Locally propagated activation immediately after internal defibrillation

The Defibrillation Conundrum: New Insights into the Mechanisms of Shock-Related Myocardial Injury Sustained from a Life-Saving Therapy

Implantable cardiac defibrillators (ICDs) are recommended to prevent the risk of sudden cardiac death. However, shocks are associated with an increased mortality with a dose response effect, and a strategy of reducing electrical therapy burden improves the prognosis of implanted patients. We review the mechanisms of defibrillation and its consequences, including cell damage, metabolic remodeling, calcium metabolism anomalies, and inflammatory and pro-fibrotic remodeling. Electrical shocks do save lives, but also promote myocardial stunning, heart failure, and pro-arrhythmic effects as seen in electrical storms. Limiting unnecessary implantations and therapies and proposing new methods of defibrillation in the future are recommended.

Imaging of Ventricular Fibrillation and Defibrillation: The Virtual Electrode Hypothesis

Ventricular fibrillation is the major underlying cause of sudden cardiac death. Understanding the complex activation patterns that give rise to ventricular fibrillation requires high resolution mapping of localized activation. The use of multi-electrode mapping unraveled re-entrant activation patterns that underlie ventricular fibrillation. However, optical mapping contributed critically to understanding the mechanism of defibrillation, where multi-electrode recordings could not measure activation patterns during and immediately after a shock. In addition, optical mapping visualizes the virtual electrodes that are generated during stimulation and defibrillation pulses, which contributed to the formulation of the virtual electrode hypothesis. The generation of virtual electrode induced phase singularities during defibrillation is arrhythmogenic and may lead to the induction of fibrillation subsequent to defibrillation. Defibrillating with low energy may circumvent this problem. Therefore, the current challenge is to use the knowledge provided by optical mapping to develop a low energy approach of defibrillation, which may lead to more successful defibrillation.

New insights into defibrillation of the heart from realistic simulation studies

Cardiac defibrillation, as accomplished nowadays by automatic, implantable devices, constitutes the most important means of combating sudden cardiac death. Advancing our understanding towards a full appreciation of the mechanisms by which a shock interacts with the heart, particularly under diseased conditions, is a promising approach to achieve an optimal therapy. The aim of this article is to assess the current state-of-the-art in whole-heart defibrillation modelling, focusing on major insights that have been obtained using defibrillation models, primarily those of realistic heart geometry and disease remodelling. The article showcases the contributions that modelling and simulation have made to our understanding of the defibrillation process. The review thus provides an example of biophysically based computational modelling of the heart (i.e. cardiac defibrillation) that has advanced the understanding of cardiac electrophysiological interaction at the organ level, and has the potential to contribute to the betterment of the clinical practice of defibrillation.

The effect of pinacidil on postshock activation and ventricular defibrillation threshold in canine hearts

AIM

To determine the postshock activation patterns with both successful and failed shocks in a canine model of ventricular fibrillation, and whether piniacidil, an early after-depolarization (EAD) inhibitor, altered the defibrillation threshold (DFT) and postshock activation patterns.

METHODS

In 6 beagles, a basket catheter with 64 unipolar electrodes was placed in the LV for global endocardial mapping, a monophasic action potential catheter was inserted into the LV apex, and a catheter with the negative electrode in the right ventricle and the positive electrode in the superior vena cava was inserted for defibrillation. The DFT, 90% action potential duration (APD(90)) and activation recovery interval (ARI) were evaluated before and after pinacidil administration (loading dosage 0.5 mg/kg and maintenance dosage 0.5 mg·kg(-1)·h(-1), iv). Electrical heterogeneities were defined with the dispersion of ARI. After successful and failed shocks with near-DFT strength, the earliest postshock activation patterns (focal or nonfocal endocardial activation), interval and location were detected.

RESULTS

Pinacidil significantly decreased APD(90) (from 178±16 ms to 168±18 ms) and ARI from (152±10 ms to 143±10 ms) at pacing cycle length of 300 ms. The drug significantly increased VF activation rate (from 10.0±1.9 Hz to 10.8±2.0 Hz). The drug did not affect the dispersion of ARI, neither it changed DFT (baseline: 480±110 V; pinacidil: 425±55 V, P>0.05). The earliest postshock activation arose locally on the LV apical endocardium before and after the drug treatment. Pinacidil significantly prolonged the postshock cycle length of cycles 2 to 5 for the successful episodes but not for the failed episodes.

CONCLUSION

Pinacidil increases the postshock cycle length suggesting that EAD may play a role in postshock activation, while it fails to alter DFT suggesting that EAD produced by shock does not determine a defibrillation success or failure.

