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Weipert KF, Kostic S, Gökyildirim T, Johnson V, Chasan R, Gemein C, Rosenbauer J, Erkapic D, Schmitt J. Safety and Performance of the Subcutaneous Implantable Cardioverter Defibrillator Detection Algorithm INSIGHT TM in Pacemaker Patients. J Clin Med 2023; 13:129. [PMID: 38202136 PMCID: PMC10779836 DOI: 10.3390/jcm13010129] [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: 11/16/2023] [Revised: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND The use of the S-ICD is limited by its inability to provide backup pacing. Combined use of the S-ICD with a pacemaker may be a good choice in certain situations, yet current experience concerning the compatibility is limited. The goal of this study was to determine the safety and efficacy of the S-ICD in patients with a pacemaker. METHODS A total of 74 consecutive patients with a bipolar pacemaker were prospectively enrolled. First, surface rhythm strips were recorded in all possible pacemaker stimulation modes, to screen for T-wave oversensing (TWOS). Second, a S-ICD functional dummy was placed epicutaneously on the patient in the typical implant position. The same standardized pacing protocol was used as mentioned above, and every stimulation mode was recorded via S-ECG in all vectors. RESULTS In 16 patients (21.6%), programmed stimulation would have led to VT/VF detection. Triggered episodes were due to counting of the pacing spike(s), QRS complex, premature ventricular contractions, and/or additional TWOS. Three cases triggered in the bipolar stimulation mode. Oversensing was associated with lung emphysema and a reduced QRS amplitude in the S-ECG. CONCLUSION The combination of an S-ICD and a pacemaker may lead to inadequate shock delivery due to oversensing, even under programmed bipolar stimulation. Oversensing cannot be sufficiently predicted by the screening tool in pacemaker patients. Testing with an epicutaneous S-ICD dummy in all vectors and stimulation settings is recommended in patients with pre-existing pacemakers.
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Affiliation(s)
- Kay F. Weipert
- Department of Cardiology, Rhythmology and Angiology, Medizinische Klinik II, Diakonie Klinikum Jung Stilling, 57074 Siegen, Germany; (R.C.); (J.R.); (D.E.)
| | - Srdjan Kostic
- Department of Cardiology, Kantonsspital Aarau, 5001 Aarau, Switzerland;
| | - Timur Gökyildirim
- Department of Cardiology, Lahn-Dill Kliniken, 35578 Wetzlar, Germany
| | - Victoria Johnson
- Department of Cardiology and Angiology, Medizinische Klinik I, Universitätsklinikum Gießen und Marburg, 35392 Giessen, Germany
| | - Ritvan Chasan
- Department of Cardiology, Rhythmology and Angiology, Medizinische Klinik II, Diakonie Klinikum Jung Stilling, 57074 Siegen, Germany; (R.C.); (J.R.); (D.E.)
| | - Christopher Gemein
- Department of Cardiology, Nephrology, Pneumology and Rhythmology, Klinikum Aschaffenburg-Alzenau, 63739 Aschaffenburg, Germany
| | - Josef Rosenbauer
- Department of Cardiology, Rhythmology and Angiology, Medizinische Klinik II, Diakonie Klinikum Jung Stilling, 57074 Siegen, Germany; (R.C.); (J.R.); (D.E.)
| | - Damir Erkapic
- Department of Cardiology, Rhythmology and Angiology, Medizinische Klinik II, Diakonie Klinikum Jung Stilling, 57074 Siegen, Germany; (R.C.); (J.R.); (D.E.)
