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Gentile FR, Wik L, Isasi I, Baldi E, Aramendi E, Steen-Hansen JE, Fasolino A, Compagnoni S, Contri E, Palo A, Primi R, Bendotti S, Currao A, Quilico F, Vicini Scajola L, Lopiano C, Savastano S. Amplitude spectral area of ventricular fibrillation and defibrillation success at low energy in out-of-hospital cardiac arrest. Intern Emerg Med 2023; 18:2397-2405. [PMID: 37556074 DOI: 10.1007/s11739-023-03386-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/25/2023] [Indexed: 08/10/2023]
Abstract
The optimal energy for defibrillation has not yet been identified and very often the maximum energy is delivered. We sought to assess whether amplitude spectral area (AMSA) of ventricular fibrillation (VF) could predict low energy level defibrillation success in out-of-hospital cardiac arrest (OHCA) patients. This is a multicentre international study based on retrospective analysis of prospectively collected data. We included all OHCAs with at least one manual defibrillation. AMSA values were calculated by analyzing the data collected by the monitors/defibrillators used in the field (Corpuls 3 and Lifepak 12/15) and using a 2-s-pre-shock electrocardiogram interval. We run two different analyses dividing the shocks into three tertiles (T1, T2, T3) based on AMSA values. 629 OHCAs were included and 2095 shocks delivered (energy ranging from 100 to 360 J; median 200 J). Both in the "extremes analysis" and in the "by site analysis", the AMSA values of the effective shocks at low energy were significantly higher than those at high energy (p = 0.01). The likelihood of shock success increased significantly from the lowest to the highest tertile. After correction for age, call to shock time, use of mechanical CPR, presence of bystander CPR, sex and energy level, high AMSA value was directly associated with the probability of shock success [T2 vs T1 OR 3.8 (95% CI 2.5-6) p < 0.001; T3 vs T1 OR 12.7 (95% CI 8.2-19.2), p < 0.001]. AMSA values are associated with the probability of low-energy shock success so that they could guide energy optimization in shockable cardiac arrest patients.
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Affiliation(s)
- Francesca R Gentile
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Lars Wik
- Division of Prehospital Emergency Medicine, Oslo University Hospital, National Service of Competence for Prehospital Acute Medicine (NAKOS), Ullevål Hospital, Oslo, Norway
- Prehospital Clinic, Doctor car, Oslo University Hospital HF, Ullevål Hospital, Oslo, Norway
| | - Iraia Isasi
- BioRes Group, University of the Basque Country, Bilbao, Spain
| | - Enrico Baldi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
| | | | | | - Alessandro Fasolino
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Sara Compagnoni
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Enrico Contri
- AAT 118 Pavia, Agenzia Regionale Urgenza Emergenza at Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandra Palo
- AAT 118 Pavia, Agenzia Regionale Urgenza Emergenza at Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberto Primi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
| | - Sara Bendotti
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
| | - Alessia Currao
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
| | - Federico Quilico
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Luca Vicini Scajola
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Clara Lopiano
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Simone Savastano
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy.
