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Qian S, Monaci S, Mendonca-Costa C, Campos F, Gemmell P, Zaidi HA, Rajani R, Whitaker J, Rinaldi CA, Bishop MJ. Additional coils mitigate elevated defibrillation threshold in right-sided implantable cardioverter defibrillator generator placement: a simulation study. Europace 2023; 25:euad146. [PMID: 37314196 PMCID: PMC10265967 DOI: 10.1093/europace/euad146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/13/2023] [Indexed: 06/15/2023] Open
Abstract
AIMS The standard implantable cardioverter defibrillator (ICD) generator (can) is placed in the left pectoral area; however, in certain circumstances, right-sided cans may be required which may increase defibrillation threshold (DFT) due to suboptimal shock vectors. We aim to quantitatively assess whether the potential increase in DFT of right-sided can configurations may be mitigated by alternate positioning of the right ventricular (RV) shocking coil or adding coils in the superior vena cava (SVC) and coronary sinus (CS). METHODS AND RESULTS A cohort of CT-derived torso models was used to assess DFT of ICD configurations with right-sided cans and alternate positioning of RV shock coils. Efficacy changes with additional coils in the SVC and CS were evaluated. A right-sided can with an apical RV shock coil significantly increased DFT compared to a left-sided can [19.5 (16.4, 27.1) J vs. 13.3 (11.7, 19.9) J, P < 0.001]. Septal positioning of the RV coil led to a further DFT increase when using a right-sided can [26.7 (18.1, 36.1) J vs. 19.5 (16.4, 27.1) J, P < 0.001], but not a left-sided can [12.1 (8.1, 17.6) J vs. 13.3 (11.7, 19.9) J, P = 0.099). Defibrillation threshold of a right-sided can with apical or septal coil was reduced the most by adding both SVC and CS coils [19.5 (16.4, 27.1) J vs. 6.6 (3.9, 9.9) J, P < 0.001, and 26.7 (18.1, 36.1) J vs. 12.1 (5.7, 13.5) J, P < 0.001]. CONCLUSION Right-sided, compared to left-sided, can positioning results in a 50% increase in DFT. For right-sided cans, apical shock coil positioning produces a lower DFT than septal positions. Elevated right-sided can DFTs may be mitigated by utilizing additional coils in SVC and CS.
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Affiliation(s)
- Shuang Qian
- Department of Biomedical Engineering, School of Imaging Sciences and Biomedical Engineering, Kings College London, 4th North Wing, St Thomas’ Hospital, London SE1 7EH, UK
| | - Sofia Monaci
- Department of Biomedical Engineering, School of Imaging Sciences and Biomedical Engineering, Kings College London, 4th North Wing, St Thomas’ Hospital, London SE1 7EH, UK
| | - Caroline Mendonca-Costa
- Department of Biomedical Engineering, School of Imaging Sciences and Biomedical Engineering, Kings College London, 4th North Wing, St Thomas’ Hospital, London SE1 7EH, UK
| | - Fernando Campos
- Department of Biomedical Engineering, School of Imaging Sciences and Biomedical Engineering, Kings College London, 4th North Wing, St Thomas’ Hospital, London SE1 7EH, UK
| | - Philip Gemmell
- Department of Biomedical Engineering, School of Imaging Sciences and Biomedical Engineering, Kings College London, 4th North Wing, St Thomas’ Hospital, London SE1 7EH, UK
| | - Hassan A Zaidi
- Department of Biomedical Engineering, School of Imaging Sciences and Biomedical Engineering, Kings College London, 4th North Wing, St Thomas’ Hospital, London SE1 7EH, UK
| | - Ronak Rajani
- Department of Cardiology, Guy’s and St Thomas’ Hospital, Westminster Bridge Rd, London SE1 7EH, UK
| | - John Whitaker
- Department of Biomedical Engineering, School of Imaging Sciences and Biomedical Engineering, Kings College London, 4th North Wing, St Thomas’ Hospital, London SE1 7EH, UK
- Department of Cardiology, Guy’s and St Thomas’ Hospital, Westminster Bridge Rd, London SE1 7EH, UK
| | - Christopher A Rinaldi
- Department of Biomedical Engineering, School of Imaging Sciences and Biomedical Engineering, Kings College London, 4th North Wing, St Thomas’ Hospital, London SE1 7EH, UK
- Department of Cardiology, Guy’s and St Thomas’ Hospital, Westminster Bridge Rd, London SE1 7EH, UK
| | - Martin J Bishop
- Department of Biomedical Engineering, School of Imaging Sciences and Biomedical Engineering, Kings College London, 4th North Wing, St Thomas’ Hospital, London SE1 7EH, UK
