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Kawada S, Chakraborty P, Albertini L, Bhaskaran A, Oechslin EN, Sliversides C, Wald RM, Roche SL, Harris L, Swan L, Alonso-Gonzalez R, Thorne S, Downar E, Nanthakumar K, Mondésert B, Khairy P, Nair K. Safety and Long-term Outcomes of Defibrillator Therapy in Patients With Right-Sided Implantable Cardiac Devices in Adults With Congenital Heart Disease. Can J Cardiol 2020; 37:407-416. [PMID: 32522524 DOI: 10.1016/j.cjca.2020.05.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/22/2020] [Accepted: 05/30/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Implantable cardioverter-defibrillators (ICDs) have been proven to prevent sudden cardiac death in adult congenital heart disease (ACHD) patients. Although the left side is chosen by default, implantation from the right side is often required. However, little is known about the efficacy and safety of right-sided ICDs in ACHD patients. METHODS In this study we reviewed a total of 191 ACHD patients undergoing ICD/cardioverter resynchronisation therapy-defibrillator (CRT-D) implantation at our hospital between 2001 and 2019 (134 men and 57 women; age [mean ± standard deviation], 41.5 ± 14.8 years). RESULTS Twenty-seven patients (14.1%) had right-sided devices. The most common causes of right-sided implantation were persistent left superior vena cava and vein occlusion (37.0%). Although procedure time (202.8 ± 60.5 minutes vs 143.8 ± 69.1 minutes, P = 0.008) was longer and the procedural success was lower (92.6% vs 99.4%, P = 0.008) for right-sided devices, no difference in R-wave and pacing threshold were noted. Among the 47 patients (24.6%) who underwent defibrillation threshold testing (DFT), no difference in DFT was observed (25.2 ± 5.3 J vs 23.8 ± 4.1 J, P = 0.460). During the median follow-up of 42.4 months, appropriate ICD therapy was observed in 5 (18.5%) and 30 (18.3%) patients for right- and left-sided ICDs/CRTDs, respectively (P = 0.978). No significant difference was seen in complications between them. CONCLUSIONS Implantation of an ICD on the right side is technically challenging, but it is feasible as an alternative approach for ACHD patients with contraindications to left-sided device implantation.
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Affiliation(s)
- Satoshi Kawada
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada
| | - Praloy Chakraborty
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada
| | - Lisa Albertini
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada
| | - Abhishek Bhaskaran
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada
| | - Erwin N Oechslin
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada
| | - Candice Sliversides
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada
| | - Rachel M Wald
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada
| | - S Lucy Roche
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada
| | - Louise Harris
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada
| | - Lorna Swan
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada
| | - Rafael Alonso-Gonzalez
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada
| | - Sara Thorne
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada
| | - Eugene Downar
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada
| | - Kumaraswamy Nanthakumar
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada
| | - Blandine Mondésert
- Department of Cardiology, Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
| | - Paul Khairy
- Department of Cardiology, Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
| | - Krishnakumar Nair
- University Health Network Toronto, Peter Munk Cardiac Centre and University of Toronto, Toronto, Ontario, Canada.
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2
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Neuzner J, Hohnloser SH, Kutyifa V, Glikson M, Dietze T, Mabo P, Vinolas X, Kautzner J, O'Hara G, Lawo T, Brachmann J, VanErven L, Gadler F, Appl U, Wang J, Connolly SJ, Healey JS. Effectiveness of single- vs dual-coil implantable defibrillator leads: An observational analysis from the SIMPLE study. J Cardiovasc Electrophysiol 2019; 30:1078-1085. [PMID: 30945798 DOI: 10.1111/jce.13943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/08/2019] [Accepted: 04/01/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Dual-coil leads (DC-leads) were the standard of choice since the first nonthoracotomy implantable cardioverter/defibrillator (ICD). We used contemporary data to determine if DC-leads offer any advantage over single-coil leads (SC-leads), in terms of defibrillation efficacy, safety, clinical outcome, and complication rates. METHODS AND RESULTS In the Shockless IMPLant Evaluation study, 2500 patients received a first implanted ICD and were randomized to implantation with or without defibrillation testing. Two thousand and four hundred seventy-five patients received SC-coil or DC-coil leads (SC-leads in 1025/2475 patients; 41.4%). In patients who underwent defibrillation testing (n = 1204), patients with both lead types were equally likely to achieve an adequate defibrillation safety margin (88.8% vs 91.2%; P = 0.16). There was no overall effect of lead type on the primary study endpoint of "failed appropriate shock or arrhythmic death" (adjusted HR 1.18; 95% CI, 0.86-1.62; P = 0.300), and on all-cause mortality (SC-leads: 5.34%/year; DC-leads: 5.48%/year; adjusted HR 1.16; 95% CI, 0.94-1.43; P = 0.168). However, among patients without prior heart failure (HF), and SC-leads had a significantly higher risk of failed appropriate shock or arrhythmic death (adjusted HR 7.02; 95% CI, 2.41-20.5). There were no differences in complication rates. CONCLUSION In this nonrandomized evaluation, there was no overall difference in defibrillation efficacy, safety, outcome, and complication rates between SC-leads and DC-leads. However, DC-leads were associated with a reduction in the composite of failed appropriate shock or arrhythmic death in the subgroup of non-HF patients. Considering riskier future lead extraction with DC-leads, SC-leads appears to be preferable in the majority of patients.