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Trendafilova E, Dimitrova E, Didon JP, Krasteva V. A Randomized Comparison of Delivered Energy in Cardioversion of Atrial Fibrillation: Biphasic Truncated Exponential Versus Pulsed Biphasic Waveforms. Diagnostics (Basel) 2021; 11:diagnostics11061107. [PMID: 34204498 PMCID: PMC8235401 DOI: 10.3390/diagnostics11061107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 11/29/2022] Open
Abstract
A few randomized trials have compared impedance-compensated biphasic defibrillators in clinical use. We aim to compare pulsed biphasic (PB) and biphasic truncated exponential (BTE) waveforms in a non-inferiority cardioversion (CVS) study. This was a prospective monocentric randomized clinical trial. Eligible patients admitted for elective CVS of atrial fibrillation (AF) between February 2019 and March 2020 were alternately randomized to treatment with either a PB defibrillator (DEFIGARD TOUCH7, Schiller Médical, Wissembourg, France) or a BTE high-energy (BTE-HE) defibrillator (LIFEPAK15, Physio-Control Inc., Redmond, WA, USA). Fixed-energy protocol (200–200–200 J) was administered. CVS success was accepted if sinus rhythm was restored at 1 min post-shock. The study design considered non-inferiority testing of the primary outcome: cumulative delivered energy (CDE). Seventy-three out of 78 randomized patients received allocated intervention: 38 BTE-HE (52%), 35 PB (48%). Baseline characteristics were well-balanced between groups (p > 0.05). Both waveforms had similar CDE (mean ± standard deviation, 95% confidence interval): BTE-HE (253.9 ± 120.2 J, 214–293 J) vs. PB (226.0 ± 109.8 J, 188–264 J), p = 0.31. Indeed, effective PB shocks delivered significantly lower energies by mean of 25.6 J (95% CI 24–27.1 J, p < 0.001). Success rates were similar (BTE-HE vs. PB): 1 min first-shock (84.2% vs. 82.9%), 1 min CVS (97.4% vs. 94.3%), 2 h CVS (94.7% vs. 94.3%), 24 h CVS (92.1% vs. 94.3%), p > 0.05. Safety analysis did not find CVS hazards, reporting insignificant changes of myocardial-specific biomarkers, transient and rare ST-segment deviations, and no case of harmful tachyarrhythmias and apnea. Cardioversion of AF with fixed-energy protocol 200–200–200 J was highly efficient and safe for both PB and BTE-HE waveforms. These similar performances were achieved despite differences in the waveforms’ technical design, associated with significantly lower delivered energy for the effective PB shocks. Clinical Trial Registration: Registration number: NCT04032678, trial register: ClinicalTrials.gov.
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Affiliation(s)
- Elina Trendafilova
- Intensive Cardiology Care Unit, Cardiology Clinic, National Cardiology Hospital, 65 Konyovitza Str., 1309 Sofia, Bulgaria; (E.T.); (E.D.)
| | - Elena Dimitrova
- Intensive Cardiology Care Unit, Cardiology Clinic, National Cardiology Hospital, 65 Konyovitza Str., 1309 Sofia, Bulgaria; (E.T.); (E.D.)
| | | | - Vessela Krasteva
- Institute of Biophysics and Biomedical Engineering, Bulgarian Academy of Sciences, Acad. G. Bonchev Str. Bl 105, 1113 Sofia, Bulgaria
- Correspondence:
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A framework of current based defibrillation improves defibrillation efficacy of biphasic truncated exponential waveform in rabbits. Sci Rep 2021; 11:1586. [PMID: 33452293 PMCID: PMC7810866 DOI: 10.1038/s41598-020-80521-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/22/2020] [Indexed: 11/08/2022] Open
Abstract
Defibrillation is accomplished by the passage of sufficient current through the heart to terminate ventricular fibrillation (VF). Although current-based defibrillation has been shown to be superior to energy-based defibrillation with monophasic waveforms, defibrillators with biphasic waveforms still use energy as a therapeutic dosage. In the present study, we propose a novel framework of current-based, biphasic defibrillation grounded in transthoracic impedance (TTI) measurements: adjusting the charging voltage to deliver the desired current based on the energy setting and measured pre-shock TTI; and adjusting the pulse duration to deliver the desired energy based on the output current and intra-shock TTI. The defibrillation efficacy of current-based defibrillation was compared with that of energy-based defibrillation in a simulated high impedance rabbit model of VF. Cardiac arrest was induced by pacing the right ventricle for 60 s in 24 New Zealand rabbits (10 males). A defibrillatory shock was applied with one of the two defibrillators after 90 s of VF. The defibrillation thresholds (DFTs) at different pathway impedances were determined utilizing a 5-step up-and-down protocol. The procedure was repeated after an interval of 5 min. A total of 30 fibrillation events and defibrillation attempts were investigated for each animal. The pulse duration was significantly shorter, and the waveform tilt was much lower for the current-based defibrillator. Compared with energy-based defibrillation, the energy, peak voltage, and peak current DFT were markedly lower when the pathway impedance was > 120 Ω, but there were no differences in DFT values when the pathway impedance was between 80 and 120 Ω for current-based defibrillation. Additionally, peak voltage and the peak current DFT were significantly lower for current-based defibrillation when the pathway impedance was < 80 Ω. In sum, a framework of adjusting the charging voltage and shock duration to deliver constant energy for low impedance and constant current for high impedance via pre-shock and intra-shock impedance measurements, greatly improved the defibrillation efficacy of high impedance by lowering the energy DFT.