| | - Jörn Schmitt
- Department of Cardiology, Pneumology and Angiology, Medizinische Klinik II, Westpfalz-Klinikum, 67655 Kaiserslautern, Germany;
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Johnson V, Hamm CW, Schmitt J. [Device-device interaction]. Herzschrittmacherther Elektrophysiol 2019; 30:183-190. [PMID: 30989336 DOI: 10.1007/s00399-019-0617-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 03/24/2019] [Indexed: 06/09/2023]
Abstract
With a continuous increase in the approval of cardiac implantable electronic devices (CIED), not only pacemakers (PM) and implantable cardioverter defibrillators (ICD) but especially devices for treating chronic heart failure, more and more possibilities of device-device interactions arise, which in isolated cases can lead to death of the patient. Because of the still low numbers of patients overall, there are very few scientific studies and only isolated case reports on this topic. Devices which are at risk of interaction with a previously implanted PM are wearable cardioverter defibrillators (WCD) and subcutaneous ICDs (S-ICD). These two devices both use the surface electrocardiogram (ECG) in their algorithm for detecting ventricular arrhythmia. These surface ECGs seem to be prone to unipolar pacemaker stimulation artefacts. By correct programming of implanted pacemakers in the bipolar stimulation mode it is possible to avoid ECG artefacts and inadequate treatment. In baroreceptor activation therapy (BAT) there seem to be no device interactions so far, even though this device shows substantial highly frequent artefacts in the ECG. The cardiac contractility modulation (CCM) system has also until now not shown interactions with transvenous or subcutaneous ICD devices, even though randomized trials are missing.
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Affiliation(s)
- Victoria Johnson
- Med. Klinik I, Abteilung für Kardiologie und Angiologie, Universitätsklinik Gießen, UKGM, Klinikstraße 33, 35392, Gießen, Deutschland.
- Deutsches Zentrum für Herzinsuffizienz, Translationale Forschung, Uniklinikum Würzburg, Würzburg, Deutschland.
| | - Christian W Hamm
- Med. Klinik I, Abteilung für Kardiologie und Angiologie, Universitätsklinik Gießen, UKGM, Klinikstraße 33, 35392, Gießen, Deutschland
| | - Jörn Schmitt
- Med. Klinik I, Abteilung für Kardiologie und Angiologie, Universitätsklinik Gießen, UKGM, Klinikstraße 33, 35392, Gießen, Deutschland
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Amiodarone Versus Lidocaine for Pediatric Cardiac Arrest Due to Ventricular Arrhythmias: A Systematic Review. Pediatr Crit Care Med 2017; 18:183-189. [PMID: 28009655 DOI: 10.1097/pcc.0000000000001026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We performed a systematic review as part of the International Liaison Committee on Resuscitation process to create a consensus on science statement regarding amiodarone or lidocaine during pediatric cardiac arrest for the 2015 International Liaison Committee on Resuscitation's Consensus on Science and Treatment Recommendations. DATA SOURCES Studies were identified from comprehensive searches in PubMed, Embase, and the Cochrane Library. STUDY SELECTION Studies eligible for inclusion were randomized controlled and observational studies on the relative clinical effect of amiodarone or lidocaine in cardiac arrest. DATA EXTRACTION Studies addressing the clinical effect of amiodarone versus lidocaine were extracted and reviewed for inclusion and exclusion criteria by the reviewers. Studies were rigorously analyzed thereafter. DATA SYNTHESIS We identified three articles addressing lidocaine versus amiodarone in cardiac arrest: 1) a prospective study assessing lidocaine versus amiodarone for refractory ventricular fibrillation in out-of-hospital adults; 2) an observational retrospective cohort study of inpatient pediatric patients with ventricular fibrillation or pulseless ventricular tachycardia who received lidocaine, amiodarone, neither or both; and 3) a prospective study of ventricular tachycardia with a pulse in adults. The first study showed a statistically significant improvement in survival to hospital admission with amiodarone (22.8% vs 12.0%; p = 0.009) and a lack of statistical difference for survival at discharge (p = 0.34). The second article demonstrated 44% return of spontaneous circulation for amiodarone and 64% for lidocaine (odds ratio, 2.02; 1.36-3.03) with no statistical difference for survival at hospital discharge. The third article demonstrated 48.3% arrhythmia termination for amiodarone versus 10.3% for lidocaine (p < 0.05). All were classified as lower quality studies without preference for one agent. CONCLUSIONS The confidence in effect estimates is so low that International Liaison Committee on Resuscitation felt that a recommendation to use of amiodarone over lidocaine is too speculative; we suggest that amiodarone or lidocaine can be used in the setting of pulseless ventricular tachycardia/ventricular fibrillation in infants and children.
