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Prutkin JM, Wang Y, Escudero CA, Stephenson EA, Minges KE, Curtis JP, Hsu JC. Defibrillation Safety Margin Testing in Patients With Congenital Heart Disease: Results From the NCDR. JACC Clin Electrophysiol 2021; 7:1145-1154. [PMID: 33933411 DOI: 10.1016/j.jacep.2021.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/10/2021] [Accepted: 02/17/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study analyzed the predictors of defibrillation safety margin (DSM) testing at the time of implantable cardioverter-defibrillator (ICD) insertion and factors associated with inadequate DSM in patients with congenital heart disease (CHD). BACKGROUND There are few data about the prevalence and safety of DSM testing in those with CHD. METHODS A retrospective analysis was performed of all patients with atrial or ventricular septal defect, tetralogy of Fallot, transposition of the great vessels, Ebstein anomaly, or common ventricle undergoing a transvenous ICD procedure in the National Cardiovascular Data Registry (NCDR) ICD Registry from April 2010 to March 2016, and DSM testing was assessed. Inadequate DSM was defined as a lowest successful energy tested <10 J than the maximum output of the ICD generator. RESULTS Of all ICD recipients (N = 7,024), DSM testing was performed in 52.0% (n = 3,654). The mean lowest successful energy tested was 20.7 ± 7.3 J. Of those with DSM adequacy data available (n = 3,623), an inadequate DSM occurred in 13.8% (n = 501). After multivariable adjustment, DSM testing was not associated with in-hospital complications or death (odds ratio [OR]: 1.00; 95% confidence interval [CI]: 0.79 to 1.28) but was associated with lower odds of prolonged hospital stay (>3 days) (OR: 0.71; 95% CI: 0.60 to 0.84; p < 0.0001). An inadequate DSM was not associated with in-hospital death or complications (OR: 1.27; 95% CI: 0.79 to 2.04) or prolonged hospital stay (OR: 1.34; 95% CI: 0.995 to 1.81). CONCLUSIONS DSM testing is being performed less frequently over time and seems safe in those with CHD. An inadequate DSM was not associated with worse in-hospital outcomes.
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Affiliation(s)
- Jordan M Prutkin
- Division of Cardiology, Section of Electrophysiology, University of Washington, Seattle, Washington, USA.
| | - Yongfei Wang
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Carolina A Escudero
- Division of Pediatric Cardiology, Section of Electrophysiology, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
| | | | - Karl E Minges
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Jeptha P Curtis
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Jonathan C Hsu
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California-San Diego, La Jolla, California, USA
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Prevalence, predictors and complications with defibrillation threshold testing in pediatric patients: Results from the NCDR. Int J Cardiol 2020; 305:44-49. [DOI: 10.1016/j.ijcard.2020.01.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/30/2019] [Accepted: 01/13/2020] [Indexed: 11/17/2022]
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Kannabhiran M, Mustafa U, Acharya M, Telles N, Alexandria B, Reddy P, Dominic P. Routine DFT testing in patients undergoing ICD implantation does not improve mortality: A systematic review and meta-analysis. J Arrhythm 2018; 34:598-606. [PMID: 30555603 PMCID: PMC6288554 DOI: 10.1002/joa3.12109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/24/2018] [Indexed: 01/30/2023] Open
Abstract
Defibrillation threshold (DFT) testing has been an integral part of implantable cardioverter-defibrillator (ICD) implantation to confirm appropriate sensing of ventricular fibrillation and to establish an adequate safety margin for defibrillation. However, there is a lack of evidence regarding benefits of routine DFT testing. Therefore, we performed a meta-analysis to assess its mortality benefit. We searched MEDLINE for studies comparing mortality outcomes in ICD recipients who underwent DFT testing to those who did not. For the second analysis, studies comparing outcomes in patients with high- vs low-energy DFT were included. Odds ratio and standard errors were calculated, and inverse variance method in a random-effect model was used to combine effect sizes. Fifteen studies with 10,975 subjects comparing outcomes in patients who underwent routine DFT testing during ICD implantation and those who did not were included. There was no difference in the group that did not undergo DFT testing with regards to all-cause mortality (OR 0.935; CI 0.725-1.207; P = 0.606), cardiac mortality (OR 0.709; CI 0.385-1.307; P = 0.271), noncardiac mortality (OR 0.921; CI 0.701-1.210; P = 0.554), and arrhythmic mortality (OR 1.152; CI 0.831-1.596; P = 0.396). Percentage of successful appropriate first shocks among the two groups showed no difference. Five studies with 2278 subjects were included in the second analysis comparing patients with low DFT vs high DFT. Patients with high DFT had no significant increase in all-cause mortality compared to patients with low DFT (OR 0.527; CI 0.034-8.107; P = 0.646). Patients requiring higher DFT had no increased all-cause mortality compared to patients with lower DFT. Routine DFT testing during ICD implantation does not confer any significant benefit.