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Neumann T, Finke SR, Henninger M, Lemke S, Hoepfner B, Steven D, Maul AC, Schroeder DC, Annecke T. First-time evaluation of ascending compared to rectangular transthoracic defibrillation waveforms in modelled out-of-hospital cardiac arrest. Resusc Plus 2020; 1-2:100006. [PMID: 34223293 PMCID: PMC8244241 DOI: 10.1016/j.resplu.2020.100006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/30/2020] [Accepted: 05/05/2020] [Indexed: 11/04/2022] Open
Abstract
Aim of the study Prognosis in out-of-hospital cardiac arrest (OHCA) depends on cardiopulmonary resuscitation (CPR) duration. Therefore, the optimal biphasic defibrillation waveform shows high conversion rates besides low energy. Matthew Fishler theoretically predicted it to be truncated ascending exponential. We realised a prototypic defibrillator and compared ascending with conventional rectangular waveforms in modelled OHCA and CPR. Methods Approved by the authorities, 57 healthy swine (Landrace × Piétrain) were randomised to ASCDefib (n 26) or CONVDefib (n 26). Five swine served as sham control. We induced ventricular fibrillation (VF) electrically in anaesthetised swine randomised to ASCDefib or CONVDefib and discontinued mechanical ventilation. After 5 min of untreated cardiac arrest, we started CPR with mechanical chest compressions and ventilation. We performed transthoracic biphasic defibrillations after 2, 4, 6 and 8 min CPR targeting 4 J/kg in either group. Depending on the randomised group, the defibrillation protocol was either three ascending followed by one rectangular waveform (ASCDefib) or three rectangular followed by one ascending waveform (CONVDefib). Results Under our model-specific conditions, VF was initially terminated by 13/80 ascending waveforms and 13/79 rectangular waveforms and persistent return of spontaneous circulation was achieved in 8/26 (ASCDefib) vs. 10/26 (CONVDefib) animals. Mean current rather than waveform design was predictive for defibrillation success in a generalised linear model. Conclusion Contrary to theoretical assumptions, transthoracic biphasic defibrillation with ascending waveforms is not superior to rectangular waveforms in modelled OHCA. We advocate defibrillation dosage to be guided by current, that has proven its predictive value again. Institutional protocol number 84–02.04.2017.A176.
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Affiliation(s)
- Tobias Neumann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Research Group "Clinical Research and Teaching", Kerpener Str. 62, 50937 Cologne, Germany
| | - Simon-Richard Finke
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Research Group "Clinical Research and Teaching", Kerpener Str. 62, 50937 Cologne, Germany
| | - Maja Henninger
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Research Group "Clinical Research and Teaching", Kerpener Str. 62, 50937 Cologne, Germany
| | - Sebastian Lemke
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Research Group "Clinical Research and Teaching", Kerpener Str. 62, 50937 Cologne, Germany
| | - Ben Hoepfner
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Research Group "Clinical Research and Teaching", Kerpener Str. 62, 50937 Cologne, Germany
| | - Daniel Steven
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Electrophysiology, Kerpener Str. 62, 50937 Cologne, Germany
| | - Alexandra C Maul
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Center for Experimental Medicine, Kerpener Str. 62, 50937 Cologne, Germany
| | - Daniel C Schroeder
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Research Group "Clinical Research and Teaching", Kerpener Str. 62, 50937 Cologne, Germany
| | - Thorsten Annecke
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Research Group "Clinical Research and Teaching", Kerpener Str. 62, 50937 Cologne, Germany
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Defibrillation for Ventricular Fibrillation: A Shocking Update. J Am Coll Cardiol 2017; 70:1496-1509. [PMID: 28911514 DOI: 10.1016/j.jacc.2017.07.778] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/24/2017] [Indexed: 01/09/2023]
Abstract
Cardiac arrest is defined as the termination of cardiac activity associated with loss of consciousness, of spontaneous breathing, and of circulation. Sudden cardiac arrest and sudden cardiac death (SCD) are terms often used interchangeably. Most patients with out-of-hospital cardiac arrest have shown coronary artery disease or symptoms during the hour before the event. Cardiac arrest is potentially reversible by cardiopulmonary resuscitation, defibrillation, cardioversion, cardiac pacing, or treatments targeted at the underlying disease (e.g., acute coronary occlusion). We restrict SCD hereafter to cardiac arrest due to ventricular fibrillation, including rhythms shockable by an automatic external defibrillator (AED), implantable cardioverter-defibrillator (ICD), or wearable cardioverter-defibrillator (WCD). We summarize the state of the art related to defibrillation in treating SCD, including a brief history of the evolution of defibrillation, technical characteristics of modern AEDs, strategies to improve AED access and increase survival, ancillary treatments, and use of ICDs or WCDs.