Modeling defibrillation of the heart: approaches and insights

Cardiac defibrillation, as accomplished nowadays by automatic, implantable devices (ICDs), constitutes the most important means of combating sudden cardiac death. While ICD therapy has proved to be efficient and reliable, defibrillation is a traumatic experience. Thus, research on defibrillation mechanisms, particularly aimed at lowering defibrillation voltage, remains an important topic. Advancing our understanding towards a full appreciation of the mechanisms by which a shock interacts with the heart is the most promising approach to achieve this goal. The aim of this paper is to assess the current state-of-the-art in ventricular defibrillation modeling, focusing on both numerical modeling approaches and major insights that have been obtained using defibrillation models, primarily those of realistic ventricular geometry. The paper showcases the contributions that modeling and simulation have made to our understanding of the defibrillation process. The review thus provides an example of biophysically based computational modeling of the heart (i.e., cardiac defibrillation) that has advanced the understanding of cardiac electrophysiological interaction at the organ level and has the potential to contribute to the betterment of the clinical practice of defibrillation.

Physiologic cardiovascular strain and intrinsic wave imaging

Cardiovascular disease remains the primary killer worldwide. The heart, essentially an electrically driven mechanical pump, alters its mechanical and electrical properties to compensate for loss of normal mechanical and electrical function. The same adjustment also is performed in the vessels, which constantly adapt their properties to accommodate mechanical and geometrical changes related to aging or disease. Real-time, quantitative assessment of cardiac contractility, conduction, and vascular function before the specialist can visually detect it could be feasible. This new physiologic data could open up interactive therapy regimens that are currently not considered. The eventual goal of this technology is to provide a specific method for estimating the position and severity of contraction defects in cardiac infarcts or angina. This would improve care and outcomes as well as detect stiffness changes and overcome the current global measurement limitations in the progression of vascular disease, at little more cost or risk than that of a clinical ultrasound.

Electromechanical wave imaging of normal and ischemic hearts in vivo

Electromechanical wave imaging (EWI) has recently been introduced as a noninvasive, ultrasound-based imaging modality, which could map the electrical activation of the heart in various echocardiographic planes in mice, dogs, and humans in vivo. By acquiring radio-frequency (RF) frames at very high frame rates (390-520 Hz), the onset of small, localized, transient deformations resulting from the electrical activation of the heart, i.e., generating the electromechanical wave (EMW), can be mapped. The correlation between the EMW and the electrical activation speed and pacing scheme has previously been reported. In this study, we pursue the development of EWI using both displacements and strains and analysis of the EMW properties in dogs in vivo for early detection of ischemia. EWI was performed in normal and ischemic open-chest dogs during sinus rhythm. Ischemia of increasing severity was obtained by gradually obstructing the left-anterior descending (LAD) coronary artery flow. We also introduce the novel method of motion-matching that achieves the reconstruction of the full EWI ciné-loop at very high frame rates even when the ECG may be irregular or unavailable. Incremental displacements were previously used by our group to map the EMW. This paper focuses on the associated incremental strains, which facilitate the interpretation of the EMW by relating it directly to contraction. Moreover, we define the onset of the EMW as the time, at which the incremental strains change sign after the onset of the QRS complex of the ECG. Based on this definition, isochronal representations of the EMW were generated using a semi-automated method. The isochronal representation of the EMW during sinus rhythm was reproducible and shown similar to electrical activation maps previously reported in the literature. After segmentation using a contour-tracking method, the two- and four-chamber views were imaged and displayed in bi-plane views, allowing a 3-D interpretation of the EMW. EWI was shown to be sensitive to the presence of intermediate ischemia. EWI localized the ischemic region when the LAD flow was obstructed at 60% and beyond and was capable of mapping the increase of the ischemic region size as the LAD occlusion level increased. In conclusion, the activation maps and wave patterns obtained with EWI were similar to the electrical equivalents previously reported in the literature. Moreover, EWI was found to be sensitive enough to detect and map intermediate ischemia. Those results indicate that EWI could be used to assess the conduction properties of the myocardium, and detect its ischemic onset and disease progression entirely noninvasively.

Noninvasive electromechanical wave imaging and conduction-relevant velocity estimation in vivo