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Schmitt J, Abaci G, Johnson V, Erkapic D, Gemein C, Chasan R, Weipert K, Hamm CW, Klein HU. Safety of the Wearable Cardioverter Defibrillator (WCD) in Patients with Implanted Pacemakers. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 40:271-277. [PMID: 27943296 DOI: 10.1111/pace.12986] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 10/19/2016] [Accepted: 11/13/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND The wearable cardioverter defibrillator (WCD) is an important approach for better risk stratification, applied to patients considered to be at high risk of sudden arrhythmic death. Patients with implanted pacemakers may also become candidates for use of the WCD. However, there is a potential risk that pacemaker signals may mislead the WCD detection algorithm and cause inappropriate WCD shock delivery. The aim of the study was to test the impact of different types of pacing, various right ventricular (RV) lead positions, and pacing modes for potential misleading of the WCD detection algorithm. METHODS Sixty patients with implanted pacemakers received the WCD for a short time and each pacing mode (AAI, VVI, and DDD) was tested for at least 30 seconds in unipolar and bipolar pacing configuration. In case of triggering the WCD detection algorithm and starting the sequence of arrhythmia alarms, shock delivery was prevented by pushing of the response buttons. RESULTS In six of 60 patients (10%), continuous unipolar pacing in DDD mode triggered the WCD detection algorithm. In no patient, triggering occurred with bipolar DDD pacing, unipolar and bipolar AAI, and VVI pacing. Triggering was independent of pacing amplitude, RV pacing lead position, and pulse generator implantation site. CONCLUSION Unipolar DDD pacing bears a high risk of false triggering of the WCD detection algorithm. Other types of unipolar pacing and all bipolar pacing modes do not seem to mislead the WCD detection algorithm. Therefore, patients with no reprogrammable unipolar DDD pacing should not become candidates for the WCD.
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Affiliation(s)
- Joern Schmitt
- Medizinische Klinik I - Kardiologie und Angiologie, Universitätsklinikum Giessen und Marburg GmbH, Giessen, Germany
| | - Guezine Abaci
- Medizinische Klinik I - Kardiologie und Angiologie, Universitätsklinikum Giessen und Marburg GmbH, Giessen, Germany
| | - Victoria Johnson
- Medizinische Klinik I - Kardiologie und Angiologie, Universitätsklinikum Giessen und Marburg GmbH, Giessen, Germany
| | - Damir Erkapic
- Medizinische Klinik I - Kardiologie und Angiologie, Universitätsklinikum Giessen und Marburg GmbH, Giessen, Germany
| | - Christopher Gemein
- Medizinische Klinik I - Kardiologie und Angiologie, Universitätsklinikum Giessen und Marburg GmbH, Giessen, Germany
| | - Ritvan Chasan
- Medizinische Klinik I - Kardiologie und Angiologie, Universitätsklinikum Giessen und Marburg GmbH, Giessen, Germany
| | - Kay Weipert
- Medizinische Klinik I - Kardiologie und Angiologie, Universitätsklinikum Giessen und Marburg GmbH, Giessen, Germany
| | - Christian W Hamm
- Medizinische Klinik I - Kardiologie und Angiologie, Universitätsklinikum Giessen und Marburg GmbH, Giessen, Germany.,Abteilung für Kardiologie, Kerckhoff-Klinik, Bad Nauheim, Germany
| | - Helmut U Klein
- Heart Research Follow Up Program, University Hospital of Rochester Medical Center, Rochester, New York
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Haddow GR, Neville M. Anesthetic Implications for Patients With Implantable Cardioverter Defibrillators. Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1053/scva.2000.8498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Implantable cardioverter defibrillators have become one of the preferred methods for treating many life- threatening ventricular arrhythmias. Many tens of thou sands of these devices have been implanted and this, together with the ease of worldwide travel, has made it more likely that anesthesiologists everywhere may come into contact with these patients either for elective or emergency surgery. These patients present unique anesthetic challenges because of the combination of the device and severe underlying cardiac disease. This article presents an overview of the implantable defibril lator as it affects the anesthesiologist, including device function, device assessment, electromagnetic interfer ence, and perioperative management.