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Santos H, Figueiredo M, Paula SB, Santos M, Osório P, Portugal G, Valente B, Lousinha A, Silva Cunha P, Oliveira M. Apical or Septal Right Ventricular Location in Patients Receiving Defibrillation Leads: A Systematic Review and Meta-Analysis. Cardiol Rev 2023; Publish Ahead of Print:00045415-990000000-00080. [PMID: 36883833 DOI: 10.1097/crd.0000000000000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
This study reviews the published data comparing the efficacy and safety of apical and septal right ventricle defibrillator lead positioning at 1-year follow-up. Systemic research on Medline (PubMed), ClinicalTrials.gov, and Embase was performed using the keywords "septal defibrillation," "apical defibrillation," "site defibrillation," and "defibrillation lead placement," including implantable cardioverter-defibrillator and cardiac resynchronization therapy devices. Comparisons between apical and septal position were performed regarding R-wave amplitude, pacing threshold at a pulse width of 0.5 ms, pacing and shock lead impedance, suboptimal lead performance, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter, readmissions due to heart failure and mortality rates. A total of 5 studies comprising 1438 patients were included in the analysis. Mean age was 64.5 years, 76.9% were male, with a median LVEF of 27.8%, ischemic etiology in 51.1%, and a mean follow-up period of 26.5 months. The apical lead placement was performed in 743 patients and septal lead placement in 690 patients. Comparing the 2 placement sites, no significant differences were found regarding R-wave amplitude, lead impedance, suboptimal lead performance, LVEF, left ventricular end-diastolic diameter, and mortality rate at 1-year follow-up. Pacing threshold values favored septal defibrillator lead placement (P = 0.003), as well as shock impedance (P = 0.009) and readmissions due to heart failure (P = 0.02). Among patients receiving a defibrillator lead, only pacing threshold, shock lead impedance, and readmission due to heart failure showed results favoring septal lead placement. Therefore, generally, the right ventricle lead placement does not appear to be of major importance.
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Affiliation(s)
- Helder Santos
- From the Department of Cardiology, Centro Hospitalar de Lisboa Central - Hospital Santa Marta, Lisbon, Portugal
- Department of Cardiology, Centro Hospitalar Barreiro- Montijo, Barreiro, Portugal
| | - Margarida Figueiredo
- Department of Cardiology, Centro Hospitalar Barreiro- Montijo, Barreiro, Portugal
| | - Sofia B Paula
- Department of Cardiology, Centro Hospitalar Barreiro- Montijo, Barreiro, Portugal
| | - Mariana Santos
- Department of Cardiology, Centro Hospitalar Barreiro- Montijo, Barreiro, Portugal
| | - Paulo Osório
- From the Department of Cardiology, Centro Hospitalar de Lisboa Central - Hospital Santa Marta, Lisbon, Portugal
| | - Guilherme Portugal
- From the Department of Cardiology, Centro Hospitalar de Lisboa Central - Hospital Santa Marta, Lisbon, Portugal
| | - Bruno Valente
- From the Department of Cardiology, Centro Hospitalar de Lisboa Central - Hospital Santa Marta, Lisbon, Portugal
| | - Ana Lousinha
- From the Department of Cardiology, Centro Hospitalar de Lisboa Central - Hospital Santa Marta, Lisbon, Portugal
| | - Pedro Silva Cunha
- From the Department of Cardiology, Centro Hospitalar de Lisboa Central - Hospital Santa Marta, Lisbon, Portugal
| | - Mário Oliveira
- From the Department of Cardiology, Centro Hospitalar de Lisboa Central - Hospital Santa Marta, Lisbon, Portugal
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3
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Monaci S, Gillette K, Puyol-Antón E, Rajani R, Plank G, King A, Bishop M. Automated Localization of Focal Ventricular Tachycardia From Simulated Implanted Device Electrograms: A Combined Physics-AI Approach. Front Physiol 2021; 12:682446. [PMID: 34276403 PMCID: PMC8281305 DOI: 10.3389/fphys.2021.682446] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Focal ventricular tachycardia (VT) is a life-threating arrhythmia, responsible for high morbidity rates and sudden cardiac death (SCD). Radiofrequency ablation is the only curative therapy against incessant VT; however, its success is dependent on accurate localization of its source, which is highly invasive and time-consuming. Objective: The goal of our study is, as a proof of concept, to