Electromechanical wave imaging is a novel technique for the noninvasive mapping of conduction waves in the left ventricle through the combination of ECG gating, high frame rate ultrasound imaging and radio-frequency (RF)-based displacement estimation techniques. In this paper, we describe this new technique and characterize the origin and velocity of the wave under distinct pacing schemes. First, in vivo imaging (30 MHz) was performed on anesthetized, wild-type mice (n=12) at high frame rates in order to take advantage of the transient electromechanical coupling occurring in the myocardium. The RF signal acquisition in a long-axis echocardiographic view was gated between consecutive R-wave peaks of the mouse electrocardiogram (ECG) and yielded an ultra-high RF frame rate of 8000 frames/s (fps). The ultrasound RF signals in each frame were digitized at 160 MHz. Axial, frame-to-frame displacements were estimated using 1D cross-correlation (window size of 240 microm, overlap of 90%). Three pacing protocols were sequentially applied in each mouse: (1) sinus rhythm (SR), (2) right-atrial (RA) pacing and (3) right-ventricular (RV) pacing. Pacing was performed using an eight-electrode catheter placed into the right side of the heart with the capability of pacing from any adjacent bipole. During a cardiac cycle, several waves were depicted on the electromechanical wave images that propagated transmurally and/or from base to apex, or apex to base, depending on the type of pacing and the cardiac phase. Through comparison between the ciné-loops and their corresponding ECG obtained at different pacing protocols, we were able to identify and separate the electrically induced, or contraction, waves from the hemodynamic (or, blood-wall coupling) waves. In all cases, the contraction wave was best observed along the posterior wall starting at the S-wave of the ECG, which occurs after Purkinje fiber, and during myocardial, activation. The contraction wave was identified based on the fact that it changed direction only when the pacing origin changed, i.e., it propagated from the apex to the base at SR and RA pacing and from base to apex at RV pacing. This reversal in the wave propagation direction was found to be consistent in all mice scanned and the wave velocity values fell within the previously reported conduction wave range with statistically significant differences between SR/RA pacing (0.85+/-0.22 m/s and 0.84+/-0.20 m/s, respectively) and RV pacing (-0.52+/-0.31 m/s; p<0.0001). This study thus shows that imaging the electromechanical function of the heart noninvasively is feasible. It may therefore constitute a unique noninvasive method for conduction wave mapping of the entire left ventricle. Such a technology can be extended to 3D mapping and/or used for early detection of dyssynchrony, arrhythmias, left-bundle branch block, or other conduction abnormalities as well as diagnosis and treatment thereof.

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

Background

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

Methods

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

Results

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

Discussion

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

Ventricular fibrillation: how do we put the genie back in the bottle?

I am deeply grateful and honored to receive the 2006 Distinguished Scientist Award from the Heart Rhythm Society. Many outstanding individuals have received this award since it was established in 1982, and it is humbling to realize that my small feet are walking in the footsteps of these giants. I would be remiss if I did not thank the numerous colleagues, fellows, and students who performed most of the work leading to the papers of which I am a coauthor.

Effects of Sildenafil Citrate on Defibrillation Efficacy

INTRODUCTION

Although fatal arrhythmia and sudden death have been reported in patients taking sildenafil citrate, its effect on defibrillation efficacy has not been investigated. The aim of this study was to test the hypothesis that sildenafil citrate increases the shock strength required to successfully defibrillate during ventricular fibrillation (VF).

METHODS AND RESULTS

A total of 26 pigs (20-25 kg) were randomly assigned into three groups. In each group, the defibrillation threshold (DFT) was determined at the beginning of the study using a three-reversal up/down protocol. Each shock (RV-SVC, biphasic) was delivered after 10 seconds of VF. Group 1 (n = 10) received 50 mg and group 2 (n = 10) received 100 mg of sildenafil citrate intravenously at a rate of 2 mL/minute for 50 minutes. Group 3 (n = 6) received 100 mL of saline intravenously at the same rate as in group 1. The DFT was determined again after the drug (drug-DFT) and saline (saline-DFT) administration. For 100-mg sildenafil citrate infusion, the DFT (483 +/- 39 V, 18 +/- 3 J) was significantly (P < 0.003 and P < 0.01, respectively) higher than the control-DFT (407 +/- 123 V, 13 +/- 7 J). This sildenafil citrate infusion increased the DFT approximately 19% by voltage, and approximately 38% by total energy. After 50-mg sildenafil citrate infusion, the DFT (454 +/- 28 V, 15 +/- 2 J) was not different than the control DFT (449 +/- 28 V, 15 +/- 2 J). Saline infusion (391 +/- 18 V, 12 +/- 1 J) did not alter the control DFT (399 +/- 22 V, 12 +/- 1 J).

CONCLUSION

The 100-mg sildenafil citrate infusion, representing a supra-therapeutic plasma level, significantly increased the DFT. This finding indicates that VF occurring during supra-therapeutic sildenafil citrate treatment would require a stronger shock to successfully defibrillate.

Characterization of the relationship between preshock state and virtual electrode polarization-induced propagated graded responses resulting in arrhythmia induction

BACKGROUND

Studies have demonstrated that failed defibrillation shocks often are followed by an electrically quiescent period (isoelectric window); however, the underlying mechanisms remain incompletely understood. We recently suggested a new mechanism termed "virtual electrode polarization-induced propagated graded responses" (VEPiPGRs) that might play a role in the origin of the global postshock activation following the isoelectric window.

OBJECTIVES

The purpose of this study to elucidate the circumstances under which VEPiPGR activations originate for shocks given to paced right ventricular preparations. Specifically, we examined the dependence of VEPiPGRs on coupling interval (CI) and shock polarity and whether VEPiPGRs emerge preferentially on the epicardium or the endocardium.

METHODS

Simultaneous endocardial and epicardial activity in isolated right ventricular preparations (n = 4) was imaged optically following shocks of strength +/-5A. All VEPiPGRs were analyzed, and the time T from shock end to activation onset was recorded (isoelectric window is the smallest T among activations that propagated globally).