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Affiliation(s)
- Munish Kannabhiran
- The Department of Medicine/Division of Cardiology and Center for Cardiovascular Diseases & SciencesLouisiana State University Health Sciences Center‐ Shreveport (LSUHSC‐S)ShreveportLouisiana
| | - Usman Mustafa
- The Department of Medicine/Division of Cardiology and Center for Cardiovascular Diseases & SciencesLouisiana State University Health Sciences Center‐ Shreveport (LSUHSC‐S)ShreveportLouisiana
| | - Madan Acharya
- The Department of Medicine/Division of Cardiology and Center for Cardiovascular Diseases & SciencesLouisiana State University Health Sciences Center‐ Shreveport (LSUHSC‐S)ShreveportLouisiana
| | - Nelson Telles
- The Department of Medicine/Division of Cardiology and Center for Cardiovascular Diseases & SciencesLouisiana State University Health Sciences Center‐ Shreveport (LSUHSC‐S)ShreveportLouisiana
| | - Brackett Alexandria
- The Department of Medicine/Division of Cardiology and Center for Cardiovascular Diseases & SciencesLouisiana State University Health Sciences Center‐ Shreveport (LSUHSC‐S)ShreveportLouisiana
| | - Pratap Reddy
- The Department of Medicine/Division of Cardiology and Center for Cardiovascular Diseases & SciencesLouisiana State University Health Sciences Center‐ Shreveport (LSUHSC‐S)ShreveportLouisiana
| | - Paari Dominic
- The Department of Medicine/Division of Cardiology and Center for Cardiovascular Diseases & SciencesLouisiana State University Health Sciences Center‐ Shreveport (LSUHSC‐S)ShreveportLouisiana
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Liu X, Asirvatham S, Kabell GG. Orthostatic increase in defibrillation threshold leading to defibrillation failure and prolonged cardiac arrest in a sitting position: Lessons from a patient’s near-fatal experience. HeartRhythm Case Rep 2016; 2:313-317. [PMID: 28491699 PMCID: PMC5419841 DOI: 10.1016/j.hrcr.2016.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Xiaoke Liu
- Division of Cardiology, Borgess Medical Center, and Department of Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan
- Address reprints and correspondence: Dr Xiaoke Liu, Director, Device and EP Clinic, Borgess Medical Center, 1722 Shaffer St, Kalamazoo, MI 49048Device and EP Clinic, Borgess Medical Center, 1722 Shaffer St, Kalamazoo, MI 49048
| | | | - G. Glenn Kabell
- Division of Cardiology, Borgess Medical Center, and Department of Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan
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Defibrillation Threshold Testing: Who Doesn't Get It? Card Electrophysiol Clin 2016; 4:135-41. [PMID: 26939810 DOI: 10.1016/j.ccep.2012.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Defibrillation testing has been routinely performed as part of the implantable cardioverter-defibrillator (ICD) implantation procedure, and is currently supported by practice guidelines; however, more recently, this practice has been called into question. Such testing is safe, and serious complications are rare. With modern ICD systems, physicians will rarely encounter a patient in whom defibrillation will fail. This article reviews the literature regarding the utility, necessity, complications, and cost of routine operative and follow-up defibrillation testing, and, it is hoped, clarifies the issue of "Who doesn't get it?"
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Ito H, Kawamura M, Badhwar N, Vedantham V, Tseng ZH, Lee BK, Lee RJ, Marcus GM, Gerstenfeld EP, Scheinman MM. The Effect of Direct Current Stimulation versus T-Wave Shock on Defibrillation Threshold Testing. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1173-80. [PMID: 26137999 DOI: 10.1111/pace.12684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/03/2015] [Accepted: 06/22/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There are several methods to induce ventricular fibrillation (VF) during defibrillation threshold (DFT) testing. Delivering a shock at a critical time during the T wave (T-shock) is the conventional approach, while delivering a constant direct current voltage (DC stim) from the implantable cardioverter defibrillator is an alternative method. Only a few reports compare VF induction methods. The purpose of this study was to evaluate the effects and safety of DC stim versus T-shock. METHODS We retrospectively investigated 414 consecutive patients undergoing DFT testing. We compared the two groups (DC stim and T-shock) with respect to clinical characteristics, electrocardiogram (ECG) changes, and complications. RESULTS Ventricular arrhythmia, including ventricular tachycardia (VT) and VF, was induced by DC stim in 93 patients or T-shock in 321 patients. No more than three attempts were performed during one procedure. There was no significant difference in the baseline ECG, induced tachycardia cycle length (TCL), or complications between the two groups. However, the induced TCL was significantly shorter than the clinical TCL regardless of induction method (P = 0.001). Five patients suffered major complications (i.e., electromechanical dissociation or incessant VT). A history of atrial fibrillation was significantly greater in patients with major complications than the others (80% vs 24%, P = 0.004), and was an independent predictor on multivariate analysis. CONCLUSIONS There is no significant difference in induced TCL or complications between the DC stim and T-shock. The induced TCL is significantly shorter than clinical TCL regardless of induction method.
