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Uyguanco ER, Berger A, Budzikowski AS, Gunsburg M, Kassotis J. Management of high defibrillation threshold. Expert Rev Cardiovasc Ther 2014; 6:1237-48. [DOI: 10.1586/14779072.6.9.1237] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Gold MR, Hedayati A, Alaeddini J, Payne JP, Bailin S, Sturdivant JL, Pradhan S, Oza AL. Temporal stability of defibrillation thresholds with cardiac resynchronization therapy. Heart Rhythm 2011; 8:1008-13. [DOI: 10.1016/j.hrthm.2011.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 02/02/2011] [Indexed: 11/29/2022]
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Bindra PS, Ruskin JN, Keane D. Usefulness of predischarge defibrillation testing after defibrillator implantation in hospitalized patients. Am J Cardiol 2002; 90:798-9. [PMID: 12356406 DOI: 10.1016/s0002-9149(02)02618-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Paveljit S Bindra
- Cardiac Arrhythmia Service, Cardiac Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
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Gold MR, Higgins S, Klein R, Gilliam FR, Kopelman H, Hessen S, Payne J, Strickberger SA, Breiter D, Hahn S. Efficacy and temporal stability of reduced safety margins for ventricular defibrillation: primary results from the Low Energy Safety Study (LESS). Circulation 2002; 105:2043-8. [PMID: 11980683 DOI: 10.1161/01.cir.0000015508.59749.f5] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Traditionally, a safety margin of at least 10 J between the maximum output of the pulse generator and the energy needed for ventricular defibrillation has been used because lower safety margins were associated with unacceptably high rates of failed defibrillation and sudden cardiac death. The Low Energy Safety Study (LESS) was a prospective, randomized assessment of the safety margin requirements for modern implantable cardioverter-defibrillator (ICD) systems. METHODS AND RESULTS A total of 636 patients undergoing initial ICD implantation with a dual-coil lead and active pulse generator were evaluated. The defibrillation threshold (DFT) and enhanced DFT (DFT+ and DFT++) were measured using a modified step-down protocol. Conversion testing of induced ventricular fibrillation before discharge, at 3 months, and at 12 months was performed, as was randomization to chronic programming at either 2 steps above DFT++ or maximal output. The induced ventricular fibrillation data had conversion success rates of 91.4%, 97.9%, 99.1%, 99.6%, and 99.8% for safety margins of 0, 1, 2, 3, and 4 steps above the DFT++, respectively. A margin of 4 to 6 J was adequate to maintain high conversion success over time (98.9% before discharge versus 99.2% at 12 months; P=NS). Over a mean follow-up of 24+/-13 months, conversion of spontaneously occurring ventricular tachyarrhythmias >200 bpm was identical (97.3%), despite a safety margin difference of 5.2+/-1.1 J for the 2-step group versus 20.8+/-4.2 J for maximal output. CONCLUSIONS With a rigorous implantation algorithm, a safety margin of about 5 J is adequate for safe implantation of modern ICD systems.
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Affiliation(s)
- Michael R Gold
- Medical University of South Carolina, Division of Cardiology, Charleston 29425, USA.
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Rashba EJ, Olsovsky MR, Shorofsky SR, Kirk MM, Peters RW, Gold MR. Temporal decline in defibrillation thresholds with an active pectoral lead system. J Am Coll Cardiol 2001; 38:1150-5. [PMID: 11583896 DOI: 10.1016/s0735-1097(01)01483-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The objective of this study was to characterize temporal changes in defibrillation thresholds (DFTs) after implantation with an active pectoral, dual-coil transvenous lead system. BACKGROUND Ventricular DFTs rise over time when monophasic waveforms are used with non-thoracotomy lead systems. This effect is attenuated when biphasic waveforms are used with transvenous lead systems; however, significant increases in DFT still occur in a minority of patients. The long-term stability of DFTs with contemporary active pectoral lead systems is unknown. METHODS This study was a prospective assessment of temporal changes in DFT using a uniform testing algorithm, shock polarity and dual-coil active pectoral lead system. Thresholds were measured at implantation, before discharge and at long-term follow-up (70 +/- 40 weeks) in 50 patients. RESULTS The DFTs were 9.2 +/- 5.4 J at implantation, 8.3 +/- 5.8 J before discharge and 6.9 +/- 3.6 J at long-term follow-up (p < 0.01 by analysis of variance; p < 0.05 for long-term follow-up vs. at implantation or before discharge). The effect was most marked in a prespecified subgroup with high implant DFTs (> or =15 J). No patient developed an inadequate safety margin (< 9 J) during follow-up. CONCLUSIONS The DFTs declined significantly after implantation with an active pectoral, dual-coil transvenous lead system, and no clinically significant increases in DFT were observed. Therefore, routine defibrillation testing may not be required during the first two years after implantation with this lead system, in the absence of a change in the cardiac substrate or treatment with antiarrhythmic drugs.