RESULTS

VEPiPGR activations occurred for CIs in the range from 80 to 150 ms. Average duration of T was 64.5 +/- 18.15 ms, with T decreasing as CI increased (Tmax = 82 ms, Tmin = 46 ms, linear-fit slope = -0.675). The average earliest CI at which cathodal (+5A) shocks resulted in VEPiPGRs was 87 ms compared with 116 ms for anodal (-5A) shocks. All VEPiPGR activations emerged first on the epicardium in a focal pattern, and all induced ventricular fibrillation.

CONCLUSION

The global activation that terminates the isoelectric window could result from VEPiPGRs that find an exit pathway. VEPiPGRs originate at the sites of maximum action potential abbreviation by the shock, always on the epicardium for the preparation used here.

Evidence that activation following failed defibrillation is not caused by triggered activity

BACKGROUND

Earliest postshock activation following failed defibrillation shocks slightly lower than the defibrillation threshold (DFT) in large animals appears to arise from a focus. We tested the hypothesis that these foci are caused by early or delayed afterdepolarizations (EADs or DADs) by performing epicardial electrical mapping and giving the EAD inhibitor pinacidil or the DAD inhibitor flunarizine to see if the foci were extinguished or altered in timing or location.

METHODS AND RESULTS

A sock containing 504 electrodes was placed over the entire ventricular epicardium of 12 open-chested pigs. After the DFT was determined and additional shocks given, pinacidil was administered to 6 pigs and flunarizine to 6 pigs. Then, the DFT was again determined and additional shocks were given. Pinacidil significantly shortened the effective refractory period (ERP) (162 +/- 16 vs 130 +/- 28 msec) and action potential duration (APD(90)) (179 +/- 6 vs 149 +/- 19 msec) and significantly increased the peak frequency of the power spectrum of a left ventricle (LV) electrode during ventricular fibrillation (VF) (9.3 +/- 0.6 vs 10.5 +/- 1.0 Hz), while flunarizine did not significantly alter the ERP (162 +/- 8 vs 167 +/- 18 msec) or APD(90) (187 +/- 12 vs 191 +/- 20) but significantly reduced the peak frequency (9.2 +/- 0.5 vs 7.5 +/- 1.0 Hz). These findings suggest the drugs had their expected electrophysiological effects. However, the DFT was not significantly changed by either drug. Following the same strength shock 10% below the predrug DFT, earliest postshock activation arose in a focal epicardial pattern from the anterior-apical LV both before and after the drugs. The time from the shock until the appearance of this activation was not significantly different before and after either drug.

CONCLUSION

The lack of change in DFT as well as the lack of change in the incidence, location, and timing of the postshock focus with sub-DFT strength shocks before and after pinacidil and flunarizine provide evidence that these foci are not caused by triggered activity.

Activation sequences following failed atrial defibrillation

OBJECTIVES

The purposes of this study were to examine the first activations following atrial defibrillation shocks to help understand how and where atrial fibrillation (AF) relapsed following failed shocks and to assess the difference in postshock activation between failed and successful shocks.

BACKGROUND

While many studies have investigated the mechanism of ventricular defibrillation, much less is known about the mechanisms of AF.

METHODS

Sustained AF was induced electrically after pericardial infusion of methylcholine in 10 sheep. Biphasic subthreshold shocks were delivered to three configurations: right atrium to distal coronary sinus (RA-CS), sequential shocks with RA-CS as the first pathway followed by proximal CS to superior vena cava as the second pathway (Sequential), and right ventricle to superior vena cava plus can (V-triad). In eight sheep, global atrial mapping was performed with 504 electrodes spaced 3 to 4 mm apart.

RESULTS

Earliest postshock activations mostly arose from the left atrium for V-triad but arose from either atrium for RA-CS and Sequential. Preshock AF cycle lengths were significantly shorter at the earliest activation sites than at seven of eight other sites globally distributed over both atria. In all type B successful episodes in which one or more rapid activations occurred after the shock and in 50 of the 72 failed episodes analyzed, activation fronts spread away from the earliest site in a focal pattern, and discrete nonfragmented activation complexes were present in the first derivatives of the electrograms. In the other 22 failed episodes, earliest activation fronts spread in a nonfocal pattern, and earliest postshock electrogram derivatives were fractionated. To better interpret the activation pattern in the fragmented regions, a 504 electrode plaque with 1.5-mm electrode spacing was placed on the right atrial appendage in two additional sheep. In 11 of 108 failed episodes, earliest postshock activation appeared inside the plaque and spread in a focal pattern with nonfragmented electrogram derivatives in 10 episodes and in a reentrant pattern with fragmented electrogram derivatives in the other.

CONCLUSIONS

(1) The electrode configuration influenced the location of earliest postshock activation. (2) Earliest postshock activation occurred where the preshock AF cycle length was short. (3) Earliest activations following all type B successful and most failed episodes were not fragmented and spread in a focal pattern. (4) The region of earliest postshock activation in the failed episodes without a focal postshock activation pattern exhibited regions of fragmented electrogram derivatives that may represent conduction block and possibly reentry.