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Affiliation(s)
- Gordon R. Haddow
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA
| | - Michael Neville
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA
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Ventricular arrhythmias in patients with heart failure secondary to reduced ejection fraction: a current perspective. Curr Opin Cardiol 2014; 29:152-9. [PMID: 24378634 DOI: 10.1097/hco.0000000000000035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To review the management of ventricular arrhythmias in patients with heart failure secondary to reduced ejection fraction (HFrEF). RECENT FINDINGS Recurrent ventricular arrhythmias and automatic implantable cardioverter defibrillator (AICD) shocks are responsible for significant mortality and morbidity in patients with HFrEF. Antiarrhythmic drugs and catheter ablation are the main treatment options. Frequent premature ventricular contractions (PVCs; >10,000-20,000/24-h period) are being recognized as a cause of cardiomyopathy and suboptimal response to cardiac resynchronization therapy (CRT). Patients with ventricular assist devices (VADs) have frequent ventricular tachyarrhythmias resulting in increased morbidity and mortality. Such patients may need continuation of active ICD therapy and adjunctive catheter ablation. SUMMARY There is a pressing need to develop new antiarrhythmic drugs to treat patients with recurrent AICD shocks. The effectiveness of catheter ablation as first-line therapy for preventing ventricular arrhythmias and recurrent AICD shocks needs to be directly compared with amiodarone. Ventricular tachyarrhythmias are common in CRT patients and patients with VADs. Frequent PVCs may result in a reversible form of HFrEF.
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Rapsang AG, Bhattacharyya P. Pacemakers and implantable cardioverter defibrillators--general and anesthetic considerations. Braz J Anesthesiol 2014; 64:205-14. [PMID: 24907883 DOI: 10.1016/j.bjane.2013.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 02/28/2013] [Indexed: 11/28/2022] Open
Abstract
A pacemaking system consists of an impulse generator and lead or leads to carry the electrical impulse to the patient's heart. Pacemaker and implantable cardioverter defibrillator codes were made to describe the type of pacemaker or implantable cardioverter defibrillator implanted. Indications for pacing and implantable cardioverter defibrillator implantation were given by the American College of Cardiologists. Certain pacemakers have magnet-operated reed switches incorporated; however, magnet application can have serious adverse effects; hence, devices should be considered programmable unless known otherwise. When a device patient undergoes any procedure (with or without anesthesia), special precautions have to be observed including a focused history/physical examination, interrogation of pacemaker before and after the procedure, emergency drugs/temporary pacing and defibrillation, reprogramming of pacemaker and disabling certain pacemaker functions if required, monitoring of electrolyte and metabolic disturbance and avoiding certain drugs and equipments that can interfere with pacemaker function. If unanticipated device interactions are found, consider discontinuation of the procedure until the source of interference can be eliminated or managed and all corrective measures should be taken to ensure proper pacemaker function should be done. Post procedure, the cardiac rate and rhythm should be monitored continuously and emergency drugs and equipments should be kept ready and consultation with a cardiologist or a pacemaker-implantable cardioverter defibrillator service may be necessary.
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Affiliation(s)
- Amy G Rapsang
- Department of Anesthesiology & Intensive Care, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India.