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Affiliation(s)
- E J Rashba
- Division of Cardiology, University of Maryland School of Medicine, Baltimore, Maryland 21201-1595, USA.
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Gold MR. ICD therapy in the new millennium. Cardiol Clin 2000; 18:375-89. [PMID: 10849879 DOI: 10.1016/s0733-8651(05)70147-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Remarkable progress has been made in the 15 years since ICD therapy was approved for human use. The early "shock boxes" had almost no diagnostic capabilities and required thoracotomy for epicardial patch implantation with typical duration of hospitalization of about a week. Pulse-generator longevity was less than 2 years. Modern devices provide detailed information about the morphology and rate of electrocardiographic signals before, during, and after arrhythmia therapy. The down-sizing of pulse generators and improvements in lead design and shock waveforms allow the simplicity of defibrillator implantation to approach that of pacemakers, with defibrillation thresholds comparable with those initially observed with epicardial patches. Despite the marked reduction in size and increase in diagnostic capabilities, device longevity is now longer than 6 years. Routine outpatient ICD implantation is presently feasible and will increase in frequency if ongoing primary prevention trials prove beneficial. Further advances in lead technology and arrhythmia discrimination should increase the efficacy and reliability of therapy. Finally, devices have the capabilities to treat multiple problems in addition to life-threatening ventricular arrhythmias including atrial arrhythmias and congestive heart failure.
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Affiliation(s)
- M R Gold
- Department of Medicine, University of Maryland Medical Center, Baltimore, USA.
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Brodsky CM, Chang F, Vlay SC. Multicenter evaluation of implantable cardioverter defibrillator testing after implant: the Post Implant Testing Study (PITS). Pacing Clin Electrophysiol 1999; 22:1769-76. [PMID: 10642130 DOI: 10.1111/j.1540-8159.1999.tb00409.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To reassess the function of the implantable cardioverter defibrillator (ICD) many electrophysiology centers perform a second test after the initial test at implant. A prospective multicenter study evaluated the necessity and yield of routine postimplant defibrillator testing. The results of 843 postimplant defibrillator tests were collected from 31 centers. The 764 routine tests in which ventricular fibrillation was successfully induced were analyzed. Variables examined included patient age, presenting arrhythmia, underlying heart disease, left ventricular ejection fraction, defibrillator age, make and model of ICD, electrode system, defibrillation threshold, polarity, and waveform. The overall failure rate was 3.1% (24/764). Units tested later than 365 days after implant tended to have a higher failure rate than those tested within the first month or the next eleven months (6.5%, 3.0%, 2.3%, respectively, P = 0.374). The failure rate was higher in patients with left ventricular ejection fraction < 40% than those with higher ejection fractions (3.8% vs 2.0%, P = 0.167). These trends did not reach statistical significance. No other baseline characteristic was associated with higher failure rates. Routine testing of ICDs reveals an overall failure rate of 3.1%. While the rate was low, defibrillator failure places the patient at high risk for sudden cardiac death. As any failure in this population is associated with a high risk of sudden cardiac death, routine defibrillator testing may be justified.