A comparison of biventricular and conventional transvenous defibrillation: a computational study using patient derived models

Conventional transvenous defibrillation is performed with an ICD using a dual current pathway. The defibrillation energy is delivered from the RV electrode to the superior vena cava (SVC) electrode and the metallic case (CAN) of the ICD. Biventricular defibrillation uses an additional electrode placed in the LV free wall with sequential shocks to create an additional current vector. Clinical studies of biventricular defibrillation have reported a 45% reduction in mean defibrillation threshold (DFT) energy. The aim of the study was to use computational methods to examine the biventricular defibrillation fields together with their corresponding DFTs in a variety of patient derived models and to compare them to simulations of conventional defibrillation. A library of thoracic models derived from nine patients was used to solve for electric field distributions. The defibrillation waveform consisted of a LV --> SVC + CAN monophasic shock followed by a biphasic shock delivered via the RV --> SVC + CAN electrodes. When the initial voltage of the two shocks is the same, the simulations show that the biventricular configuration reduces the mean DFT by 46% (3.5 +/- 1.3 vs 5.5 +/- 2.7 J, P = 0.005). When the leading edge of the biphasic shock is equal to the trailing edge of the monophasic shock, there is no statistically significant difference in the mean DFT (4.9 +/- 1.9 vs 5.5 +/- 2.7 J, P > 0.05) with the DFT decreasing in some patients and increasing in others. These results suggest that patient-specific computational models may be able to identify those patients who would most benefit from a biventricular configuration.

Effect of Rapid Biphasic Shock Subpulse Switching on Ventricular Defibrillation Thresholds

INTRODUCTION

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

METHODS AND RESULTS

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

CONCLUSION

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

Defibrillation causes immediate cardiac dilation in humans

Defibrillation Causes Dilation.

INTRODUCTION

Prior studies in isolated heart tissue have shown both excitation and deexcitation to be the primary mechanism of defibrillation. This article presents the first evidence in man of deexcitation immediately following defibrillation by tracking the heart's mechanical response.

METHODS AND RESULTS

The geometric changes of the ventricular chambers were measured before and after defibrillation in seven human subjects receiving an implantable cardioverter defibrillator (ICD). The ICD was used to produce approximately three episodes of ventricular fibrillation and defibrillation in each subject. Twenty-two two-dimensional echocardiographic images of the right ventricle (RV) and 11 images of the left ventricle (LV) were recorded and analyzed at 30 frames per second. Just over 2 seconds of each episode were digitized, beginning half a second before the defibrillation shock. Individual frames were analyzed to yield cross-sectional, ventricular chamber area as a function of time. Immediately following defibrillation, ventricular chambers dilated with significant fractional area increase (RV: 1.58 +/- 0.25, LV: 1.10 +/- 0.06), with peak dilation at 194 +/- 114 msec.

CONCLUSION

Defibrillation causes a rapid increase in ventricular chamber area due to relaxation of the myocardium, suggesting that defibrillation synchronizes the cardiac cells to the deexcited state in man.

Effect of sotalol and acute ventricular dilatation on action potential duration and dispersion of repolarization after defibrillation shocks

Ventricular dilatation shortens action potential duration and increases the defibrillation threshold, whereas sotalol prolongs action potential duration and may decrease the defibrillation threshold. Whether these action potential changes remain after defibrillation shocks, and how they relate to defibrillation success, is not known. In this study, eight monophasic action potentials were recorded simultaneously during electrical defibrillation (shock strength: 20%-200% of the defibrillation threshold) in 16 normal and acutely dilated isolated rabbit hearts at baseline and after addition of sotalol (2 x 10-5 M). Post-shock action potential duration (PS-APD) and dispersion of PS-APD [Disp(PS-APD)] of monophasic action potentials were analyzed after 322 defibrillation shocks at different repolarization levels and related to defibrillation success. Acute ventricular dilatation shortened PS-APD, whereas sotalol prolonged PS-APD. Successful defibrillation was associated with lower Disp(PS-APD) at all repolarization levels in the normal and dilated heart at baseline and with sotalol (mean difference: 33%-46%, all P < 0.005). Minimal PS-APD was longer (mean difference: 5%-11%), while maximal PS-APD was shorter (mean difference: 2%-16%) after successful defibrillation shocks than after failing defibrillation shocks. Therefore, sotalol prolongs action potential duration after defibrillation shocks. Synchronization of repolarization, caused by both prolongation of short PS-APD and shortening of long PS-APD, is associated with successful defibrillation in the normal, acutely dilated, and sotalol-treated heart.