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Affiliation(s)
- Hiroyuki Ito
- Division of Cardiac Electrophysiology, University of California San Francisco, San Francisco, California
| | - Mitsuharu Kawamura
- Division of Cardiology, Department of Medicine, Showa University, Tokyo, Japan
| | - Nitish Badhwar
- Division of Cardiac Electrophysiology, University of California San Francisco, San Francisco, California
| | - Vasanth Vedantham
- Division of Cardiac Electrophysiology, University of California San Francisco, San Francisco, California
| | - Zian H Tseng
- Division of Cardiac Electrophysiology, University of California San Francisco, San Francisco, California
| | - Byron K Lee
- Division of Cardiac Electrophysiology, University of California San Francisco, San Francisco, California
| | - Randall J Lee
- Division of Cardiac Electrophysiology, University of California San Francisco, San Francisco, California
| | - Gregory M Marcus
- Division of Cardiac Electrophysiology, University of California San Francisco, San Francisco, California
| | - Edward P Gerstenfeld
- Division of Cardiac Electrophysiology, University of California San Francisco, San Francisco, California
| | - Melvin M Scheinman
- Division of Cardiac Electrophysiology, University of California San Francisco, San Francisco, California
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Bänsch D, Bonnemeier H, Brandt J, Bode F, Svendsen JH, Táborský M, Kuster S, Blomström-Lundqvist C, Felk A, Hauser T, Suling A, Wegscheider K. Intra-operative defibrillation testing and clinical shock efficacy in patients with implantable cardioverter-defibrillators: the NORDIC ICD randomized clinical trial. Eur Heart J 2015; 36:2500-7. [PMID: 26112885 PMCID: PMC4589656 DOI: 10.1093/eurheartj/ehv292] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 06/07/2015] [Indexed: 11/14/2022] Open
Abstract
AIMS This trial was designed to test the hypothesis that shock efficacy during follow-up is not impaired in patients implanted without defibrillation (DF) testing during first implantable cardioverter-defibrillator (ICD) implantation. METHODS AND RESULTS Between February 2011 and July 2013, 1077 patients were randomly assigned (1 : 1) to first time ICD implantation with (n = 540) or without (n = 537) DF testing. The intra-operative DF testing was standardized across all participating centres, and all ICD shocks were programmed to 40 J irrespective of DF test results. The primary end point was the average first shock efficacy (FSE) for all true ventricular tachycardia and fibrillation (VT/VF) episodes during follow-up. The secondary end points included procedural data, serious adverse events, and mortality. During a median follow-up of 22.8 months, the model-based FSE was found to be non-inferior in patients with an ICD implanted without a DF test, with a difference in FSE of 3.0% in favour of the no DF test [confidence interval (CI) -3.0 to 9.0%, Pnon-inferiority <0.001 for the pre-defined non-inferiority margin of -10%). A total of 112 procedure-related serious adverse events occurred within 30 days in 94 patients (17.6%) tested compared with 89 events in 74 patients (13.9%) not tested (P = 0.095). CONCLUSION Defibrillation efficacy during follow-up is not inferior in patients with a 40 J ICD implanted without DF testing. Defibrillation testing during first time ICD implantation should no longer be recommended for routine left-sided ICD implantation.