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Affiliation(s)
| | - Stefan H Hohnloser
- Department of Cardiology, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Valentina Kutyifa
- Semmelweis University, Budapest, Hungary.,University of Rochester Medical Center, Rochester, New York
| | - Michael Glikson
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | | | | | | | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Gilles O'Hara
- Institute Universitaire de Cardiologie et de Pneumologie de, Quebec, QC, Canada
| | - Thomas Lawo
- Elisabeth Krankenhaus, Recklinghausen, Germany
| | | | | | | | - Ursula Appl
- Boston Scientific, Minneapolis, Minnesota.,Boston Scientific, Brussels, Belgium
| | - Jia Wang
- Population Health Research Institute, Hamilton, Canada
| | | | - Jeff S Healey
- Population Health Research Institute, Hamilton, Canada.,Mc Master University, Hamilton, Canada
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Single and dual coil shock efficacy and predictors of shock failure in patients with modern implantable cardioverter defibrillators—a single-center paired randomized study. J Interv Card Electrophysiol 2019; 54:65-72. [DOI: 10.1007/s10840-018-0443-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 09/06/2018] [Indexed: 10/28/2022]
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4
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Almehmadi F, Manlucu J. Should Single-Coil Implantable Cardioverter Defibrillator Leads Be Used in all Patients? Card Electrophysiol Clin 2018; 10:59-66. [PMID: 29428142 DOI: 10.1016/j.ccep.2017.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The historical preference for dual-coil implantable cardioverter defibrillator leads stems from high defibrillation thresholds associated with old device platforms. The high safety margins generated by contemporary devices have rendered the modest difference in defibrillation efficacy between single- and dual-coil leads clinically insignificant. Cohort data demonstrating worse lead extraction outcomes and higher all-cause mortality have brought the incremental utility of an superior vena cava coil into question. This article summarizes the current literature and re-evaluates the utility of dual-coil leads in the context of modern device technology.
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Affiliation(s)
- Fahad Almehmadi
- Division of Cardiology, Department of Medicine, Western University, PO Box 5339, 339 Windermere Road, Room B6-127, London, Ontario N6A 5A5, Canada
| | - Jaimie Manlucu
- Division of Cardiology, Department of Medicine, Western University, PO Box 5339, 339 Windermere Road, Room B6-127, London, Ontario N6A 5A5, Canada.
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Bänsch D, Bonnemeier H, Brandt J, Bode F, Svendsen JH, Ritter O, Aring J, Gutleben KJ, Schneider R, Felk A, Hauser T, Buchholz A, Hindricks G, Wegscheider K. Shock efficacy of single and dual coil electrodes—new insights from the NORDIC ICD Trial. Europace 2017; 20:971-978. [DOI: 10.1093/europace/eux075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 02/28/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Dietmar Bänsch
- Heart Center Rostock, Department of Internal Medicine I, Divisions of Cardiology, University Hospital Rostock, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany
| | - Hendrik Bonnemeier
- Department of Internal Medicine III Cardiology and Angiology, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straβe 3, 24105 Kiel, Germany
| | - Johan Brandt
- Arrhythmia Department, Skane University Hospital, SE-221 85 Lund, Sweden
| | - Frank Bode
- Medical Clinic II Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Jesper Hastrup Svendsen
- Heart Center, Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen and Danish Arrhythmia Research Centre, University of Copenhagen, Blegdamsvej 9, 2100 København Ø, Denmark
| | - Oliver Ritter
- Department Cardiology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, Germany
| | - Johannes Aring
- Department of Internal Medicine I, Divisions of Cardiology, Internal and Intersive Care Medicine, Hospital Leverkusen, Am Gesundheitspark 11, 51375 Leverkusen, Germany
| | - Klaus-Jürgen Gutleben
- Heart and Diabetes Center North Rhine-Westphalia, University Clinic, Ruhr-University Bochum, Georgstr. 11, 32545 Bad Oeynhausen, Germany
| | - Ralph Schneider
- Heart Center Rostock, Department of Internal Medicine I, Divisions of Cardiology, University Hospital Rostock, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany
| | | | - Tino Hauser
- Biotronik, Woermannkehre 1, 12359 Berlin, Germany
| | - Anika Buchholz
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
| | - Karl Wegscheider
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
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Sunderland N, Kaura A, Murgatroyd F, Dhillon P, Scott PA. Outcomes with single-coil versus dual-coil implantable cardioverter defibrillators: a meta-analysis. Europace 2017; 20:e21-e29. [DOI: 10.1093/europace/euw438] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 12/20/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nicholas Sunderland
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Amit Kaura
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Francis Murgatroyd
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Para Dhillon
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Paul A Scott
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
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Kumar P, Baker M, Gehi AK. Comparison of Single-Coil and Dual-Coil Implantable Defibrillators. JACC Clin Electrophysiol 2017; 3:12-19. [DOI: 10.1016/j.jacep.2016.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 06/27/2016] [Accepted: 06/29/2016] [Indexed: 11/15/2022]
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Multicentre comparison Of shock efficacy using single-vs. Dual-coil lead systems and Anodal vs. cathodaL polarITY defibrillation in patients undergoing transvenous cardioverter-defibrillator implantation. The MODALITY study. J Interv Card Electrophysiol 2015; 43:45-54. [DOI: 10.1007/s10840-015-9980-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/23/2015] [Indexed: 10/24/2022]
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9
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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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10
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Sadoul N, Defaye P, Mouton E, Bizeau O, Dupuis JM, Blangy H, Delarche N, Blanc JJ, Lazarus A. Defibrillation testing in everyday medical practice during implantable cardioverter defibrillator implantation in France: Analysis from the LEADER registry. Arch Cardiovasc Dis 2013; 106:562-9. [DOI: 10.1016/j.acvd.2013.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 07/01/2013] [Accepted: 07/16/2013] [Indexed: 11/15/2022]
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11
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BAROLD SS, HERWEG BENGT. Are Dual-Coil ICD Leads Obsolete? Pacing Clin Electrophysiol 2013; 36:923-5. [DOI: 10.1111/pace.12192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 03/30/2013] [Accepted: 04/10/2013] [Indexed: 11/29/2022]
Affiliation(s)
- S. S. BAROLD
- From the Florida Heart Rhythm Institute; Tampa; Florida
| | - BENGT HERWEG
- From the Florida Heart Rhythm Institute; Tampa; Florida
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12
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Kutyifa V, Huth Ruwald AC, Aktas MK, Jons C, McNitt S, Polonsky B, Geller L, Merkely B, Moss AJ, Zareba W, Bloch Thomsen PE. Clinical impact, safety, and efficacy of single- versus dual-coil ICD leads in MADIT-CRT. J Cardiovasc Electrophysiol 2013; 24:1246-52. [PMID: 23889863 DOI: 10.1111/jce.12219] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Revised: 05/26/2013] [Accepted: 05/28/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Current data on efficacy, safety and impact on clinical outcome of single- versus dual-coil implantable cardioverter-defibrillator (ICD) leads are limited and contradictory. METHODS Defibrillation threshold (DFT) at implantation and first shock efficacy were compared in patients implanted with single- versus dual-coil ICD leads in MADIT-CRT. The risk for atrial tachyarrhythmias and all-cause mortality were evaluated. Short- (< 30 days after the implantation) and long-term (throughout the entire study duration) complications were assessed. RESULTS Patients with dual-coil ICD leads had significantly lower DFTs compared to patients with single-coil ICD leads (17.6 ± 5.8 J vs 19.4 ± 6.1 J, P < 0.001). First shock efficacy was similar among patients with dual and single-coil ICD leads (89.6% vs 92.3%, P = 1.00). When comparing patients with dual versus single-coil ICD leads, there was no difference in the risk of atrial tachyarrhythmias (HR = 1.57, 95% CI: 0.81-3.02, P = 0.18), or in the risk of all-cause mortality (HR = 1.10, 95% CI: 0.58-2.07, P = 0.77). Patients implanted with single- or dual-coil ICD lead had similar short and long-term complication rates (short-term HR = 0.96, 95% CI: 0.56-1.65, P = 0.88, long-term procedure-related HR = 0.99, 95% CI: 0.62-1.59, P = 1.00, long-term ICD lead related: HR = 1.2, 95% CI: 0.5-2.9, P = 0.68) during the mean follow-up of 3.3 years. CONCLUSIONS Patients with single-coil ICD leads have slightly higher DFTs compared to those with dual-coil leads, but the efficacy, safety, and clinical impact on atrial tachyarrhythmias, and mortality is similar. Implantation of single-coil ICD leads may be favorable in most patients.