Left ventricular geometry immediately following defibrillation: shock-induced relaxation

A previous two-dimensional (2D) ultrasound study suggested that there is relaxation of the myocardium after defibrillation. The 2D study could not measure activity occurring within the first 33 ms after the shock, a period that may be critical for discriminating between shock- and excitation-induced relaxation. The objective of our study was to determine the left ventricular (LV) geometry during the first 33 ms after defibrillation. Biphasic defibrillation shocks were delivered 5-50 s after the induction of ventricular fibrillation in each of the seven dogs. One-dimensional, short-axis ultrasound images of the LV cavity were acquired at a rate of 250 samples/s. The LV cavity diameter was computed from 32 ms before to 32 ms after the shock. Preshock and postshock percent changes in LV diameter were analyzed as a function of time with the use of regression analysis. The normalized mean pre- and postshock slopes (0.2 +/- 2.2 and 3.3 +/- 7.9% per 10 ms) were significantly different (P < 0.01). The postshock slope was positive (P < 0.005). Our results confirm that the bulk of the myocardium is relaxing immediately after defibrillation.

Comparison of coronary venous defibrillation with conventional transvenous internal defibrillation in man

OBJECTIVE

Animal studies have shown that defibrillation in coronary veins is more effective than in the right ventricle. We aimed to assess the feasibility of placing defibrillation electrodes in the middle cardiac vein (MCV) in man and its impact on defibrillation requirements.

METHODS

A prospective randomised study conducted in a tertiary referral centre. 10 patients (9 male) undergoing ICD implantation (65 (12) yrs) for NASPE/BPEG indications were studied. Defibrillation thresholds (DFT) were measured, using a binary search and an external defibrillator after 10 seconds of ventricular fibrillation, for the following configurations in each patient (order of testing randomised): RV + MCV --> Can and RV --> SVC + Can.

INTERVENTIONS

A dual coil defibrillation electrode was placed transvenously in the right ventricle (RV) in the conventional manner. Using a guiding catheter a 3.2 Fr (67.5 mm length) electrode was placed transvenously in MCV. A test-can was placed subcutaneously in the left pectoral region.

RESULTS

Lead placement was possible in 8/10 pts. Time to perform a middle cardiac venogram and place the electrode was 21 (23) mins. No adverse events were observed. Defibrillation current was less (6.7 (2.7) A) with RV + MCV --> Can compared to the conventional RV --> SVC + Can configuration (8.9 (3.4) A, p = 0.03). There was no significant difference in defibrillation voltage or energy. However, shock impedance was higher in the former configuration (57 (10) v. 43 (6) Omega, p = 0.001).

CONCLUSIONS

In the majority of cases placement of a defibrillation lead in MCV is feasible. Defibrillation current requirements are 25% less when the shock is delivered using a MCV electrode.

Automatic implantable cardioverter-defibrillators

Ventricular fibrillation, a loss of synchronous electrical activity in the heart which leads to hemodynamic collapse, is a leading cause of death. Because of the devastating personal and societal effects of this phenomenon, the automatic cardioverter-defibrillator has been developed for automatic detection and termination of the arrhythmia and is in widespread clinical use. Advances in circuits, leads, waveforms, and signal processing along with increased knowledge of the mechanisms of fibrillation have led to continuing improvements in this device, extending its use to many patients. A device has also been developed for the automatic or semiautomatic treatment of atrial fibrillation, an arrhythmia less life-threatening than ventricular fibrillation, but still a serious health problem. Continued improvement of these devices and the development of qualitatively new approaches hold great promise for exciting therapeutic advances in this area.

Single capacitive discharge utilizing an auxiliary shock in the coronary venous system reduces the defibrillation threshold

Auxiliary shocks (AS) from electrodes sutured to the left ventricle (LV) prior to primary biphasic shocks (PS) have been shown to reduce defibrillation thresholds (DFT). Two capacitors are required to generate these waveforms. We investigate delivery of AS from one capacitor using a novel waveform. The epicardial surface of the LV is accessed transvenously via the middle cardiac vein (MCV) avoiding a thoracotomy.

METHODS

A defibrillation electrode was placed in the right ventricle (RV) and superior vena cava (SVC) in 12 pigs (37+/-2 kg). A 50x1.8 mm electrode was inserted in the MCV through a guide catheter. A can was placed in the left pectoral region. A monophasic AS (100 microF, 1.5 J) was delivered along one pathway before switching to deliver a biphasic waveform (40% tilt, 2 ms phase 2) along another. DFTs (PS+AS) were assessed using a binary search. Two configurations not incorporating AS acted as controls. DFTs were compared using repeated measures analysis of variance.

RESULTS

DFTs of the four novel configurations (AS/PS) were: RV-->Can/MCV-->Can=14.9+/-3.7 J, MCV-->Can/RV-->Can=17.2+/-5.7 J, RV-->SVC+Can/MCV-->SVC+Can=13.4+/-4.6 J, MCV-->SVC+Can/RV-->SVC+Can=17.1+/-5.9 J. Delivering AS in the RV followed by PS in the MCV reduced the DFT (RV-->Can (19.9+/-7.3 J, P<0.01) and RV-->SVC+Can (19.2+/-6.0 J, P<0.05)).