demonstrate the possibility of utilizing electrogram (EGM) recordings from cardiac implantable electronic devices (CIEDs). To achieve this, we utilize fast and accurate whole torso electrophysiological (EP) simulations in conjunction with convolutional neural networks (CNNs) to automate the localization of focal VTs using simulated EGMs. Materials and Methods: A highly detailed 3D torso model was used to simulate ∼4000 focal VTs, evenly distributed across the left ventricle (LV), utilizing a rapid reaction-eikonal environment. Solutions were subsequently combined with lead field computations on the torso to derive accurate electrocardiograms (ECGs) and EGM traces, which were used as inputs to CNNs to localize focal sources. We compared the localization performance of a previously developed CNN architecture (Cartesian probability-based) with our novel CNN algorithm utilizing universal ventricular coordinates (UVCs). Results: Implanted device EGMs successfully localized VT sources with localization error (8.74 mm) comparable to ECG-based localization (6.69 mm). Our novel UVC CNN architecture outperformed the existing Cartesian probability-based algorithm (errors = 4.06 mm and 8.07 mm for ECGs and EGMs, respectively). Overall, localization was relatively insensitive to noise and changes in body compositions; however, displacements in ECG electrodes and CIED leads caused performance to decrease (errors 16-25 mm). Conclusion: EGM recordings from implanted devices may be used to successfully, and robustly, localize focal VT sources, and aid ablation planning.
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Affiliation(s)
| | - Karli Gillette
- Division of Biophysics, Medical University of Graz, Graz, Austria
| | | | | | - Gernot Plank
- Division of Biophysics, Medical University of Graz, Graz, Austria
| | - Andrew King
- King’s College London, London, United Kingdom
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4
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De Meester P, Budts W, Gewillig M. Transvenous valve-in-valve replacement preserving the function of a transvalvular defibrillator lead. Catheter Cardiovasc Interv 2014; 84:1148-52. [DOI: 10.1002/ccd.25451] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 12/03/2013] [Accepted: 02/16/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Pieter De Meester
- Department of Congenital Cardiology; University Hospitals Leuven; Leuven Belgium
| | - Werner Budts
- Department of Congenital Cardiology; University Hospitals Leuven; Leuven Belgium
| | - Marc Gewillig
- Department of Pediatric Cardiology; University Hospitals Leuven; Leuven Belgium
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5
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Incidence and clinical predictors of low defibrillation safety margin at time of implantable defibrillator implantation. J Interv Card Electrophysiol 2012; 34:93-100. [DOI: 10.1007/s10840-011-9648-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Accepted: 11/15/2011] [Indexed: 11/27/2022]
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6
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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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7
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Reynolds CR, Nikolski V, Sturdivant JL, Leman RB, Cuoco FA, Wharton JM, Gold MR. Randomized comparison of defibrillation thresholds from the right ventricular apex and outflow tract. Heart Rhythm 2010; 7:1561-6. [DOI: 10.1016/j.hrthm.2010.06.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Accepted: 06/09/2010] [Indexed: 11/28/2022]
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8
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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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9