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Affiliation(s)
- Valentina Kutyifa
- University of Rochester Medical Center, Heart Research Follow-Up Program, Rochester, NY, USA; Semmelweis University Heart Center, Budapest, Hungary
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13
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No benefit of a dual coil over a single coil ICD lead: Evidence from the Sudden Cardiac Death in Heart Failure Trial. Heart Rhythm 2013; 10:970-6. [DOI: 10.1016/j.hrthm.2013.03.046] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Indexed: 11/17/2022]
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14
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Netzler PC, Gold MR. How many transvenous coils are optimal for defibrillators: one, two, or none? Heart Rhythm 2013; 10:977-8. [PMID: 23624160 DOI: 10.1016/j.hrthm.2013.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Indexed: 11/29/2022]
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Daubert JC, Saxon L, Adamson PB, Auricchio A, Berger RD, Beshai JF, Breithard O, Brignole M, Cleland J, DeLurgio DB, Dickstein K, Exner DV, Gold M, Grimm RA, Hayes DL, Israel C, Leclercq C, Linde C, Lindenfeld J, Merkely B, Mont L, Murgatroyd F, Prinzen F, Saba SF, Shinbane JS, Singh J, Tang AS, Vardas PE, Wilkoff BL, Zamorano JL, Anand I, Blomström-Lundqvist C, Boehmer JP, Calkins H, Cazeau S, Delgado V, Estes NAM, Haines D, Kusumoto F, Leyva P, Ruschitzka F, Stevenson LW, Torp-Pedersen CT. 2012 EHRA/HRS expert consensus statement on cardiac resynchronization therapy in heart failure: implant and follow-up recommendations and management. Europace 2013; 14:1236-86. [PMID: 22930717 DOI: 10.1093/europace/eus222] [Citation(s) in RCA: 201] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Daubert JC, Saxon L, Adamson PB, Auricchio A, Berger RD, Beshai JF, Breithard O, Brignole M, Cleland J, Delurgio DB, Dickstein K, Exner DV, Gold M, Grimm RA, Hayes DL, Israel C, Leclercq C, Linde C, Lindenfeld J, Merkely B, Mont L, Murgatroyd F, Prinzen F, Saba SF, Shinbane JS, Singh J, Tang AS, Vardas PE, Wilkoff BL, Zamorano JL. 2012 EHRA/HRS expert consensus statement on cardiac resynchronization therapy in heart failure: implant and follow-up recommendations and management. Heart Rhythm 2012; 9:1524-76. [PMID: 22939223 DOI: 10.1016/j.hrthm.2012.07.025] [Citation(s) in RCA: 186] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Indexed: 11/30/2022]
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Yamada T, Robertson PG, McElderry HT, Doppalapudi H, Plumb VJ, Kay GN. Successful reduction of a high defibrillation threshold by a combined implantation of a subcutaneous array and azygos vein lead. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:e173-6. [PMID: 22360586 DOI: 10.1111/j.1540-8159.2012.03332.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A 72-year-old man with nonischemic cardiomyopathy was referred because his implantable cardioverter defibrillator had failed to terminate spontaneous ventricular fibrillation (VF). Defibrillation threshold (DFT) testing confirmed that 830-V shocks failed to defibrillate VF despite optimization of the biphasic waveform and reversal of shock polarity. The placement of a new right ventricular lead and the addition of a subcutaneous array failed to defibrillate VF at 830 V. The combination of a subcutaneous array and azygos vein coil successfully defibrillated VF. The mechanism for successful DFT reduction was likely greater current supplied to the posterior basal left ventricle by the azygos vein lead.
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Affiliation(s)
- Takumi Yamada
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama 35294-0019, USA.