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Affiliation(s)
- Dietmar Bänsch
- Heart Center Rostock, Department of Internal Medicine I, Divisions of Cardiology, University Hospital Rostock, Ernst-Heydemann-Str. 6, Rostock 18057, Germany
| | - Hendrik Bonnemeier
- Department of Internal Medicine III Cardiology and Angiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Johan Brandt
- Arrhythmia Department, Skane University Hospital, Lund, Sweden
| | - Frank Bode
- Medical Clinic II Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jesper Hastrup Svendsen
- Heart Center, Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark Danish Arrhythmia Research Centre, University of Copenhagen, Copenhagen, Denmark
| | - Miloš Táborský
- Department of Internal Medicine I Cardiology, Faculty Hospital Olomouc, Olomouc, Czech Republic
| | - Stefan Kuster
- Department of Internal Medicine, Cardiology, DRK Hospital Mölln-Ratzeburg, Ratzeburg, Germany
| | | | | | | | - Anna Suling
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Karl Wegscheider
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
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Mizukami K, Yokoshiki H, Mitsuyama H, Watanabe M, Tenma T, Matsui Y, Tsutsui H. Predictors of high defibrillation threshold in patients with implantable cardioverter-defibillator using a transvenous dual-coil lead. Circ J 2014; 79:77-84. [PMID: 25391259 DOI: 10.1253/circj.cj-14-0860] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Defibrillation testing (DT) is considered a standard procedure during implantable cardioverter-defibrillator (ICD) implantation. However, little is known about the factors that are significantly related to patients with high defibrillation threshold (DFT) using the present triad system. METHODS AND RESULTS We examined 286 consecutive patients who underwent ICD implantation with a transvenous dual-coil lead and DT from December 2000 to December 2011. We defined patients who required 25 J or more by the implanted device as the high DFT group, and those who required less than 25 J as the normal DFT group. For each patient, assessment parameters included underlying disease, comorbidities, NYHA functional class, drugs, and echocardiographic measures. The high DFT group consisted of 12 patients (4.2%). Multivariate analysis identified 3 independent predictors for high DFT: atrial fibrillation (odds ratio (OR) 4.85, 95% confidence interval (CI) 1.24-22.33, P=0.023), hypertension (OR 4.01, 95% CI 1.08-15.96, P=0.039), thickness of interventricular septum (IVS) >12 mm (OR 4.82, 95% CI 1.17-20.31, P=0.030). CONCLUSIONS Atrial fibrillation, hypertension and IVS hypertrophy were significantly associated with high DFT. Identification of such patients could help to lower the risk of complications with DT.
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Affiliation(s)
- Kazuya Mizukami
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
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Hsu JC, Marcus GM, Al-Khatib SM, Wang Y, Curtis JP, Sood N, Parker MW, Kluger J, Lampert R, Russo AM. Predictors of an inadequate defibrillation safety margin at ICD implantation: insights from the National Cardiovascular Data Registry. J Am Coll Cardiol 2014; 64:256-64. [PMID: 25034061 DOI: 10.1016/j.jacc.2014.01.085] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 01/22/2014] [Accepted: 01/27/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Defibrillation testing is often performed to establish effective arrhythmia termination, but predictors and consequences of an inadequate defibrillation safety margin (DSM) remain largely unknown. OBJECTIVES The aims of this study were to develop a simple risk score predictive of an inadequate DSM at implantable cardioverter-defibrillator (ICD) implantation and to examine the association of an inadequate DSM with adverse events. METHODS A total of 132,477 ICD Registry implantations between 2010 and 2012 were analyzed. Using logistic regression models, factors most predictive of an inadequate DSM (defined as the lowest successful energy tested <10 J from maximal device output) were identified, and the association of an inadequate DSM with adverse events was evaluated. RESULTS Inadequate DSMs occurred in 12,397 patients (9.4%). A simple risk score composed of 8 easily identifiable variables characterized patients at high and low risk for an inadequate DSM, including (with assigned points) age <70 years (1 point); male sex (1 point); race: black (4 points), Hispanic (2 points), or other (1 point); New York Heart Association functional class III (1 point) or IV (3 points); no ischemic heart disease (2 points); renal dialysis (3 points); secondary prevention indication (1 point); and ICD type: single-chamber (2 points) or biventricular (1 point) device. An inadequate DSM was associated with greater odds of complications (odds ratio: 1.22; 95% confidence interval: 1.09 to 1.37; p = 0.0006), hospital stay >3 days (odds ratio: 1.24; 95% confidence interval: 1.19 to 1.30; p < 0.0001), and in-hospital mortality (odds ratio: 1.96; 95% confidence interval: 1.63 to 2.36; p < 0.0001). CONCLUSIONS A simple risk score identified ICD recipients at risk for an inadequate DSM. An inadequate DSM was associated with an increased risk for in-hospital adverse events.