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Rashba EJ, Bonner M, Wilson J, Shorofsky SR, Peters RW, Gold MR. Distal Right Ventricular Coil Position Reduces Defibrillation Thresholds. J Cardiovasc Electrophysiol 2003; 14:1036-40. [PMID: 14521655 DOI: 10.1046/j.1540-8167.2003.03205.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED Distal RV Coil Position Reduces DFTs. INTRODUCTION Understanding the factors that affect defibrillation thresholds (DFTs) has important implications both for optimization of defibrillation efficacy and for the design of new transvenous leads. The aim of this prospective study was to test the hypothesis that defibrillation efficacy is improved with the right ventricular (RV) coil in a distal position compared with a more proximal RV coil position. METHODS AND RESULTS A novel defibrillation lead with three adjacent RV defibrillation coils (distal 0.8 cm, middle 3.7 cm, proximal 0.8 cm) was used for this study to permit comparison of DFTs with the proximal and distal RV coil positions without lead repositioning. In the distal RV configuration, the distal and middle RV coils were connected electrically as the anode for defibrillation. In the proximal RV configuration, the middle and proximal coils were the anode. A superior vena cava (SVC) coil and active can were connected electrically as the cathode (reversed polarity, RV-->Can+SVC). In each patient, the DFT was measured twice using a binary search protocol with the distal RV and proximal RV configurations, with the order of testing randomized. The study cohort consisted of 31 subjects (mean age 65 +/- 12 years, mean left ventricular ejection fraction 30% +/- 16%, 81% male predominance). The mean delivered energy (8.2 +/- 5.3 J vs 11.2 +/- 6.1 J), leading-edge voltage (335 +/- 109 V vs 393 +/- 118 V), and peak current (11.6 +/- 5.2 A vs 14.9 +/- 7.3 A) at DFT all were significantly lower with the distal RV configuration compared to the proximal RV configuration (P < 0.01 for all comparisons). CONCLUSION DFTs are significantly reduced with the distal RV configuration compared to the proximal RV configuration. Defibrillation leads should be designed with the shortest tip to coil distance that can be achieved without compromising ventricular fibrillation sensing.
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Affiliation(s)
- Eric J Rashba
- Division of Cardiology, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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10
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Carlsson J, Schulte B, Erdogan A, Sperzel J, Güttler N, Schwarz T, Pitschner HF, Neuzner J. Prospective randomized comparison of two defibrillation safety margins in unipolar, active pectoral defibrillator therapy. Pacing Clin Electrophysiol 2003; 26:613-8. [PMID: 12710322 DOI: 10.1046/j.1460-9592.2003.00102.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Various techniques are used to establish defibrillation efficacy and to evaluate defibrillation safety margins in patients with an ICD. In daily practice a safety margin of 10 J is generally accepted. However, this is based on old clinical data and there are no data on safety margins using current ICD technology with unipolar, active pectoral defibrillators. Therefore, a randomized study was performed to test if the likelihood of successful defibrillation at defibrillation energy requirement (DER) + 5 J and + 10 J is equivalent. Ninety-six patients (86 men; age 61.0 +/- 10.3 years; ejection fraction 0.341 +/- 0.132; coronary artery disease [n = 65], dilated cardiomyopathy [n = 18], other [n = 13]) underwent implantation of an active pectoral ICD system with unidirectional current pathway and a truncated, fixed tilt biphasic shock waveform. The defibrillation energy requirement (DER) was determined with the use of a step-down protocol (delivered energy 15, 10, 8, 6, 4, 3, 2 J). The patients were then randomized to three inductions of ventricular fibrillation at implantation and three at predischarge testing with shock strengths programmed to DER + 5 J at implantation and + 10 J at predischarge testing or vice versa. The mean DER in the total study population was 7.88 +/- 2.96 J. The number of defibrillation attempts was 288 for + 5 J and 288 for + 10 J. The rate of successful defibrillation was 94.1% (DER + 5 J) and 98.9% (DER + 10 J; P < 0.01 for equivalence). Charge times for DER + 5 J were significantly shorter than for DER + 10 J (3.65 +/- 1.14 vs 5.45 +/- 1.47 s; P < 0.001). A defibrillation safety margin of DER + 5 J is associated with a defibrillation probability equal to the standard DER + 10 J. In patients in whom short charge times are critical for avoidance of syncope, a safety margin of DER + 5 J seems clinically safe for programming of the first shock energy.
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Affiliation(s)
- Joerg Carlsson
- Department of Cardiology, Kerckhoff-Clinic, Bad Nauheim, Germany.