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Neuzner J, Carlsson J. Dual- versus single-coil implantable defibrillator leads: review of the literature. Clin Res Cardiol 2012; 101:239-45. [DOI: 10.1007/s00392-011-0407-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 12/23/2011] [Indexed: 11/25/2022]
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Quin EM, Cuoco FA, Forcina MS, Coker JB, Yoe RH, Spencer WH, Fernandes VL, Nielsen CD, Sturdivant JL, Leman RB, Wharton JM, Gold MR. Defibrillation thresholds in hypertrophic cardiomyopathy. J Cardiovasc Electrophysiol 2010; 22:569-72. [PMID: 21091965 DOI: 10.1111/j.1540-8167.2010.01943.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Defibrillation threshold (DFT) testing is performed in part to ensure an adequate safety margin for the termination of spontaneous ventricular arrhythmias. Left ventricular mass is a predictor of high DFTs, so patients with hypertrophic cardiomyopathy (HCM) are often considered to be at risk for increased defibrillation energy requirements. However, there are little prospective data addressing this issue. OBJECTIVE To assess DFTs in patients with HCM and evaluate the clinical predictors of elevated DFTs. METHODS Eighty-nine consecutive patients with HCM and 600 control patients with ischemic or nonischemic cardiomyopathy underwent a uniform modified step-down DFT testing protocol. DFT was compared between the control and HCM populations. Predictors of elevated DFT were evaluated in the HCM group. RESULTS There was no difference in DFT between HCM and control groups (10.4 ± 5.8 J vs 11.2 ± 5.6 J, respectively). Among patients with HCM, clinical parameters such as left ventricular ejection fraction, interventricular septal thickness, left ventricular mass, and QRS duration were not predictive of an elevated DFT. Only 3 patients (3.4%) with HCM had a DFT >20 J. CONCLUSION Patients with HCM do not have elevated DFTs as compared to more typical populations undergoing implantable cardioverter-defibrillator implant; high-energy devices or complex lead systems are not needed routinely in this population.
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Affiliation(s)
- Ernest M Quin
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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NILSSON KENTR, JACKSON KEVINP. Hemiazygous Coil Placement for High-Defibrillation Thresholds in a Patient with a Right-Sided Implantable Cardioverter Defibrillator. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 35:e10-2. [DOI: 10.1111/j.1540-8159.2010.02862.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kroll MW, Schwab JO. Achieving low defibrillation thresholds at implant: pharmacological influences, RV coil polarity and position, SVC coil usage and positioning, pulse width settings, and the azygous vein. Fundam Clin Pharmacol 2010; 24:561-73. [DOI: 10.1111/j.1472-8206.2010.00848.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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FAHEEM OSMAN, PADALA ARUN, KLUGER JEFFREY, ZWEIBEL STEVEN, CLYNE CHRISTOPHERA. Coronary Sinus Shocking Lead As Salvage In Patients with Advanced CHF and High Defibrillation Thresholds. Pacing Clin Electrophysiol 2010; 33:967-72. [DOI: 10.1111/j.1540-8159.2010.02726.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Yang F, Patterson R. Optimal Transvenous Coil Position on Active-can Single-coil ICD Defibrillation Efficacy: A Simulation Study. Ann Biomed Eng 2008; 36:1659-67. [DOI: 10.1007/s10439-008-9548-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2008] [Accepted: 07/31/2008] [Indexed: 11/30/2022]
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24
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Optimization of superior vena cava coil position and usage for transvenous defibrillation. Heart Rhythm 2008; 5:394-9. [DOI: 10.1016/j.hrthm.2007.12.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Accepted: 12/01/2007] [Indexed: 11/20/2022]
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25
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A computer modeling tool for comparing novel ICD electrode orientations in children and adults. Heart Rhythm 2008; 5:565-72. [PMID: 18362024 DOI: 10.1016/j.hrthm.2008.01.018] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Accepted: 01/09/2008] [Indexed: 11/21/2022]
Abstract
BACKGROUND Use of implantable cardiac defibrillators (ICDs) in children and patients with congenital heart disease is complicated by body size and anatomy. A variety of creative implantation techniques has been used empirically in these groups on an ad hoc basis. OBJECTIVE To rationalize ICD placement in special populations, we used subject-specific, image-based finite element models (FEMs) to compare electric fields and expected defibrillation thresholds (DFTs) using standard and novel electrode configurations. METHODS FEMs were created by segmenting normal torso computed tomography scans of subjects ages 2, 10, and 29 years and 1 adult with congenital heart disease into tissue compartments, meshing, and assigning tissue conductivities. The FEMs were modified by interactive placement of ICD electrode models in clinically relevant electrode configurations, and metrics of relative defibrillation safety and efficacy were calculated. RESULTS Predicted DFTs for standard transvenous configurations were comparable with published results. Although transvenous systems generally predicted lower DFTs, a variety of extracardiac orientations were also predicted to be comparably effective in children and adults. Significant trend effects on DFTs were associated with body size and electrode length. In many situations, small alterations in electrode placement and patient anatomy resulted in significant variation of predicted DFT. We also show patient-specific use of this technique for optimization of electrode placement. CONCLUSION Image-based FEMs allow predictive modeling of defibrillation scenarios and predict large changes in DFTs with clinically relevant variations of electrode placement. Extracardiac ICDs are predicted to be effective in both children and adults. This approach may aid both ICD development and patient-specific optimization of electrode placement. Further development and validation are needed for clinical or industrial utilization.
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26
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Swerdlow CD, Russo AM, Degroot PJ. The dilemma of ICD implant testing. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:675-700. [PMID: 17461879 DOI: 10.1111/j.1540-8159.2007.00730.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ventricular fibrillation (VF) has been induced at implantable cardioverter defibrillator (ICD) implant to ensure reliable sensing, detection, and defibrillation. Despite its risks, the value was self-evident for early ICDs: failure of defibrillation was common, recipients had a high risk of ventricular tachycardia (VT) or VF, and the only therapy for rapid VT or VF was a shock. Today, failure of defibrillation is rare, the risk of VT/VF is lower in some recipients, antitachycardia pacing is applied for fast VT, and vulnerability testing permits assessment of defibrillation efficacy without inducing VF in most patients. This review reappraises ICD implant testing. At implant, defibrillation success is influenced by both predictable and unpredictable factors, including those related to the patient, ICD system, drugs, and complications. For left pectoral implants of high-output ICDs, the probability of passing a 10 J safety margin is approximately 95%, the probability that a maximum output shock will defibrillate is approximately 99%, and the incidence of system revision based on testing is < or = 5%. Bayes' Theorem predicts that implant testing identifies < or = 50% of patients at high risk for unsuccessful defibrillation. Most patients who fail implant criteria have false negative tests and may undergo unnecessary revision of their ICD systems. The first-shock success rate for spontaneous VT/VF ranges from 83% to 93%, lower than that for induced VF. Thus, shocks for spontaneous VT/VF fail for reasons that are not evaluated at implant. Whether system revision based on implant testing improves this success rate is unknown. The risks of implant testing include those related to VF and those related to shocks alone. The former may be due to circulatory arrest alone or the combination of circulatory arrest and shocks. Vulnerability testing reduces risks related to VF, but not those related to shocks. Mortality from implant testing probably is 0.1-0.2%. Overall, VF should be induced to assess sensing in approximately 5% of ICD recipients. Defibrillation or vulnerability testing is indicated in 20-40% of recipients who can be identified as having a higher-than-usual probability of an inadequate defibrillation safety margin based on patient-specific factors. However, implant testing is too risky in approximately 5% of recipients and may not be worth the risks in 10-30%. In 25-50% of ICD recipients, testing cannot be identified as either critical or contraindicated.