| | - Prithwis Bhattacharyya
- Department of Anesthesiology & Intensive Care, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
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Rapsang AG, Bhattacharyya P. Marcapassos e cardioversores desfibriladores implantáveis – considerações gerais e anestésicas. Braz J Anesthesiol 2014; 64:205-14. [DOI: 10.1016/j.bjan.2013.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 02/28/2013] [Indexed: 11/24/2022] Open
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Beadle R, Williams L, Lim HS. Drug-implantable cardioverter–defibrillator interactions. Expert Rev Cardiovasc Ther 2014; 8:1267-73. [DOI: 10.1586/erc.10.114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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10
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Wang LW, Subbiah RN, Kilborn MJ, Dunn RF. Phenytoin: an old but effective antiarrhythmic agent for the suppression of ventricular tachycardia. Med J Aust 2013; 199:209-11. [PMID: 23909546 DOI: 10.5694/mja13.10224] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 07/11/2013] [Indexed: 11/17/2022]
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Yamada T, Robertson PG, McElderry HT, Doppalapudi H, Plumb VJ, Kay GN. Successful reduction of a high defibrillation threshold by a combined implantation of a subcutaneous array and azygos vein lead. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:e173-6. [PMID: 22360586 DOI: 10.1111/j.1540-8159.2012.03332.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A 72-year-old man with nonischemic cardiomyopathy was referred because his implantable cardioverter defibrillator had failed to terminate spontaneous ventricular fibrillation (VF). Defibrillation threshold (DFT) testing confirmed that 830-V shocks failed to defibrillate VF despite optimization of the biphasic waveform and reversal of shock polarity. The placement of a new right ventricular lead and the addition of a subcutaneous array failed to defibrillate VF at 830 V. The combination of a subcutaneous array and azygos vein coil successfully defibrillated VF. The mechanism for successful DFT reduction was likely greater current supplied to the posterior basal left ventricle by the azygos vein lead.
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Affiliation(s)
- Takumi Yamada
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama 35294-0019, USA.
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GUENTHER MICHAEL, RAUWOLF THOMASP, BOCK MANJA, STRASSER RUTHH, BRAUN MARTINU. A Rare type of Ventricular Oversensing in ICD Therapy-Inappropriate ICD Shock Delivery Due to Triple Counting. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 33:e17-9. [DOI: 10.1111/j.1540-8159.2009.02583.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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The Impact of Acute Myocardial Ischemia on the Ventricular Defibrillation Threshold During Chronic Oral Azimilide Therapy. J Cardiovasc Pharmacol 2007; 50:629-32. [DOI: 10.1097/fjc.0b013e318150d3f5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Krauthamer V. The pharmacology of electrical stimulation in the heart: Where devices meet drugs. DRUG DISCOVERY TODAY. TECHNOLOGIES 2007; 4:63-67. [PMID: 24980843 DOI: 10.1016/j.ddtec.2007.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Both cardiac electrical stimulation and cardiac pharmacological agents exert effects by acting upon ion channels, secondary messengers and autonomic nerve terminals. Defining the common substrates between devices and drugs provides the evaluation tools to warn of unsafe interactions with pacemakers, defibrillators or detection of cardiac arrhythmias. This review describes substrates of drug-device interaction, reviews research on drug-like effects of devices, and provides a framework for how the physiology of interaction translates to streamlined clinical trials.:
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Affiliation(s)
- Victor Krauthamer
- Office of Science and Engineering Labs, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD 20993, USA.
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Swerdlow CD, Friedman PA. Advanced ICD Troubleshooting: Part II. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 29:70-96. [PMID: 16441722 DOI: 10.1111/j.1540-8159.2006.00300.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Affiliation(s)
- Theresa P Yeo
- The Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
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Cesario D, Bhargava M, Valderrábano M, Fonarow GC, Wilkoff B, Shivkumar K. Azygos Vein Lead Implantation:. A Novel Adjunctive Technique for Implantable Cardioverter Defibrillator Placement. J Cardiovasc Electrophysiol 2004; 15:780-3. [PMID: 15250862 DOI: 10.1046/j.1540-8167.2004.03649.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
High defibrillation thresholds (DFTs) occasionally are encountered during placement of implantable cardioverter defibrillators (ICDs). There are multiple strategies to lower DFTs in such patients, including reassessment of right ventricular lead position, alteration of the shock waveform, and implantation of subcutaneous arrays. This article describes a novel technique of implanting a high-voltage lead in the azygos vein. This procedure may serve as an adjunctive approach to reduce DFTs. The anatomic location of the azygos vein posterior to the heart provides a suitable shocking vector between the right ventricular electrode, a high-voltage lead placed in the azygos vein, and the ICD can.
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Affiliation(s)
- David Cesario
- UCLA Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California 90095-1679, USA
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Affiliation(s)
- John P DiMarco
- Electrophysiology Laboratory, Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville 22908-0158, USA.