CONCLUSIONS

Delivering AS prior to PS in the MCV reduces the DFT by up to a third compared to conventional configurations of RV-->Can and RV-->SVC+Can. This is possible using only a single capacitor and an entirely transvenous approach to the LV.

Defibrillation and the geometry of the heart: a novel measurement with implications for defibrillation mechanisms

We present a novel measurement for studying defibrillation mechanisms: the time course of changes in the size of the left ventricular (LV) cavity within 500 ms following defibrillation. Mechanical changes can be linked to electrical mechanisms via an understanding of excitation-contraction coupling. Eight mongrel dogs were internally defibrillated 5-50 seconds (including backup shocks) after the onset of 20 ventricular fibrillation (VF) episodes per animal. Two dimensional, short axis, LV cavity, ultrasound images were recorded at 30 frames per second just prior to inducing VF, during defibrillation and following the shock. Each frame was individually analysed to yield the LV cavity area as a function of time. Defibrillation shocks were followed by a highly reproducible phenomenon: (1) a dramatic and rapid increase in LV area, (2) a more or less prominent LV area plateau and (3) a decrease in the LV area. The peak fractional area increase ranged from 1.65 to 4.64 times larger than the baseline (LV area just prior to defibrillation), averaging 2.18 +/- 0.686. Successful shocks took significantly longer (p < 0.01) to return to 1.3 times the baseline (407 +/- 209 ms) than unsuccessful shocks (296 +/- 130 ms). Extrapolating to electrical mechanisms, our novel measurement demonstrates that defibrillation causes immediate relaxation and therefore suggests a significant role for deexcitation in defibrillation.

Effect of altering the left ventricular pressure on epicardial activation time in dogs with and without pacing-induced heart failure

BACKGROUND

The influence of an increased left ventricular end-diastolic pressure (LVEDP) on the development of lethal arrhythmias in chronic heart failure is unclear. We investigated the effect of chronic and acute LVEDP increase on the epicardial activation time of sinus (SB) and paced (PB) beats.

METHODS

Six dogs underwent rapid ventricular pacing at 220-280[emsp4 ]beats/min for 6-14 weeks for induction of heart failure. On the study day, baseline (ba) LVEDP was determined for the surviving heart failure animals (HF-ba), and for seven control animals (C-ba). The epicardial activation time (EAT, time between the earliest and latest epicardial activation) for five consecutive SB and five ventricular PB during the baseline hemodynamic state were recorded using a 504 electrode mapping-sock. In the control animals a 2-litre volume (vl) was infused over 10[emsp4 ]min to acutely increase the LVEDP (C-vl) to a level comparable to the chronic increased LVEDP of the HF-ba. The same volume challenge was performed in two HF animals (HF-vl) and the EAT for SB and PB was redetermined.

RESULTS

Three of six HF animals died during induction of heart failure. In the three remaining HF animals, chronic LVEDP increased from 6+/-1 to 17+/-10.8[emsp4 ]mmHg (P=0.07), EAT for SB increased by 68 % compared to control animals (HF-ba vs. C-ba, P<0.05). In contrast, in the control animals the acute rise in LVEDP from 6.8+/-4.5 to 14.7+/-6.2 mmHg P<0.05), shortened the EAT for SB (C-ba vs. C-vl, P<0.05). A similar decrease in EAT for SB caused by acute volume load was seen in the HF animals, but did not reach significance due to the small sample size (one of the three remaining HF animals died of spontaneous ventricular fibrillation before the volume load). Chronic LVEDP elevation significantly prolonged the EAT for PB from 72+/-11 to 120+/-31[emsp4 ]ms (C-ba vs. HF-ba) while acute LVEDP increase had no significant effect on EAT for PB.

CONCLUSION

Chronic HF increases LVEDP and prolongs EAT, while an acute increase in LVEDP shortens the EAT for sinus beats. A prolongation of EAT in heart failure may make the heart more susceptible to ventricular arrhythmias and electromechanical dissociation.

Marked reduction of ventricular defibrillation threshold by application of an auxiliary shock to a catheter electrode in the left posterior coronary vein of dogs

INTRODUCTION

For endocardial shocks near the defibrillation threshold (DFT), postshock activity originates from the lateral left ventricular apex, where the shock field is weak. This study tested the hypothesis that an auxiliary shock (AS) delivered between an electrode at this site and a superior vena cava (SVC) electrode before the primary endocardial shock (PS) would reduce the DFT.

METHODS AND RESULTS

In six pentobarbital-anesthetized dogs (26 to 36 kg), catheter electrodes were placed in the right ventricular (RV) apex and the SVC. To simulate transvenous introduction, a small electrode was inserted into the posterior cardiac vein using an epicardial approach. For dual shock treatments, AS (2-msec monophasic) was applied to the coronary vein electrode at different time intervals before a biphasic PS (4 msec/3 msec) to the RV-SVC electrodes. The mean DFT energy for dual shocks treatments were significantly reduced (P < 0.05) in comparison to the control treatment (no AS, 26.5+/-8.8 J). Mean DFT energy after 10 seconds of electrically induced ventricular fibrillation for dual shocks, in which AS and PS were separated by 1, 5, 10, and 20 msec, were 10.2+/-4.1 J, 10.9+/-5.5 J, 11.3+/-6.3 J, and 15.4+/-7.2 J, respectively. These values were all significantly lower than the PS alone (26.5+/-8.8 J).