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Affiliation(s)
- Charles D Swerdlow
- Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, and the David Geffen School of Medicine, UCLA, Los Angeles, California, USA.
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27
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Gold MR, Shih HT, Herre J, Breiter D, Zhang Y, Schwartz M. Comparison of defibrillation efficacy and survival associated with right versus left pectoral placement for implantable defibrillators. Am J Cardiol 2007; 100:243-6. [PMID: 17631078 DOI: 10.1016/j.amjcard.2007.02.087] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Revised: 02/22/2007] [Accepted: 02/22/2007] [Indexed: 11/29/2022]
Abstract
The preferred location for an implantable cardioverter-defibrillator (ICD) generator is the left pectoral region as a result of the shock vector formed by the active can and the lead system. However, a right pectoral site is necessary when left-sided implantation is contraindicated. The Low Energy Safety Study was a prospective, randomized trial conducted to assess chronic defibrillation efficacy in 627 patients, including 37 (5.9%) who received right pectoral implants and 590 (94.1%) who received left pectoral implants. Patients were followed for a mean of 24 +/- 13 months. There were no significant differences observed between patients who received left versus right pectoral implants in age, gender, indications, New York Heart Association classification, or ejection fraction. Patients who received a right pectoral implant had higher defibrillation thresholds at implantation (10.6 +/- 3.8 J) than those who received a left pectoral implant (8.9 +/- 4.2 J, p = 0.01) despite similar shock impedances. The conversion efficacy for spontaneous arrhythmia episodes among patients who received right and left pectoral implants were not significantly different (33 of 33 [100%] vs 255 of 263 [97%], respectively; p = 0.31). In addition, the conversion efficacy for induced ventricular fibrillation episodes were also similar (187 of 188 [99%] on the right vs 2429 of 2475 [98%] on the left, p = 0.18). However, the all-cause mortality rate was higher for patients who received right-sided implants (hazard ratio 1.93, p <0.004). In conclusion, defibrillation thresholds are higher with right pectoral implants compared with left-sided implants, but with a proper energy safety margin, there are no significant differences in spontaneous or induced shock conversion efficacy. However, the near doubling of the mortality rate among patients with right-sided implants needs to be considered when recommending such device therapy.
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Affiliation(s)
- Michael R Gold
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA.
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28
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Mainigi SK, Cooper JM, Russo AM, Nayak HM, Lin D, Dixit S, Gerstenfeld EP, Hsia HH, Callans DJ, Marchlinski FE, Verdino RJ. Elevated defibrillation thresholds in patients undergoing biventricular defibrillator implantation: Incidence and predictors. Heart Rhythm 2006; 3:1010-6. [PMID: 16945792 DOI: 10.1016/j.hrthm.2006.05.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Accepted: 05/30/2006] [Indexed: 02/07/2023]
Abstract
BACKGROUND The biventricular implantable cardioverter-defibrillator (ICD) is an important therapy for select patients with severe heart failure. Given reported risk factors for elevated defibrillation thresholds (DFTs), patients undergoing biventricular ICD placement would be suspected of having a higher incidence of elevated DFT. OBJECTIVES The purpose of this study was to examine the clinical predictors and mortality risk of elevated DFTs in patients receiving a biventricular ICD. METHODS Characteristics of patients undergoing biventricular ICD placement with an elevated DFT were compared to those without an elevated DFT. RESULTS An elevated DFT was found in 14 (12%) of 121 patients. Mean QRS duration was 210 +/- 50 ms in the elevated DFT group and 171 +/- 36 ms in the normal DFT group (P = .01). Patients with a QRS duration >or=200 ms were more likely to have an elevated DFT than those with a duration <200 ms (odds ratio 13.4, 95% confidence interval 3.1-66.7, P <.01). No other clinical characteristics were associated with an elevated DFT. More than 90% of patients with an elevated DFT achieved an adequate safety margin through system modification or manipulation of their drug regimen. An elevated DFT did not have an impact on 2-year mortality. CONCLUSION Patients with a biventricular ICD had a 12% incidence of elevated DFT in our sequential patient cohort. QRS duration prior to biventricular ICD placement is the most powerful predictor of patients at risk for an elevated DFT. An elevated DFT does not have an impact on mortality, perhaps because of successful implementation of system modifications to ensure an adequate defibrillation safety margin.
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Affiliation(s)
- Sumeet K Mainigi
- Department of Medicine, Electrophysiology Section, Division of Cardiovascular Medicine, University of Pennsylvania School of Medicine, Philadelphia, 19104, USA
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29
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Thammanomai A, Sweeney MO, Eisenberg SR. A comparison of the output characteristics of several implantable cardioverter-defibrillators. Heart Rhythm 2006; 3:1053-9. [PMID: 16945801 DOI: 10.1016/j.hrthm.2006.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Accepted: 05/01/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND Implantable cardioverter-defibrillators (ICDs) are effective for primary and secondary prevention of sudden cardiac death due to ventricular arrhythmias. However, despite wide clinical use, there are no generally accepted standardized protocols to characterize and report the output capabilities of ICDs. OBJECTIVE The objective of this study was to measure and compare the output characteristics of standard-output and high-output ICDs from several manufacturers under a common set of conditions. METHODS The output characteristics of ICDs randomly selected from hospital stock were measured. The energy delivered for each shock to a range of fixed loads (25-75 Omega) was computed from the voltage waveform and the corresponding load. RESULTS Delivered energy varied by approximately 4 J over the range of loads tested and varied between devices (high-output 33.8-35 J; standard-output 26.7-28.6 J, at 50 Omega). Leading-edge voltage varied by approximately 6% over the range of loads tested and varied between devices (high-output 738-792 V; standard-output 593-797 V, at 50 Omega). Pulse width varied by a factor of approximately 3 over the range of loads tested and varied between devices (high-output 10-14.5 ms; standard-output 9-12.2 ms, at 50 Omega). Observed variations between devices and with load were significant (P <.001). CONCLUSIONS Potentially important differences in output characteristics of different ICD systems exist and merit further clinical investigation. The reporting of ICD output characteristics should be standardized. Additionally, it is recommended that manufacturers report output characteristics as a function of load over the typical range of patient loads clinically encountered.