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Affiliation(s)
- Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, University of California, San Diego, San Diego, California.
| | - Gregory M Marcus
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, San Francisco, California
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Yongfei Wang
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Nitesh Sood
- Cardiac Arrhythmia Services, Southcoast Health System, Fall River, Massachusetts
| | - Matthew W Parker
- Division of Cardiology, Hartford Hospital, Hartford, Connecticut
| | - Jeffrey Kluger
- Division of Cardiology, Hartford Hospital, Hartford, Connecticut
| | - Rachel Lampert
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Andrea M Russo
- Cooper Medical School of Rowan University, Cooper University Hospital, Camden, New Jersey
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Arnson Y, Suleiman M, Glikson M, Sela R, Geist M, Amit G, Schliamser JE, Goldenberg I, Ben-Zvi S, Orvin K, Rosenheck S, Adam Freedberg N, Strasberg B, Haim M. Role of defibrillation threshold testing during implantable cardioverter-defibrillator placement: Data from the Israeli ICD Registry. Heart Rhythm 2014; 11:814-21. [DOI: 10.1016/j.hrthm.2014.01.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Indexed: 10/25/2022]
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Russo AM, Chung MK. Is Defibrillation Testing Necessary for Implantable Transvenous Defibrillators? Circ Arrhythm Electrophysiol 2014; 7:337-46. [DOI: 10.1161/circep.113.000371] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrea M. Russo
- From the Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); and Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH (M.K.C.)
| | - Mina K. Chung
- From the Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); and Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH (M.K.C.)
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RUSSO ANDREAM, WANG YONGFEI, AL-KHATIB SANAM, CURTIS JEPTHAP, LAMPERT RACHEL. Patient, Physician, and Procedural Factors Influencing the Use of Defibrillation Testing during Initial Implantable Cardioverter Defibrillator Insertion: Findings from the NCDR®. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:1522-31. [DOI: 10.1111/pace.12248] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 06/02/2013] [Accepted: 06/30/2013] [Indexed: 11/27/2022]
Affiliation(s)
- ANDREA M. RUSSO
- Cooper Medical School of Rowan University; Camden New Jersey
| | - YONGFEI WANG
- Yale University School of Medicine; New Haven Connecticut
| | | | | | - RACHEL LAMPERT
- Yale University School of Medicine; New Haven Connecticut
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How to Manage a High Defibrillation Threshold in ICD Patients: and Does it Really Matter? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:497-505. [DOI: 10.1007/s11936-013-0244-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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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: 196] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Jain SKA, Ghanbari H, Hourani R, Larsen TR, Daccarett M, Machado C. Echocardiographic parameters to predict inadequate defibrillation safety margin in patients receiving implantable cardioverter defibrillators for primary prevention. J Interv Card Electrophysiol 2013; 37:79-85. [DOI: 10.1007/s10840-012-9764-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 11/20/2012] [Indexed: 10/27/2022]
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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. 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: 184] [Impact Index Per Article: 15.3] [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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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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Axillary sub-pectoral pulse generator pocket for lowering defibrillation threshold. J Interv Card Electrophysiol 2012; 34:215-8. [PMID: 22354776 DOI: 10.1007/s10840-012-9668-3] [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: 11/10/2011] [Accepted: 01/18/2012] [Indexed: 10/28/2022]
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Kartal Y, Yavuzgil O, Bozoglu M, Alp A, Can LH, Hasdemir C. Cardiac resynchronization therapy with or without anatomical reverse remodeling does not affect defibrillation threshold. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:416-21. [PMID: 22303933 DOI: 10.1111/j.1540-8159.2011.03326.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recent clinical trials have documented beneficial reverse-remodeling effects with cardiac resynchronization therapy (CRT). The aim of this study was to investigate the effect of CRT with or without reverse anatomical remodeling of the left ventricle on defibrillation threshold (DFT) levels in a prospective and consecutive group of patients with class II-IV systolic heart failure. METHODS Study population consisted of 29 patients (14 women and 15 men; mean age 61±11 years old). All patients underwent baseline (within 24-hours of cardiac resynchronization therapy-defibrillator [CRT-D] implantation) and 6-month follow-up DFT testing. Reverse anatomical remodeling of the left ventricle was defined as ≥15% reduction in left ventricular end-systolic volume at the end of 6 months of follow-up compared to baseline. RESULTS Baseline, average DFT was 8.8±5.9 J. Left ventricular end-diastolic volume was the only predictor of baseline DFT level (P=0.02) among the baseline demographics. Safety margin of at least 10 J was achieved in all patients. Average DFT at the end of 6 months of biventricular pacing was 9.2±6.9 J. One patient (3.4%) failed to have a safety margin of 10 J. Reverse anatomical remodeling was observed in 14 (48%) patients and did not have any effect on DFT level. There were no complications related to DFT testings. CONCLUSIONS Baseline average DFT in patients undergoing CRT-D was ≤10 J in our study. CRT-D with or without anatomical reverse remodeling does not affect DFT at the end of 6 months of follow-up. High DFT level at the end of 6 months of follow-up is rare (3.4%) among patients with current CRT-D devices.