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11
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Winter J, Zimmermann N, Lidolt H, Dees H, Perings C, Vester EG, Poll L, Schipke JD, Contzen K, Gams E. Optimal method to achieve consistently low defibrillation energy requirements. Am J Cardiol 2000; 86:71K-75K. [PMID: 11084103 DOI: 10.1016/s0002-9149(00)01294-7] [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: 11/22/2022]
Abstract
Reduction of the defibrillation energy requirement offers the opportunity to decrease implantable cardioverter defibrillator (ICD) size and to increase device longevity. Therefore, the purpose of this prospective study was to obtain confirmed defibrillation thresholds (DFTs) of < or = 15 J in each patient with an endocardial dual-coil lead system incorporating an active pectoral pulse generator (TRIAD lead system: RV- --> SVC+ + CAN+). According to our previous clinical and experimental studies, we tried to lower DFTs that were > 15 J by repositioning the distal coil of the endocardial lead system in the right ventricle. A total of 190 consecutive patients requiring ICDs for ventricular fibrillation and/or recurrent ventricular tachycardia were investigated at the time of ICD implantation (42 women, 148 men; mean age 61.9 +/- 12.0 years; mean left ventricular ejection fraction 42.7 +/- 16.6%). Coronary artery disease was present in 139 patients; nonischemic dilated cardiomyopathy in 34 patients; and other etiologies in 17 patients; 47 patients had undergone previous cardiac surgery. Regardless of optimal pacing and sensing parameters, for patients having DFTs > 15, we repositioned the distal coil of the endocardial lead system toward the intraventricular septum to include this part of both ventricles within the electrical defibrillating field. In 177 of 190 patients, induced ventricular fibrillation was successfully terminated with < or = 15 J (group I) using the initial lead position. Repositioning of the endocardial lead was necessary in 13 patients whose DFT(plus) (DFT(plus) = second additional success at lowest energy level) were > 15 J (group II). In all patients, repositioning was successful within a 15 J energy level (100% success). The mean DFT(plus) was 7.3 +/- 3.5 J (group I) and 11.0 +/- 4.5 J (group II; p<0.005). The mean DFT(plus) of all patients enrolled in the study was 7.6 +/- 3.7 J (range: 2 to 15 J). In 87% of all patients, DFT(plus) of < or = 10 J was achieved. Repositioning of the endocardial lead in the right ventricle is a simple and effective method to reduce intraoperative high DFTs. As a result of this procedure, ICDs with a 20 J output should be sufficient for the vast majority (87%) of our patients. Furthermore, we were able to avoid additional subcutaneous or epicardial electrodes in all patients.
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Affiliation(s)
- J Winter
- Department of Thoracic and Cardiovascular Surgery, Heinrich-Heine-University, Duesseldorf, Germany
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Trusty JM, Hayes DL, Stanton MS, Friedman PA. Factors affecting the frequency of subcutaneous lead usage in implantable defibrillators. Pacing Clin Electrophysiol 2000; 23:842-6. [PMID: 10833704 DOI: 10.1111/j.1540-8159.2000.tb00853.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Subcutaneous leads (SQ) add complexity to the defibrillation system and the implant procedure. New low output devices might increase the requirement for SQ arrays, although this might be offset by the effects of active can and biphasic technology. This study sought to assess the impact of these technologies on SQ lead usage, and to determine if clinical variables could predict the need for an SQ lead. Patients receiving nonthoracotomy systems (n = 554) at our institution underwent step-down-to-failure DFT testing with implant criteria of a 10-J safety margin. SQ leads were used only after several endovascular configurations failed. Use of biphasic waveforms significantly lowered the frequency of use of SQ leads from 48% to 3.7% (P < 0.000001). SQ leads were required in 4.4% of patients with cold can devices and 2.6% of patients with active can devices (P = NS). There was no increase in SQ lead usage with low energy (< 30-J delivered energy) devices. Clinical variables (including EF, heart disease, arrhythmia, and prior bypass) did not predict the need for an SQ lead. The implant DFT using SQ arrays (14.5 +/- 6.5 J) was not significantly lower than that for SQ patches (16.6 + 6.0 J). We conclude that biphasic waveforms significantly reduce the need for SQ leads. Despite this reduction, 3.7% of implants still use an SQ lead to achieve adequate safety margins. The introduction of lower output devices has not increased the need for SQ leads, and when an SQ lead is required, there is not a significant difference in the implant DFT of patches versus arrays. Clinical variables cannot predict which patients require SQ leads.
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Affiliation(s)
- J M Trusty
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA
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