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Affiliation(s)
- Apiradee Thammanomai
- Department of Biomedical Engineering, Boston University, Massachusetts 02215, USA
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30
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Cesario D, Bhargava M, Valderrábano M, Fonarow GC, Wilkoff B, Shivkumar K. Azygos Vein Lead Implantation:. A Novel Adjunctive Technique for Implantable Cardioverter Defibrillator Placement. J Cardiovasc Electrophysiol 2004; 15:780-3. [PMID: 15250862 DOI: 10.1046/j.1540-8167.2004.03649.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
High defibrillation thresholds (DFTs) occasionally are encountered during placement of implantable cardioverter defibrillators (ICDs). There are multiple strategies to lower DFTs in such patients, including reassessment of right ventricular lead position, alteration of the shock waveform, and implantation of subcutaneous arrays. This article describes a novel technique of implanting a high-voltage lead in the azygos vein. This procedure may serve as an adjunctive approach to reduce DFTs. The anatomic location of the azygos vein posterior to the heart provides a suitable shocking vector between the right ventricular electrode, a high-voltage lead placed in the azygos vein, and the ICD can.
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Affiliation(s)
- David Cesario
- UCLA Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California 90095-1679, USA
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31
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Rüb N, Schweitzer O, Mewis C, Kettering K, Kuehlkamp V. Addition of a Defibrillation Electrode in the Low Right Atrium to a Right Ventricular Lead Does Not Reduce Ventricular Defibrillation Thresholds. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:346-51. [PMID: 15009861 DOI: 10.1111/j.1540-8159.2004.00439.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Transvenous unipolar active can defibrillation systems have proven to be effective in treating ventricular tachyarrhythmias. However, a further reduction of ventricular defibrillation thresholds (V-DFT) would increase the longevity, reduce the size of pulse generators, and help to avoid additional leads in patients with inacceptable high V-DFTs. In a finite difference computer model, the extension of the right ventricular (RV) defibrillation coil into the low right atrium led to a 40% reduction of unipolar V-DFT. To evaluate this finding, we conducted a prospective, randomized study in 11 patients receiving an ICD. Extension of the RV electrode was simulated by adding a second coil placed in the low right atrium with the same polarity. Using a binary search protocol, V-DFT was determined with and without the additional electrode in each patient. Total shock impedance was significantly lower in the two coil (low RA) configuration, compared to the single coil (RV) configuration. Corresponding values were 49.9 +/- 6.7 Ohm and 61.1 +/- 9.3 Ohm, respectively (P < 0.01, paired t-test). However, there was no reduction, but even a nonsignificant increase in V-DFTs. Mean V-DFT in the RV configuration was 12.0 +/- 5.6 J and 16.3 +/- 7.8 J in the low RA configuration (P = 0.09, paired t-test). Despite a reduction in total impedance, the addition of a defibrillation coil in the low right atrium does not reduce ventricular defibrillation thresholds.
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Affiliation(s)
- Norman Rüb
- Department of Cardiology, University of Tuebingen, Germany Bakken Research Center, Maastricht, The Netherlands.
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32
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Hernández Madrid A, Escobar Cervantes C, Blanco Tirado B, Marín Marín I, Moya Mur JL, Moro C. Resincronización cardíaca en la insuficiencia cardíaca: bases, métodos, indicaciones y resultados. Rev Esp Cardiol (Engl Ed) 2004. [DOI: 10.1016/s0300-8932(04)77169-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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33
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Kloppe A, Müller S, Prenger-Berninghoff A, Drewes C, Hexamer M, Mügge A, Werner J. [Biventricular defibrillation using transvenous electrodes]. BIOMED ENG-BIOMED TE 2003; 47 Suppl 1 Pt 1:127-9. [PMID: 12451792 DOI: 10.1515/bmte.2002.47.s1a.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study investigated the feasibility of transvenous biventricular defibrillation using an electrode in a left ventricular vein. The standard lead configuration with a coil in the right ventricle (RV) and a coil in the superior vena cava (SVC) was compared with an additional unipolar coil in an accessible epicardial vein. Only biphasic shocks were used with different shocking modes between the coils in the RV, LV, SVC and the ICD-generator (CAN). Shocks were applied starting with 30 J, decreasing till the DFT was reached. As a result there is a lower DFT when defibrillation is performed including the left ventricular electrode. The impedance did not show a significant increase after more then 20 consecutive shocks. It is a feasible and workable application that might help to reduce the energy demand and increase the safety of such a system.
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Affiliation(s)
- A Kloppe
- Institut für Biomedizinische Technik, Medizinische Fakultät, Ruhr-Universität Bochum.
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34
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Abstract
Implantable cardioverter defibrillators (ICDs) have evolved from the treatment of last resort to the gold standard therapy for patients at high risk for ventricular tachyarrhythmias. High-risk patients include those who have survived life-threatening arrhythmias, and individuals with cardiac diseases who are at risk for such arrhythmias, but are symptomless. Use of an ICD will affect the patient's quality of life. Some drugs can substantially affect defibrillator function and efficacy, and possible drug-device interactions should be considered. Patients with ICDs may encounter cell phones, antitheft detectors, and many other sources of potential electromagnetic Interference. In addition to treating ventricular tachyarrhythmias, new defibrillators provide full featured dual chamber pacing, and could treat atrial arrhythmias, and congestive heart failure by means of biventricular pacing.