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Affiliation(s)
- Yildirim Kartal
- Department of Cardiology, Ege University School of Medicine, Izmir, Turkey
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Gold MR, Hedayati A, Alaeddini J, Payne JP, Bailin S, Sturdivant JL, Pradhan S, Oza AL. Temporal stability of defibrillation thresholds with cardiac resynchronization therapy. Heart Rhythm 2011; 8:1008-13. [DOI: 10.1016/j.hrthm.2011.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 02/02/2011] [Indexed: 11/29/2022]
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Michowitz Y, Lellouche N, Contractor T, Bourke T, Wiener I, Buch E, Boyle N, Bersohn M, Shivkumar K. Defibrillation threshold testing fails to show clinical benefit during long-term follow-up of patients undergoing cardiac resynchronization therapy defibrillator implantation. Europace 2011; 13:683-8. [PMID: 21252192 DOI: 10.1093/europace/euq519] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The utility of defibrillation threshold testing in patients undergoing implantable cardioverter-defibrillator (ICD) implantation is controversial. Higher defibrillation thresholds have been noted in patients undergoing implantation of cardiac resynchronization therapy defibrillators (CRT-D). Since the risks and potential benefits of testing may be higher in this population, we sought to assess the impact of defibrillation safety margin or vulnerability safety margin testing in CRT-D recipients. METHODS AND RESULTS A total of 256 consecutive subjects who underwent CRT-D implantation between January 2003 and December 2007 were retrospectively reviewed. Subjects were divided into two groups based on whether (n= 204) or not (n= 52) safety margin testing was performed. Patient characteristics, tachyarrhythmia therapies, procedural results, and clinical outcomes were recorded. Baseline characteristics, including heart failure (HF) severity, were comparable between the groups. Four cases of HF exacerbation (2%), including one leading to one death, were recorded in the tested group immediately post-implantation. No complications were observed in the untested group. After a mean follow-up of 32 ± 20 months, the proportion of appropriate shocks in the two groups was similar (31 vs. 25%, P = 0.49). There were three cases of failed appropriate shocks in the tested group, despite adequate safety margins at implantation, whereas no failed shocks were noted in the untested group. Survival was similar in the two groups. CONCLUSION Defibrillation efficacy testing during implant of CRT-D was associated with increased morbidity and did not predict the success of future device therapy or improve survival during long-term follow-up.
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Affiliation(s)
- Yoav Michowitz
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA 90095, USA.
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Sato A, Chinushi M, Iijima K, Watanabe H, Izumi D, Furushima H, Sonoda K, Hasegawa K, Yagihara N, Aizawa Y. An appropriate defibrillation threshold obtained by the combined connection between two shock leads and ICD generator. Intern Med 2011; 50:2815-8. [PMID: 22082895 DOI: 10.2169/internalmedicine.50.5792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 60-year-old man with arrhythmogenic right ventricular cardiomyopathy was readmitted for the battery exchange of his implantable cardioverter-defibrillator (ICD). Since (i) he had been treated with a dual-coil shock lead (Sprint Fidelis, Medtronic) and (ii) pre-operative venography showed mild collateral flow to the left subclavian vein, a single-coil lead was additionally implanted. However, the single-coil defibrillation system was unable to terminate the induced ventricular fibrillation (VF), thus dual defibrillation shock pathways were created using the connection to the superior vena cava coil of the Fidelis lead. The combined connections of the two shock leads provided an appropriate margin of the defibrillation threshold.
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Affiliation(s)
- Akinori Sato
- Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, Japan
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Jimenez A, Dickfeld T, Saliaris A, Shorofsky S. Pacemaker/implantable cardioverter-defibrillator interaction. Heart Rhythm 2010; 7:1157-60. [DOI: 10.1016/j.hrthm.2010.03.045] [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: 03/16/2010] [Accepted: 03/31/2010] [Indexed: 10/19/2022]
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Abstract
Intraoperative ICD-testing is traditionally performed in many hospitals in order to ensure reliable sensing, detection, and defibrillation of induced ventricular fibrillation. The technical progress of defibrillators allows rapid detection and delivery of high energy shocks which defibrillates effectively in the vast majority all patients at implant. This review describes arguments pro and contra of systematic testing of the defibrillation threshold in all patients. Many reasons argue against testing in all patients: experimental considerations, patients' specific and nonspecific factors, e.g., underlying severity of cardiac disease, ischemia, and medication, as well as factors specific to the ICD system, e.g., implanted type and location of electrodes and active cans. Finally, the testing method is very important, since it bears the risk of false negative test results because the a priori probability of a positive test result is >95%. Therefore, data from prospective randomized studies are necessary in order to abandon the tradition of ICD-testing on an evidence-based background.