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Lin D, Marchlinski FE. Advances in ablation therapy for complex arrhythmias: atrial fibrillation and ventricular tachycardia. Curr Cardiol Rep 2003; 5:407-14. [PMID: 12917057 DOI: 10.1007/s11886-003-0099-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Catheter ablation has evolved over the past two decades to become first-line therapy for many cardiac arrhythmias. Multiple advances in the technology and understanding of radiofrequency ablation have allowed this technique to blossom into one of the most powerful therapeutic tools available to the electrophysiologist, and have opened a new chapter in the diagnosis and management of clinical arrhythmias. Catheter ablation often eliminates the need for chronic drug therapy and can result in significant long-term cost savings. As catheter technology continues to improve, and newer, more effective energy delivery systems are developed, the applicability of catheter-based therapy will continue to expand. This review addresses some of the more commonly encountered clinical arrhythmias and the recent developments in the treatment of these arrhythmias from a catheter-based standpoint.
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Affiliation(s)
- David Lin
- University of Pennsylvania Health Systems, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104, USA.
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Ujhelyi MR, Sims JJ, Dubin SA, Vender J, Miller AW. Defibrillation energy requirements and electrical heterogeneity during total body hypothermia. Crit Care Med 2001; 29:1006-11. [PMID: 11378613 DOI: 10.1097/00003246-200105000-00025] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Determine the effects of hypothermia on defibrillation energy requirements and cardiac electrophysiology. DESIGN Prospective randomized acute intervention trial. SETTING Medical center animal laboratory. SUBJECTS Fifteen domestic farm swine. INTERVENTIONS Swine were randomized to a hypothermia group (n = 8) or a control group (n = 7). All animals were instrumented with a transvenous defibrillation system connected to a defibrillator that delivers a biphasic-truncated waveform. Values for defibrillation energy requirements were measured at baseline (normothermia, 38-40 degrees C) and during treatment with total body hypothermia (30 degrees C) or no temperature change (sham). Hypothermia was induced by circulating ice-water through anterior and posterior surgical thermal blankets. MEASUREMENTS AND MAIN RESULTS Defibrillation energy requirement values at 20%, 50%, and 80% were determined by using an up/down method. In the hypothermia group, defibrillation energy requirement values at baseline did not significantly change during hypothermia (defibrillation energy requirements 50% = 14 +/- 2 J vs. 15 +/- 2 J, respectively). Similarly, the defibrillation energy requirement values in the control group did not change from baseline to sham phase (defibrillation energy requirements 50% = 12 +/- 1 J vs. 13 +/- 1 J, respectively). Hypothermia profoundly affected cardiac electrophysiology, decreasing ventricular fibrillation threshold by 72%, conduction velocity by 25% (p < .01), and tissue excitability, while it prolonged ventricular repolarization and refractoriness by 7.5% to 15%, respectively (p < .05). CONCLUSIONS Total body cooling to 30 degrees C was highly arrhythmogenic, although this unstable electrophysiological state did not alter ventricular defibrillation energy requirements. These data suggest that hypothermia may be used to slow metabolic processes without concern over the ability to successfully defibrillate and treat hypothermia-induced arrhythmias.
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Affiliation(s)
- M R Ujhelyi
- University of Georgia College of Pharmacy, Augusta VA Medical Center, and Medical College of Georgia School of Medicine, Augusta, GA, USA
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22
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Abstract
Implantable cardioverter defibrillators (ICDs) have evolved from the treatment of last resort to the gold standard therapy for patients at high risk for ventricular tachyarrhythmias. High-risk patients include those who have survived life-threatening arrhythmias, and individuals with cardiac diseases who are at risk for such arrhythmias, but are symptomless. Use of an ICD will affect the patient's quality of life. Some drugs can substantially affect defibrillator function and efficacy, and possible drug-device interactions should be considered. Patients with ICDs may encounter cell phones, antitheft detectors, and many other sources of potential electromagnetic Interference. In addition to treating ventricular tachyarrhythmias, new defibrillators provide full featured dual chamber pacing, and could treat atrial arrhythmias, and congestive heart failure by means of biventricular pacing.