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Affiliation(s)
- C M Brodsky
- Department of Medicine, State University of New York at Stony Brook, 11794-8171, USA
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Cooklin M, Tummala RV, Peters RW, Shorofsky SR, Gold MR. Comparison of bipolar and integrated sensing for redetection of ventricular fibrillation. Am Heart J 1999; 138:133-6. [PMID: 10385776 DOI: 10.1016/s0002-8703(99)70258-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Implantable cardioverter-defibrillator function is critically dependent on reliable sensing of intracardiac signals. Lead systems that use integrated sensing, in which the distal shocking coil is part of both the sensing and shocking pathways, may be prone to undersensing of ventricular fibrillation, especially during redetection after a failed first shock. To assess the effect of endocardial lead system on redetection, we compared a dedicated rate-sensing lead and 2 generations of integrated sensing defibrillator leads with a uniform testing algorithm and pulse generator. METHODS The study group consisted of 72 patients after implantable cardioverter-defibrillator implantation. Three transvenous rate-sensing leads were evaluated: a standard pacing lead, incorporating true bipolar sensing without ventricular coils, or an integrated shocking and sensing lead (Endotak C) with either 6-mm (60 series) or 12-mm (70 series) spacing between the sensing tip and shocking coil. Redetection was assessed from a failed first shock just below defibrillation threshold. RESULTS Compared with the dedicated bipolar lead, redetection was prolonged with the 60 series lead (8.3 +/- 3.6 vs 6.6 +/- 2.3 seconds, P =.04). Moreover, prolonged redetection (>8 seconds) was observed in 41% of patients with 60 series leads compared with only 11% with dedicated bipolar leads (P <.01). No significant effects on redetection were noted with an integrated lead with greater spacing between the tip and coil (70 series). CONCLUSIONS Delayed redetection is frequently noted with an integrated lead with close spacing between the tip and coil. Detailed evaluation of detection and redetection of these leads should be performed at the time of pulse generator replacement.
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Affiliation(s)
- M Cooklin
- Division of Cardiology, University of Maryland Medical System, Baltimore 21201-1595, USA
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Olsovsky MR, Shorofsky SR, Gold MR. The effect of shock configuration and delivered energy on defibrillation impedance. Pacing Clin Electrophysiol 1999; 22:165-8. [PMID: 9990623 DOI: 10.1111/j.1540-8159.1999.tb00325.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Shock impedance is an important determinant of defibrillation efficacy. Lead configuration, shock polarity, and delivered energy can affect shock impedance, but these variables have not been studied in active can lead systems. The present study was a prospective evaluation of 25 patients undergoing initial transvenous defibrillator implantation. In all patients, a dual coil lead and pectoral emulator were placed and three lead configurations were tested in random order: Lead (distal to proximal coil), unipolar (distal coil to can), and triad (distal coil to can + proximal coil). Shock energies of 0.1- to 15-J shock were evaluated. Impedance increased a mean of 21% as delivered energy was decreased (P < 0.001), an effect independent of lead configuration. At all delivered energies, impedances in the unipolar configuration were about 40% higher than triad, while the lead configuration was about 20% higher than triad (ps < 0.001). Polarity did not affect impedance. These results indicate that transvenous lead configurations and delivered energy, but not polarity, significantly influence shock impedance. The magnitude of the increase of impedance at low energies is independent of the shocking pathway. This effect has important implications for low energy shocks used to terminate atrial fibrillation or ventricular tachycardia.