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Lim HS, Flannigan S, Marshall H. Induction by direct current pulse versus 50-Hz pacing on ventricular fibrillation and defibrillation. J Interv Card Electrophysiol 2010; 28:209-14. [PMID: 20461546 DOI: 10.1007/s10840-010-9486-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2009] [Accepted: 03/23/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Ventricular fibrillation (VF) induced by different modes of induction may have different characteristics and defibrillation thresholds. This study compares the cycle lengths and defibrillation of VF induced by direct current (DC) pulses vs 50 Hz. METHOD We compared induction by DC pulses and 50-Hz pacing in this single-centre observational study of 259 consecutive patients with implantable cardioverter defibrillators in 2007-2008. Patients with inadequate defibrillation safety margin (DSM), defined as unsuccessful defibrillation at 25 J, were identified. RESULTS Of the 259 patients, 132 underwent induction with DC pulses and 127 with 50-Hz pacing. DC pulses induced VF of shorter cycle lengths (207 ± 16 vs 231 ± 24 ms, p < 0.001) compared to 50-Hz pacing. There were 17 patients (6.6%) with inadequate DSM-13/132 (9.8%) with DC pulse vs 4/127 (3.1%) with 50-Hz pacing (p < 0.001). The induced VF cycle lengths were shorter in patients with inadequate DSM (186 ± 25 vs 221 ± 21 ms, p < 0.001). On multivariate analysis, only the induced VF cycle length (p = 0.002) was independently associated with inadequate DSM. CONCLUSION VF of shorter cycle lengths is independently associated with inadequate DSM. DC pulses are associated with greater proportion of patients with inadequate DSM as it induces VF of shorter cycle lengths compared to 50-Hz pacing.
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Affiliation(s)
- Hoong Sern Lim
- University Hospital Birmingham NHS Trust, Edgbaston, Birmingham B15 2TH, UK.
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Val-Mejias JE, Oza A. Does defibrillation threshold increase as left ventricular ejection fraction decreases? Europace 2010; 12:385-8. [PMID: 20047925 PMCID: PMC2825386 DOI: 10.1093/europace/eup408] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aims Advanced cardiac disease, entailing more hypertrophy, fibrosis, scarring, dilatation and conduction delays, poses the question of whether defibrillation thresholds (DFTs) increase as left ventricular ejection fraction (LVEF) decreases. This question has been approached indirectly or insufficiently in previous studies. In this study we add and expand on our previous work, stratifying DFT for various LVEF ranges. Methods and results This retrospective analysis included DFT data from three acute, multicentre, randomized studies that included 230 ICD/CRT-D patients. All DFTs were obtained with the SVC coil turned ON and with pulse-width optimized waveforms based on a 3.5 ms membrane time constant. As the LVEF decreased, DFT estimates increased from 395.2 ± 115 V for LVEF ≥ 46% to 425.8 ± 117.6 V for LVEF ≤ 25%. However, these changes in DFT estimates were very minor and not statistically significant. Only 3% of the patients in this population had an elevated DFT of >20 J. Conclusion This analysis shows that over a very broad range of LVEF, DFT changes minimally (approximately 1 J), if at all. Our results are consistent with previous studies that demonstrated no difference in the DFT estimates: (a) between patient groups receiving ICD (typically higher LVEF) vs. CRT-D (typically lower LVEF) and (b) between patient groups receiving a device for primary prevention indications (typically lower LVEF) vs. secondary prevention indications (typically higher LVEF).
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Affiliation(s)
- Jesus E Val-Mejias
- Galichia Heart Hospital, 2600 N. Woodlawn Avenue, Wichita, KS 67226, USA.
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BAR-COHEN YANIV, TAKAO CHERYLM, WELLS WINFIELDJ, SAXON LESLIEA, CESARIO DAVIDA, SILKA MICHAELJ. Novel Use of a Vascular Plug to Anchor an Azygous Vein ICD Lead. J Cardiovasc Electrophysiol 2010; 21:99-102. [DOI: 10.1111/j.1540-8167.2009.01510.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Calvi V, Dugo D, Capodanno D, Arancio R, Di Grazia A, Liotta C, Puzzangara E, Ragusa A, Arestia A, Tamburino C. Intraoperative defibrillation threshold testing during implantable cardioverter-defibrillator insertion: do we really need it? Am Heart J 2010; 159:98-102. [PMID: 20102873 DOI: 10.1016/j.ahj.2009.10.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Accepted: 10/21/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The assessment of defibrillation efficacy using a safety margin of 10 J has long been the standard of care for insertion of implantable cardioverter-defibrillator (ICD), but physicians are concerned about complications related to induction test. Therefore, the need for testing has been recently questioned. The aim of our study was to assess the impact of defibrillation threshold (DFT) testing of ICD on the efficacy of ICD therapy. METHODS We analyzed data obtained from follow-up visits of 122 consecutive patients who underwent ICD implantation at our institute from April 1996 to June 2008, with (n = 42) or without (n = 80) DFT testing. Patients in the DFT group were less likely to be men (83.3% vs 96.3%, P < .031) than those in the non-DFT group. Conversely, the 2 groups were similar in age, left ventricular ejection fraction at baseline, functional class, and underlying cardiovascular disease. Results during a 12-month follow-up, 13 (31.0%) and 30 (37.5%) ventricular tachyarrhythmic episodes were recorded in the DFT and non-DFT groups, respectively (P = .472). Antitachycardia pacing (ATP) terminated most of episodes, reducing the need of defibrillation at 7.7% in the DFT group and 3.3% in the non-DFT group (P = .533). Similar percentages of inappropriate ATP interventions (7.1% vs 3.8%, P = .413) and shock deliveries (2.4% vs 5.0%, P = .659) were recorded between DFT and non-DFT groups. CONCLUSIONS At 1-year follow-up, the performance of DFT testing does not seem to add any significant efficacy advantage in patients undergoing ICD implantation. Prospective randomized trials and long-term follow-up are warranted to clarify whether routine DFT testing may be safely abandoned leading to a revision of current guidelines.