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Affiliation(s)
- M Glikson
- Heart Institute, Sheba Medical Centre, Tel Aviv University, Tel Hashomer, Israel
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35
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Meisel E, Butter C, Philippon F, Higgins S, Strickberger SA, Smith J, Hahn S, Michel U, Schubert B, Pfeiffer D. Transvenous biventricular defibrillation. Am J Cardiol 2000; 86:76K-85K. [PMID: 11084104 DOI: 10.1016/s0002-9149(00)01295-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The recent success of biventricular pacing with transvenously implantable left ventricular leads suggests that left ventricular leads may be useful for other modes of therapy. Animal studies showed small leads inserted into a left ventricular vein dramatically reduced defibrillation strength requirements. This article describes a human investigation of the feasibility of biventricular defibrillation. Fifty-one patients undergoing implantable cardioverter defibrillator (ICD) implantation were enrolled. After insertion of a standard ICD lead, a prototype over-the-wire left ventricular defibrillation lead was inserted through the coronary sinus and into a vein on the left ventricle. Lead insertion was guided by retrograde venography. The left ventricular lead's location was randomized to the anterior or posterior vein. Randomized, paired defibrillation threshold (DFT) testing was performed to compare a standard ICD shock configuration (Control: right ventricle- --> superior vena cava+ + CAN+) to 1 of 3 biventricular shock configurations. In the anterior vein, the left ventricular lead was tested with either a single biphasic shock from right ventricle + left ventricle- --> superior vena cava+ + CAN+ or a dual biphasic shock. In the posterior vein, the left ventricular lead was tested with a dual biphasic shock. Dual shocks consisted of a 40% tilt biphasic shock from right ventricle- --> superior vena cava+ + CAN+ followed by another 40% tilt biphasic shock from left ventricle- --> superior vena cava+ + CAN+, delivered from a single 225 microF capacitance. Left ventricular lead positioning was successful in 41 of 46 patients (89%). Mean left ventricular lead insertion time was 17 +/- 17 minutes and 13 +/- 15 minutes for anterior and posterior locations, respectively. Mean DFTs were not statistically lower for the left ventricular shock configurations, but retrospective analysis showed a well-defined region of the posterolateral left ventricle where consistent DFT reduction was achieved with dual shocks (14.0 +/- 2.7 J vs 7.8 +/- 0.9 J; n = 5; p = 0.04). There were no adverse events requiring intervention due to the use of the left ventricular lead. Biventricular defibrillation is feasible and safe under the conditions used in this study. Additional studies are needed to verify whether dual shocks with posterolateral left ventricular lead positions consistently reduce DFTs.
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Affiliation(s)
- E Meisel
- Heart and Circulation Center, Dresden, Germany
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36
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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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37
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Gold MR, Olsovsky MR, DeGroot PJ, Cuello C, Shorofsky SR. Optimization of transvenous coil position for active can defibrillation thresholds. J Cardiovasc Electrophysiol 2000; 11:25-9. [PMID: 10695457 DOI: 10.1111/j.1540-8167.2000.tb00731.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Lead systems that include an active pectoral pulse generator are now standard for initial defibrillator implantations. However, the optimal transvenous lead system and coil location for such active can configurations are unknown. The purpose of this study was to evaluate the benefit and optimal position of a superior vena cava (SVC) coil on defibrillation thresholds with an active left pectoral pulse generator and right ventricular coil. METHODS AND RESULTS This prospective, randomized study was performed on 27 patients. Each subject was evaluated with three lead configurations, with the order of testing randomized. Biphasic shocks were delivered between the right ventricular coil and an active can alone (unipolar), or an active can in common with the proximal coil positioned either at the right atrial/SVC junction (low SVC) or in the left subclavian vein (high SVC). Stored energies at defibrillation threshold were higher for the single-coil, unipolar configuration (11.2 +/- 6.6 J) than for the high (8.9 +/- 4.2 J) or low (8.5 +/- 4.2 J) SVC configurations (P < 0.01). Moreover, 96% of subjects had low (< or = 15 J) thresholds with the SVC coil in either position compared with 81% for the single-coil configuration. Shock impedance (P < 0.001) was increased with the unipolar configuration, whereas peak current was reduced (P < 0.001). CONCLUSION The addition of a proximal transvenous coil to an active can unipolar lead configuration reduces defibrillation energy requirements. The position of this coil has no significant effect on defibrillation thresholds.
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Affiliation(s)
- M R Gold
- Department of Medicine, University of Maryland School of Medicine, Baltimore 21201, USA.
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38
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Abstract
Multiple technologic advances in the implantable cardioverter defibrillator (ICD) have resulted in smaller size, easier implantation, and improved detection, therapy, and stored diagnostic information. Advanced dual-chamber ICDs are currently available that allow dual-chamber rate-responsive pacing with mode switching, enhanced detection algorithms, antitachycardia pacing, low-energy cardioversion, high-energy shocks, and extensive diagnostics. Based on improvements in lead systems and improved energy waveforms, almost all devices are being implanted with nonthoracotomy leads in the pectoralis area. The results of recent clinical trials have expanded indications for the ICD for primary and secondary prevention of sudden cardiac death. With advances in capacitor and battery technology coupled with improved lead systems and waveform resulting in lower defibrillation thresholds, it is likely that lower-output, smaller devices will be developed. In the future, ICDs may have expanded indications and may incorporate physiologic sensors to access hemodynamic significance of arrhythmias and algorithms for prediction and prevention of cardiac arrhythmias.