CONCLUSION

Addition of an AS from the posterior cardiac vein before an endocardial PS reduces DFT energy by more than 50%. Such DFT reduction could improve therapeutic safety margin or permit reduction in volume of implantable cardioverter defibrillators.

Energy levels for defibrillation: what is of real clinical importance?

Today, transthoracic and intracardiac defibrillation offer a well-accepted and widely used form of therapy for patients with life-threatening ventricular arrhythmias. Despite the wide clinical use of defibrillators, the mechanisms by which an electrical shock halts fibrillation are still not completely understood. During a shock, different amounts of current flow through the different parts of the heart and the current distribution is highly uneven. This current distribution is affected by changes in the shock potential gradient through the heart, changes in fiber orientation, and changes in myocardial conductivity caused by connective tissue barriers. It would be ideal if the potential gradient distribution throughout the ventricles could be measured directly for each individual patient during defibrillator implantation and follow-up and the shock strength could be programmed based on this measurement, but so far this is not possible. A more feasible approach is to determine, by trial and error, the magnitude of the shock strength delivered through the defibrillation electrodes for successful defibrillation. There is no distinct threshold value above which all shocks succeed and below which all shocks fail to defibrillate. Rather, increasing shock strength increases the likelihood the shock will succeed. Therefore, instead of a distinct defibrillation threshold, a probability of success curve exists. However, increasing the shock strength above an optimal range can actually decrease the success rate for defibrillation. One possible explanation is that the high voltage gradients caused by such large shocks damage cells and result in postshock arrhythmias that may reinitiate fibrillation. Another problem that can affect the probability of defibrillation success for a particular programmed energy setting is that the shock strength required for defibrillation may increase over time due to (1) the growth of fibrotic tissue around the defibrillation electrode; (2) migration of the lead; (3) acute ischemia; or (4) other changes in the underlying cardiac disease (e.g., worsening of heart failure). Such possible increases in the defibrillation shock strength requirement should be compensated for before they occur by adding a margin of safety to the shock strength needed for effective defibrillation. When programming an implantable defibrillator, it is important to keep in mind that the defibrillation shock should be (1) strong enough to defibrillate at least 98% of the time with the first shock; (2) weak enough not to cause severe post-shock arrhythmias or reinitiation of fibrillation; but (3) strong enough to compensate for changes of defibrillation energy requirements over time. This usually can be accomplished by setting the defibrillator 7-10 J higher than the defibrillation threshold determined by a standard step-down protocol.

Relationship between shock energy and postdefibrillation ventricular arrhythmias in patients with implantable defibrillators

BACKGROUND

The relationship between postdefibrillation ventricular arrhythmias and shock strength is poorly understood in patients with implantable defibrillators. The purpose of this study was to characterize the relationship between postdefibrillation ventricular arrhythmias and shock strength.

METHODS AND RESULTS

Forty-three patients with an implanted defibrillator underwent six separate inductions of ventricular fibrillation (VF) after a step-down defibrillation energy requirement (7.3 +/- 4.6 J) was determined. For each of the first three inductions of VF, the first two shocks were low energy and equal to approximately 75% of the defibrillation energy requirement (5.4 +/- 3.3 J), or to the defibrillation energy requirement plus 10 J (17.5 +/- 4.3 J). After the first two shocks, subsequent shocks were programmed to the maximum available energy (29.0 +/- 2.5 J). The alternate technique was used for the subsequent three inductions of VF. Postdefibrillation ventricular arrhythmias were noted. Postdefibrillation ventricular arrhythmias with a cycle length < or = 300 msec were more frequent after a low-energy shock (19%), than after a high-energy shock (1.5%; P = 0.005). Postdefibrillation ventricular arrhythmias with a cycle length < or = 300 msec were more frequent after a high-energy shock (32%), than after a low-energy shock (7.1%; P = 0.002). A relationship between the cycle length of the postdefibrillation ventricular arrhythmias and the absolute defibrillation energy was observed (P < 0.001; r = 0.6), and ventricular arrhythmias with a cycle length > 300 msec were uncommon after shocks < or = 10 J (P = 0.001). The characteristics of ventricular arrhythmias after maximum-energy shocks were similar to those that occurred after high-energy shocks.

CONCLUSIONS

Postdefibrillation ventricular arrhythmias with a cycle length < or = 300 msec are more common after shocks of strength associated with a low probability of successful defibrillation. Postdefibrillation ventricular arrhythmias with a cycle length of > 300 msec are more common after high- and maximum-energy shocks, and are directly related to the absolute defibrillation energy.