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Rosenheck S, Sharon Z, Weiss A. Long-Term Follow-Up of Patients with Relatively High Effective Defibrillation Threshold during Cardioverter Defibrillator Implantation with Endocardial Leads. Cardiology 2009; 112:107-13. [DOI: 10.1159/000141463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Accepted: 04/10/2008] [Indexed: 11/19/2022]
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COOPER JONASA, LATACHA MATTHEWP, SOTO GABRIELE, GARMANY RICHARDG, GLEVA MARYEJ, CHEN JANE, FADDIS MITCHELLN, SMITH TIMOTHYW. The Azygos Defibrillator Lead for Elevated Defibrillation Thresholds: Implant Technique, Lead Stability, and Patient Series. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:1405-10. [DOI: 10.1111/j.1540-8159.2008.01203.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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GULA LORNEJ, MASSEL DAVID, KRAHN ANDREWD, YEE RAYMOND, SKANES ALLANC, KLEIN GEORGEJ. Is Defibrillation Testing Still Necessary? A Decision Analysis and Markov Model. J Cardiovasc Electrophysiol 2008; 19:400-5. [DOI: 10.1111/j.1540-8167.2007.01095.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sandstedt B, Gottfridsson C, Nyström B, Edvardsson N. Testing the Implantable Cardioverter-Defibrillator After Implantation?Is It Necessary? Pacing Clin Electrophysiol 2007; 30:985-91. [PMID: 17669081 DOI: 10.1111/j.1540-8159.2007.00796.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The results of intraoperative and postoperative predischarge implantable cardioverter-defibrillator (ICD) testing of 211 consecutive patients, starting at 15 J and requiring two successful terminations of induced VT/VF with a relative defibrillation safety margin (DSM) of >10 J, were reviewed. The aim was to define the type of intraoperative response that would make postoperative predischarge testing unnecessary. The intraoperative responses were divided into three types: A, a DSM > or =10 J and an absolute energy level of < or =20 J; B, a DSM of > or =10 J and an absolute energy level of >20 J; and C, a DSM <10 J and an absolute energy level of >20 J. At operation, the responses to defibrillation were A, 88.6%; B, 7.1%; and C, 4.3%. Accepting an A response only would leave 11.4% of the patients for postoperative testing. The positive and negative predictive values for diagnosing a postoperative C response were 0.78 and 0.97, respectively. Similarly, the predictive values for diagnosing a postoperative B or C response were 0.71 and 0.97, respectively. The postoperative testing responses were A, 89.1%; B, 4.3%; and C, 6.6%. In summary, an intraoperative A response was sufficient to make a postoperative defibrillation testing unnecessary, while it was found that intraoperative B and C responders should undergo postoperative testing. Applying these criteria, approximately 90% of the patients could be discharged without any postoperative induction test.
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Affiliation(s)
- Bengt Sandstedt
- Division of Cardiology, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
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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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Wase A. Elevated Defibrillation Thresholds With Biventricular Pacing. Heart Rhythm 2007; 4:253; author reply 253-4. [PMID: 17275772 DOI: 10.1016/j.hrthm.2006.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Indexed: 11/24/2022]
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To the Editor - Response. Heart Rhythm 2007. [DOI: 10.1016/j.hrthm.2006.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Akar JG. Predicting elevated defibrillation energy requirements in heart failure with reasonable probability. Heart Rhythm 2006; 3:1017-8. [PMID: 16945793 DOI: 10.1016/j.hrthm.2006.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Indexed: 10/24/2022]
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