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Affiliation(s)
- M R Olsovsky
- Department of Medicine, University of Maryland, Baltimore
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Tokano T, Pelosi F, Flemming M, Horwood L, Souza JJ, Zivin A, Knight BP, Goyal R, Man KC, Morady F, Strickberger SA. Long-term evaluation of the ventricular defibrillation energy requirement. J Cardiovasc Electrophysiol 1998; 9:916-20. [PMID: 9786072 DOI: 10.1111/j.1540-8167.1998.tb00132.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Defibrillation energy requirements in patients with nonthoracotomy defibrillators may increase within several months after implantation. However, the stability of the defibrillation energy requirement beyond 1 year has not been reported. The purpose of this study was to characterize the defibrillation energy requirement during 2 years of clinical follow-up. METHODS AND RESULTS Thirty-one consecutive patients with a biphasic nonthoracotomy defibrillation system underwent defibrillation energy requirement testing using a step-down technique (20, 15, 12, 10, 8, 6, 5, 4, 3, 2, and 1 J) during defibrillator implantation, and then 24 hours, 2 months, 1 year, and 2 years after implantation. The mean defibrillation energy requirement during these evaluations was 10.9+/-5.5 J, 12.3+/-7.3 J, 11.7+/-5.6 J, 10.2+/-4.0 J, and 11.7+/-7.4 J, respectively (P = 0.4). The defibrillation energy requirement was noted to have increased by 10 J or more after 2 years of follow-up in five patients. In one of these patients, the defibrillation energy requirement was no longer associated with an adequate safety margin, necessitating revision of the defibrillation system. There were no identifiable clinical characteristics that distinguished patients who did and did not develop a 10-J or more increase in the defibrillation energy requirement. CONCLUSION The mean defibrillation energy requirement does not change significantly after 2 years of biphasic nonthoracotomy defibrillator system implantation. However, approximately 15% of patients develop a 10-J or greater elevation in the defibrillation energy requirement, and 3% may require a defibrillation system revision. Therefore, a yearly evaluation of the defibrillation energy requirement may be appropriate.
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Affiliation(s)
- T Tokano
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor 48109-0022, USA
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Weiss DN, Shorofsky SR, Peters RW, Gold MR. The effect of delivered energy on defibrillation shock impedance. J Interv Card Electrophysiol 1998; 2:273-7. [PMID: 9870022 DOI: 10.1023/a:1009745222443] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The impedance of internal defibrillator shocks is an important determinant of defibrillation efficacy. To assess the effect of delivered energy on impedance, we studied 97 patients with 4 different lead systems. The lead systems evaluated were two epicardial patches, a hybrid system of a patch and right atrial coil, a dual coil transvenous lead and a transvenous lead with a subcutaneous patch. Impedances were measured for 6 shock energies between 0.1 and 30 J. Shock impedance increased at low energies for all lead systems (p < 0.001), although the rate of increase varied markedly between systems. The energy factor (FE), which is the ratio of impedances for the 0.1 and 10 J shocks, was least for the platinum transvenous lead (1.2 +/- 0.02) and greatest for the titanium hybrid lead (4.2 +/- 0.2). Reversing the polarity of the hybrid lead markedly attenuated the impedance rise. These findings indicate that there is at least a modest rise (20%) of shock impedance at very low delivered energies. The largest increases noted with titanium lead systems are primarily due to polarization. Titanium transvenous leads should be avoided when low energy shocks are utilized such as for the cardioversion of ventricular tachycardia or atrial fibrillation.
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Affiliation(s)
- D N Weiss
- Department of Medicine, University of Maryland Medical System, Baltimore, USA
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Iskos D, Lock K, Lurie KG, Fahy GJ, Petersen-Stejskal S, Benditt DG. Submuscular versus subcutaneous pectoral implantation of cardioverter-defibrillators: effect on high voltage pathway impedance and defibrillation efficacy. J Interv Card Electrophysiol 1998; 2:47-52. [PMID: 9869996 DOI: 10.1023/a:1009764823782] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Implantable cardioverter-defibrillator (ICD) pulse generators are now routinely positioned in a pectoral location, either submuscularly (under the pectoralis muscles) or subcutaneously (over the pectoralis muscles). Furthermore, in current ICDs, the generator shield usually participates in the defibrillation energy pathway ("hot can"). Consequently, the precise generator location could affect defibrillation system efficacy. To assess this issue, we compared high voltage pathway impedance and defibrillation threshold (DFT) in 20 patients undergoing submuscular and 46 patients undergoing subcutaneous pectoral implantation of an Angeion Sentinel ICD and an AngeFlex dual-coil defibrillation lead. Measurements were performed at time of ICD implant, pre-hospital discharge, and 1, 3 and/or 6 months later. Following induction of ventricular fibrillation, 569 biphasic waveform shocks were delivered between the generator shield and either the distal defibrillation coil (RV/can configuration) or both proximal and distal coils (RV/SVC/can configuration). Impedance differences between submuscular and subcutaneous implants were approximately 3-4 Ohms (p value of 0.132 to < 0.001 depending on time of follow-up and lead configuration). A significant increase in impedance over time was noted independent of implant location and lead configuration. The DFT at implant or pre-discharge was assessed in 27 individuals, and was 9.9 +/- 3.8 J in 8 patients in the submuscular group, and 7.4 +/- 3.3 J in 19 patients in the subcutaneous group (p = 0.057). In conclusion, anatomic location of a "hot can" ICD generator (submuscular versus subcutaneous) influences impedance to defibrillation current, but the impact is of small magnitude and does not appear to result in clinically important differences in DFT.