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Affiliation(s)
- C A Swygman
- New England Medical Center, Boston, MA 02111, USA
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39
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Gold MR, Hsu W, Marcovecchio AF, Olsovsky MR, Lang DJ, Shorofsky SR. A new defibrillator discrimination algorithm utilizing electrogram morphology analysis. Pacing Clin Electrophysiol 1999; 22:179-82. [PMID: 9990626 DOI: 10.1111/j.1540-8159.1999.tb00328.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Inappropriate therapies delivered by implantable cardioverter defibrillators (ICDs) for supraventricular arrhythmias remain a common problem, particularly in the event of rapidly conducted atrial fibrillation or marked sinus tachycardia. The ability to differentiate between ventricular tachycardia and supraventricular arrhythmias is the major goal of discrimination algorithms. Therefore, we developed a new algorithm, SimDis, utilizing morphological features of the shocking electrograms. This algorithm was developed from electrogram data obtained from 36 patients undergoing ICD implantation. An independent test set was evaluated in 25 patients. Recordings were made in sinus rhythm, sinus tachycardia, and following the induction of ventricular tachycardia and atrial fibrillation. The arrhythmia complex is defined as wide if the duration is at least 30% greater than the template in sinus rhythm. For narrow complexes, four maximum and minimum values were measured to form a 4-element feature vector, which was compared with a representative feature vector during normal sinus rhythm. For each rhythm, any wide complex was classified as ventricular tachycardia. For narrow complexes, the second step of the algorithm compared the electrogram with the template, computing similarity and dissimilarity values. These values were then mapped to determine if they fell within a previously established discrimination boundary. On the independent test set, the SimDis algorithm correctly classified 100% of ventricular tachycardias (27/27), 98% of sinus tachycardias (54/55), and 100% of episodes of atrial fibrillation (37/37). We conclude that the SimDis algorithm yields high sensitivity (100%) and specificity (99%) for arrhythmia discrimination, using the computational capabilities of an ICD system.
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Affiliation(s)
- M R Gold
- University of Maryland School of Medicine, Baltimore 21201-1595, USA.
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40
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de Jongh AL, Entcheva EG, Replogle JA, Booker RS, Kenknight BH, Claydon FJ. Defibrillation efficacy of different electrode placements in a human thorax model. Pacing Clin Electrophysiol 1999; 22:152-7. [PMID: 9990621 DOI: 10.1111/j.1540-8159.1999.tb00323.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The objective of this study was to measure the defibrillation threshold (DFT) associated with different electrode placements using a three-dimensional anatomically realistic finite element model of the human thorax. Coil electrodes (Endotak DSP, model 125, Guidant/CPI) were placed in the RV apex along the lateral wall (RV), withdrawn 10 mm away from the RV apex along the lateral wall (RVprox), in the RV apex along the anterior septum (RVseptal), and in the SVC. An active pulse generator (can) was placed in the subcutaneous prepectoral space. Five electrode configurations were studied: RV-->SVC, RVprox-->SVC, RVSEPTAL-->SVC, RV-->Can, and RV-->SVC + Can. DFTs are defined as the energy required to produce a potential gradient of at least 5 V/cm in 95% of the ventricular myocardium. DFTs for RV-->SVC, RVprox-->SVC, RVseptal-->SVC, RV-->Can, and RV-->SVC + Can were 10, 16, 7, 9, and 6 J, respectively. The DFTs measured at each configuration fell within one standard deviation of the mean DFTs reported in clinical studies using the Endotak leads. The relative changes in DFT among electrode configurations also compared favorably. This computer model allows measurements of DFT or other defibrillation parameters with several different electrode configurations saving time and cost of clinical studies.
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Affiliation(s)
- A L de Jongh
- Department of Biomedical Engineering, University of Memphis, Tennessee 38152-6582, USA
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41
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Min X, Mehra R. Finite element analysis of defibrillation fields in a human torso model for ventricular defibrillation. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 1998; 69:353-86. [PMID: 9785946 DOI: 10.1016/s0079-6107(98)00015-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In order to optimize defibrillation electrode systems for ventricular defibrillation thresholds (DFTs), a Finite Element Torso model was built from fast CT scans of a patient who had large cardiac dimensions (upper bound of normal) but no heart disease. Clinically used defibrillation electrode configurations, i.e. Superior Vena Cava (SVC) to Right Ventricle (RV) (SVC-RV), left pectoral Can to RV (Can-RV) and Can + SVC-RV, were analyzed. The DFTs were calculated based on 95% ventricular mass having voltage gradient > 5 V/cm and these results were also compared with clinical data. The low voltage gradient regions with voltage gradient < 5 V/cm were identified and the effect of electrode dimension and location on DFTs were also investigated for each system. A good correlation between the model results and the clinical data supports the use of Finite Element Analysis of a human torso model for optimization of defibrillation electrode systems. This correlation also indicates that the critical mass hypothesis is the primary mechanism of defibrillation. Both the FEA results and the clinical data show that Can + SVC-RV system offers the lowest voltage DFTs when compared with SVC-RV and Can-RV systems. Analysis of the effect of RV, SVC and Can electrode dimensions and locations can have an important impact on defibrillation lead designs.
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Affiliation(s)
- X Min
- Medtronic, Minneapolis, MN 55432, USA.
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42
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Abstract
BACKGROUND One of the basic characteristics of electrical defibrillation is the strength-duration relationship, or the effect of pulse width on defibrillation efficacy. This relationship is important for understanding the mechanism of defibrillation and for the design of optimal waveforms. However, a detailed evaluation of the strength-duration relationship for human transvenous defibrillation has not been performed previously. METHODS AND RESULTS This was a prospective study of 29 patients undergoing initial defibrillator implantation with a uniform dual coil, transvenous lead. In each patient defibrillation thresholds were measured for either short (2, 3, 4, 6 ms) or long (6, 12, 18 ms) pulse durations, with the order of testing randomized. The shock waveform was a truncated monophasic pulse from a capacitor of 150 microF. The leading edge voltage at defibrillation threshold was 566+/-100 V for 2-ms pulses. Voltages declined exponentially with increasing pulse width reaching an asymptote by 6 ms (451+/-68 V, P<.05). Defibrillation threshold voltage was insensitive to longer pulse widths. Stored energy at defibrillation threshold showed a similar relationship with pulse width. In contrast, mean current decreased monotonically over the full range of pulse durations evaluated, and there was no evidence of a rheobase. CONCLUSIONS The shape of the strength-duration curve and the lack of rheobase current indicate a fundamental difference between cardiac stimulation and defibrillation. The relationship between pulse duration and defibrillation threshold voltage or stored energy is well modeled by a parallel capacitor resistor circuit with a time constant of 5.3 ms.
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Affiliation(s)
- M R Gold
- Department of Medicine, University of Maryland School of Medicine, Baltimore 21201, USA.
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