTs were also determined for waveforms that split each phase of the same overall biphasic waveform between various electrode sets. Each phase was divided into 2, 3, 4, or 6 subpulses, the defibrillation shock was sequentially delivered to multiple electrode sets, and DFTs were determined (11.9 +/- 4.8 J, 11.7 +/- 2.9 J, 17.9 +/- 8.7 J, 16.7 +/- 6.1 J, respectively). DFT energy was statistically lower than the control (Wilcoxon sign rank test; P < 0.05) when each phase was divided into 2 or 3 subpulses.

CONCLUSION

Rapid shock switching within an overall biphasic waveform between electrode sets including an electrode in the middle cardiac vein potentially can lower DFT energy by 40% or more.

The middle cardiac vein--a novel pathway to reduce the defibrillation threshold

Defibrillation energy requirements of epicardial implantable cardioverter defibrillator systems are generally lower than endovascular systems currently used. The former has the disadvantage of requiring a thoracotomy and so has a greater morbidity and mortality than an endovascular procedure. The middle cardiac vein (MCV) is an epicardial structure that is accessible by a non-thoracotomy approach. This study investigated the merits of ventricular defibrillation from the middle cardiac vein. METHODS AND RESULTS. Defibrillation thresholds (DFT) were measured in 10 anesthetized pigs, weighing 34.5 +/- 44.1 kg (mean 39 kg). An Angeflex electrode (1.7 mm x 50 mm) was introduced via the left external jugular vein to the right ventricular apex. The MCV was identified with standard angiography techniques and a 4080 (Angeion Corp.) defibrillation electrode (1.6 mm x 65 mm) introduced into the vein. An active can was implanted in the left subpectoral region. The defibrillation thresholds (DFT) of the following defibrillation configurations were assessed using a modified four-reversal binary search: RV-->Can, RV + MCV-->Can and MCV-->Can. The DFT's for the three configurations were 15.5 +/- 2.8 J, 10.8 +/- 3.4 J and 13.7 +/- 2.4 J. Analysis of variance showed that the DFT with the RV + MCV combination was significantly less than the RV alone (p < 0.05)

CONCLUSIONS

Defibrillation is possible through the MCV and that incorporating an electrode in the MCV with RV-Can configuration can reduce the DFT by 30%.

Marked reduction in internal atrial defibrillation thresholds with dual-current pathways and sequential shocks in humans

BACKGROUND

This study tested the ability of sequential shocks delivered through dual-current pathways to lower the atrial defibrillation threshold (ADFT) compared with a biphasic shock through a standard single-current pathway.

METHODS AND RESULTS

Electrodes were positioned in the right atrial appendage (RA), left subclavian vein (LSV), proximal coronary sinus (CSos), and distal coronary sinus (DCS) in 14 patients with chronic atrial fibrillation (170+/-185 days). Using a step-up protocol, we compared ADFTs for a single-current pathway (RA-->DCS) that used a single 7.5/2.5-ms biphasic shock from a 150-microF capacitor with those for a dual-current pathway system (RA-->DCS followed by CSos-->LSV) using sequential 7.5/2.5-ms biphasic shocks with capacitor discharge waveforms for 150-microF and 600-microF capacitors. Both dual-current pathway configurations (2.0+/-0.4 J for 150-microF capacitance, 2.4+/-0.5 J for 600-microF capacitance) had a significantly lower ADFT than the single-current pathway (5.1+/-1.8 J). Whereas the dual-current pathway with 150-microF capacitor shocks had a significantly lower energy threshold, there was no statistical difference in terms of leading-edge voltage compared with the dual-current pathway with 600-microF capacitance shocks. There were no ventricular arrhythmias induced with appropriately synchronized shocks.

CONCLUSIONS

For internal atrial defibrillation in humans, sequential biphasic waveforms delivered over dual-current pathways resulted in a markedly reduced (>50% reduction) ADFT compared with a single shock over a single-current pathway.