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Savastano S, Vanni V, Burkart R, Raimondi M, Canevari F, Molinari S, Baldi E, Danza AI, Caputo ML, Mauri R, Regoli F, Conte G, Benvenuti C, Auricchio A. Comparative performance assessment of commercially available automatic external defibrillators: A simulation and real-life measurement study of hands-off time. Resuscitation 2016; 110:12-17. [PMID: 27780740 DOI: 10.1016/j.resuscitation.2016.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 10/08/2016] [Accepted: 10/11/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Early and good quality cardiopulmonary resuscitation (CPR) and the use of automated external defibrillators (AEDs) improve cardiac arrest patients' survival. However, AED peri- and post-shock/analysis pauses may reduce CPR effectiveness. METHODS The time performance of 12 different commercially available AEDs was tested in a manikin based scenario; then the AEDs recordings from the same tested models following the clinical use both in Pavia and Ticino were analyzed to evaluate the post-shock and post-analysis time. RESULTS None of the AEDs was able to complete the analysis and to charge the capacitors in less than 10s and the mean post-shock pause was 6.7±2.4s. For non-shockable rhythms, the mean analysis time was 10.3±2s and the mean post-analysis time was 6.2±2.2s. We analyzed 154 AED records [104 by Emergency Medical Service (EMS) rescuers; 50 by lay rescuers]. EMS rescuers were faster in resuming CPR than lay rescuers [5.3s (95%CI 5-5.7) vs 8.6s (95%CI 7.3-10). CONCLUSIONS AEDs showed different performances that may reduce CPR quality mostly for those rescuers following AED instructions. Both technological improvements and better lay rescuers training might be needed.
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Affiliation(s)
- Simone Savastano
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | | | | | | | | | - Simone Molinari
- AAT 118 Pavia Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Enrico Baldi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Aurora I Danza
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maria Luce Caputo
- Fondazione Ticino Cuore, Breganzona, Switzerland; Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Romano Mauri
- Anesthesiology and Intensive Care, Clinica Luganese, Lugano, Switzerland
| | - Francois Regoli
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Giulio Conte
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | | | - Angelo Auricchio
- Fondazione Ticino Cuore, Breganzona, Switzerland; Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
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Abstract
Background—
This study sought to validate the ability of amplitude spectrum area (AMSA) to predict defibrillation success and long-term survival in a large population of out-of-hospital cardiac arrests.
Methods and Results—
ECGs recorded by automated external defibrillators from different manufacturers were obtained from patients with cardiac arrests occurring in 8 city areas. A database, including 2447 defibrillations from 1050 patients, was used as the derivation group, and an additional database, including 1381 defibrillations from 567 patients, served as validation. A 2-second ECG window before defibrillation was analyzed, and AMSA was calculated. Univariable and multivariable regression analyses and area under the receiver operating characteristic curve were used for associations between AMSA and study end points: defibrillation success, sustained return of spontaneous circulation, and long-term survival. Among the 2447 defibrillations of the derivation database, 26.2% were successful. AMSA was significantly higher before a successful defibrillation than a failing one (13±5 versus 6.8±3.5 mV-Hz) and was an independent predictor of defibrillation success (odds ratio, 1.33; 95% confidence interval, 1.20–1.37) and sustained return of spontaneous circulation (odds ratio, 1.22; 95% confidence interval, 1.17–1.26). Area under the receiver operating characteristic curve for defibrillation success prediction was 0.86 (95% confidence interval, 0.85–0.88). AMSA was also significantly associated with long-term survival. The following AMSA thresholds were identified: 15.5 mV-Hz for defibrillation success and 6.5 mV-Hz for defibrillation failure. In the validation database, AMSA ≥15.5 mV-Hz had a positive predictive value of 84%, whereas AMSA ≤6.5 mV-Hz had a negative predictive value of 98%.
Conclusions—
In this large derivation-validation study, AMSA was validated as an accurate predictor of defibrillation success. AMSA also appeared as a predictor of long-term survival.
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