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Affiliation(s)
- D Iskos
- Department of Medicine, University of Minnesota School of Medicine, Minneapolis 55455, USA
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Olsovsky MR, Pelini MA, Shorofsky SR, Gold MR. Temporal stability of defibrillation thresholds with an active pectoral lead system. J Cardiovasc Electrophysiol 1998; 9:240-4. [PMID: 9554728 DOI: 10.1111/j.1540-8167.1998.tb00908.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Monophasic defibrillation thresholds rise over time with a variety of lead systems. These chronic changes are attenuated or eliminated by biphasic waveforms, although the effect appears dependent upon the lead system. With the downsizing of pulse generator size to allow for routine pectoral implantation, active can lead systems have now become standard. However, the temporal stability of such lead systems has not been evaluated previously. METHODS AND RESULTS This study was a prospective assessment of the changes of active pectoral defibrillation thresholds over time. Thresholds were measured at implant, predischarge, and at a mean follow-up of 50 days in 46 patients with a uniform testing protocol and shock polarity. The lead system was a dual-coil Endotak DSP lead with an active pectoral pulse generator. Defibrillation thresholds were 9.9+/-5.5 J at implantation, 8.5+/-6.0 J predischarge, and 7.6+/-5.5 J at follow-up (ANOVA, P = 0.007). Moreover, only two patients developed an increased threshold > 5 J, and no patient had an inadequate safety margin at follow-up. CONCLUSION These results indicate that active pectoral defibrillation thresholds are stable over the first 2 months postimplantation and question the need for routine serial defibrillation threshold testing.
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Affiliation(s)
- M R Olsovsky
- Department of Medicine, University of Maryland School of Medicine, Baltimore 21201, USA
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Gold MR, Kavesh NG, Peters RW, Shorofsky SR. Biphasic waveforms prevent the chronic rise of defibrillation thresholds with a transvenous lead system. J Am Coll Cardiol 1997; 30:233-6. [PMID: 9207647 DOI: 10.1016/s0735-1097(97)00115-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The purpose of this study was to compare chronic changes in monophasic and biphasic defibrillation thresholds using a uniform transvenous lead system and testing protocol. BACKGROUND Defibrillation thresholds increase over time in patients with nonthoracotomy lead systems. This increase can result in an inadequate chronic defibrillation safety margin and could limit the safety of smaller pulse generators, which have a reduced maximal output. However, previous studies of the temporal changes of defibrillation thresholds evaluated complex lead systems or monophasic shock waveforms, neither of which are used with current technology. METHODS This study was a prospective, randomized assessment of the effects of shock waveforms on the changes of transvenous defibrillation thresholds over time. Paired monophasic and biphasic thresholds were measured both at implantation and at follow-up (250 +/- 105 days) in 24 consecutive patients who were not receiving antiarrhythmic drugs. The lead system was a dual-coil Endotak C lead, and reverse polarity shocks (distal coil = anode) were delivered. RESULTS Monophasic defibrillation thresholds increased from (mean +/- SD) 13.7 +/- 6.0 J to 16.8 +/- 6.7 J (p = 0.02), whereas biphasic thresholds were unchanged (10.4 +/- 4.3 J to 10.2 +/- 4.8 J, p = 0.86) in the same patients. Shock impedance chronically increased (47.0 omega to 50.5 omega, p = 0.02) and was unaffected by waveform. CONCLUSIONS These results indicate that biphasic shocks prevent the chronic increase in defibrillation thresholds with a transvenous lead system.
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Affiliation(s)
- M R Gold
- Department of Medicine, Division of Cardiology, University of Maryland School of Medicine, Baltimore, USA.
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