Internal cardioversion of atrial fibrillation: marked reduction in defibrillation threshold with dual current pathways

BACKGROUND

The ultimate acceptance of a fully automatic atrial defibrillator will depend on the reduction of pain to acceptable levels, requiring a marked decrease in defibrillation thresholds. The purpose of this study was to determine whether atrial defibrillation thresholds can be reduced by sequential shocks delivered through two current pathways.

METHODS AND RESULTS

Sustained atrial fibrillation was induced with rapid atrial pacing in 12 adult sheep. Defibrillation electrodes were positioned in the right atrial appendage (RAap), distal coronary sinus (DCS), proximal coronary sinus (CSos), main/left pulmonary artery junction (PA), and right ventricular apex (RV). Single-capacitor biphasic waveforms (3/1 ms) were delivered through combinations of these electrodes. Probability-of-success curves were determined for single shocks with a single current pathway and sequential shocks with either single- or dual current pathways. The ED50 for delivered energy for the dual current pathway RAap to DCS then CSos to PA was 0.36+/-0.13 J, which was significantly lower than the ED50 of the standard single current pathway RAap to DCS (1.31+/-0.3 J) and was significantly lower than all other configurations tested.

CONCLUSIONS

Internal atrial defibrillation thresholds can be markedly reduced with two sequential biphasic shocks delivered over two current pathways compared with the standard single shock delivered over a single current pathway or with sequential shocks delivered over a single current pathway.

Comparison of single-biphasic versus sequential-biphasic shocks on defibrillation threshold in pigs

Current generation implantable cardioverter defibrillators use monophasic, biphasic, or sequential pulse shocks, most of which truncate after a given time, dumping the remaining charge on the capacitor through an internal resistor. We hypothesized that having an additional current pathway, and delivering the majority of the remaining charge on a single capacitor to the two pathways using additional shock phases, would improve defibrillation efficacy. This hypothesis was tested by comparing DFTs using a simulated single capacitor, single-biphasic shock (two 5-ms pulses separated by 0.2 ms), delivered to coupled pairs of electrodes, to those using a sequential-biphasic shock (four 5-ms pulses separated by 0.2 ms) delivered to separate opposing electrodes, delivered from the same electrodes for both waveforms. In eight open-chest anesthetized pigs, four mesh electrodes (Medtronic TX-7, 6.5 cm2), were sutured on the epicardium of the anterior and posterior surfaces of each ventricle. Shocks were delivered from a 200-microF capacitor bank. Triplicate DFTs were obtained using each waveform in a randomized crossover design. Initial leading edge voltage (mean +/- SEM: 420 +/- 33 V vs 497 +/- 34 V; P < 0.05), initial peak current (4.8 +/- 0.4 A vs 13 +/- 1.1 A; P < 0.001), and delivered energy (16.9 +/- 2.6 J vs 30.4 +/- 5.3 J; P < 0.05) at the DFT were all significantly lower using sequential-biphasic shocks than those using single-biphasic shocks, respectively. We conclude that for direct heart defibrillation, it is worthwhile to combine sequential capability to biphasic shocks and deliver the remaining charge on the capacitor to the two different pathways.

Myocardial vulnerability to T wave shocks: relation to shock strength, shock coupling interval, and dispersion of ventricular repolarization

INTRODUCTION

Induction of ventricular fibrillation (VF) by T wave shocks is of clinical interest due to the correlation between the upper limit of vulnerability (ULV) and the defibrillation threshold (DFT). However, the ULV has not yet been defined precisely in reference to the entire "area of vulnerability" (AOV), which is defined bifunctionally by both shock strengths and shock coupling intervals, nor has it been related to the dispersion of ventricular repolarization, considered to be an important determinant of vulnerability.

METHODS AND RESULTS

In 11 isolated perfused rabbit hearts immersed in a tissue bath containing a 3-lead ECG recording system and two opposite plate electrodes for field shock administration, 7 monophasic action potentials (MAPs) were recorded simultaneously from different epicardial and endocardial regions of the right and left ventricles. An average of 90 +/- 25 monophasic waveform shocks of varying shock strengths and coupling intervals were delivered to each heart to determine the horizontal and vertical boundaries of the AOV. The AOV approximated a rhomboid with homogenous VF inducibility. The ULV and lower limit of vulnerability (LLV) represented discrete corners of the AOV with significant changes in VF inducibility if either shock coupling intervals or shock strength were changed by only 10 msec or 10 V, respectively (P < 0.001). The ULV occurred at 7 +/- 10 msec shorter coupling intervals than the LLV (P < 0.05), and VF-inducing shock strengths at the left corner of the AOV were 50 +/- 67 V higher as compared to the right corner (P < 0.01). The maximal range of VF-inducing coupling intervals coincided (within < 2 msec) with the dispersion of MAPs at 70% repolarization, and the ULV coupling interval coincided (within < 4 msec) with the longest repolarization at 50%.

CONCLUSIONS

(1) VF vulnerability to monophasic T wave shocks is defined by an AOV that has the shape of a leftward tilted rhomboid. (2) Both the ULV and LLV are sharply defined upper and lower corners of the AOV rhomboid. (3) The width of the AOV corresponds to the dispersion of ventricular repolarization at the 70% level. (4) Considering the dispersion of ventricular repolarization may yield more precise ULV determinations and a better understanding of the correlation between the ULV and DFT.

Impact of pulse characteristics on atrial defibrillation energy requirements

In summary, many issues pertaining to pulse characteristics and atrial defibrillation remain unsolved. Perhaps the most burning questions are whether a further reduction in atrial defibrillation energy requirements can be achieved by the combination of biphasic waveforms with dual pathway sequential shocks to produce a more homogenous distribution of charge, whether right and left atrial polarity of the first phase of asymmetrical biphasic shocks can reduce energy requirements in individual patients and whether the delivery of very long biphasic shocks (possibly > 20 msec) can reduce the discomfort of shorter shocks by decreasing the peak current density. Only then will the wide-spread acceptance of the implantable atrial defibrillator become closer to reality.

Effective defibrillation in pigs using interleaved and common phase sequential biphasic shocks

Previous studies have shown that low internal defibrillation thresholds (DFTs) can be attained by using two pairs of electrodes and combining biphasic shocks with sequential timing. The purpose of this two-part study was to test the defibrillation efficacy of two new shock sequences, an interleaved biphasic, and a common phase sequential biphasic, that utilized two pairs of electrodes and were developed from the concept of sequential biphasic shocks. In the first part, defibrillation catheters were placed in the right ventricle and the superior vena cava of six anesthetized pigs. A small patch electrode was placed on the LV apex through a subxiphoid incision and a cutaneous patch was placed on the left thorax. The mean DFT energies for the interleaved biphasic (5.2 +/- 0.4 J) and the common phase sequential biphasic waveforms (5.4 +/- 0.4 J) were substantially less (P < 0.0001) than those for either the sequential monophasic (10.6 +/- 1.0 J) or single biphasic waveforms (9.0 +/- 1.0 J). In the second study, which used nine anesthetized pigs, the importance of phase reversal was demonstrated by the finding that the DFT energy of a common phase sequential biphasic shock (6.2 +/- 0.4 J) was much less than a common phase sequential monophasic shock (17.9 +/- 1.3 J, P < 0.0001); furthermore, the average DFT for four common phase sequential biphasic configurations (5.7 +/- 0.2 J) was much less than for a configuration that was similar except that current flow was not reversed in one phase so that no biphasic effect was present (19.7 +/- 1.2 J). The efficacy of common phase sequential biphasics was comparable to that of sequential biphasics. The effectiveness of sequential biphasics, interleaved biphasics, and common phase sequential biphasics is possibly due to two mechanisms: (A) an increase in the potential gradient during a later phase in regions that were low during the first phase, and (B) the exposure of most of the myocardium to a biphasic shock that reduces the minimum extracellular potential gradient needed to defibrillate.