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Affiliation(s)
- M Glikson
- Heart Institute, Sheba Medical Centre, Tel Aviv University, Tel Hashomer, Israel
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23
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Abstract
Clinical trials have established the superiority of the implantable cardioverter-defibrillator (ICD) over antiarrhythmic drug therapy in survivors of sudden cardiac death and in high-risk patients with coronary artery disease. The ICD has evolved to overcome the limitation of earlier devices that required thoracotomy for implantation and were fraught with inappropriate shock delivery. Current ICDs are implanted in a similar manner to cardiac pacemakers and incorporate sophisticated rhythm-discrimination algorithms to prevent inappropriate therapy. Managing the patient with an ICD requires an understanding of the multiprogrammable features of modern devices. Drug interactions and potential sources of electromagnetic interference may adversely affect ICD function. Driving restrictions may be necessary under certain conditions. The cost-effectiveness of ICD therapy appears favorable, given the marked survival benefit seen in randomized trials relative to antiarrhythmic drug treatment. The growing number of ICD recipients necessitates an understanding of the specialized features of the modern ICD and the role of device therapy in clinical practice.
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Affiliation(s)
- M H Gollob
- Section of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA.
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24
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Abstract
Implantable cardioverter-defibrillators (ICDs) have become the dominant therapeutic modality for patients with life-threatening ventricular arrhythmias. ICDs are implanted using techniques similar to standard pacemaker implantation. They not only provide high-energy shocks for ventricular fibrillation and rapid ventricular tachycardia, but also provide antitachycardia pacing for monomorphic ventricular tachycardia and antibradycardia pacing. Devices incorporating an atrial lead allow dual-chamber pacing and better discrimination between ventricular and supraventricular tachyarrhythmias. Intensivists are increasingly likely to encounter patients with ICDs. Electrosurgery can be safely performed in ICD patients as long as the device is deactivated before the procedure and reactivated and reassessed immediately afterward. Prompt and skilled intervention can prove to be life-saving in patients presenting with ICD-related emergencies, including lack of response to ventricular tachyarrhythmias, pacing failure, and multiple shocks. Recognition and treatment of tachyarrhythmia can be temporarily disabled by placing a magnet on top of an ICD. The presence of an ICD should not deter standard resuscitation techniques. Multiple ICD discharges in a short period of time constitute a serious situation. Causes include ventricular electrical storm, inefficient defibrillation, nonsustained ventricular tachycardia, and inappropriate shocks caused by supraventricular tachyarrhythmias or oversensing of signals. ICD system infection requires hardware removal and intravenous antibiotic therapy. Deactivation of an ICD with the consent of the patient or relatives is reasonable and ethical in terminally ill patients.
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Affiliation(s)
- S L Pinski
- Section of Cardiology, Rush-Presbyterian-St. Luke's Medical Center and Rush Medical College, Chicago, IL 60612, USA.
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25
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Ellenbogen KA, Edel T, Moore S, Higgins S, Pacifico A, Wilber D, Wood MA, Rogers R, Dahn A, Zhu A. A prospective randomized-controlled trial of ventricular fibrillation detection time in a DDDR ventricular defibrillator. Ventak AV II DR Study Investigators. Pacing Clin Electrophysiol 2000; 23:1268-72. [PMID: 10962750 DOI: 10.1111/j.1540-8159.2000.tb00942.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Implantable cardioverter defibrillators (ICDs) with dual chamber and dual chamber rate responsive pacing may offer hemodynamic advantages for some ICD patients. Separate ICDs and DDDR pacemakers can result in device to device interactions, inappropriate shocks, and underdetection of ventricular fibrillation (VF). The objectives of this study were to compare the VF detection times between the Ventak AV II DR and the Ventak AV during high rate DDDR and DDD pacing and to test the safety of dynamic ventricular refractory period shortening. Patients receiving an ICD were randomized in a paired comparison to pacing at 150 beats/min (DDD pacing) or 175 beats/min (DDDR pacing) during ICD threshold testing to create a "worst case scenario" for VF detection. The VF detection rate was set to 180 beats/min, and VF was induced during high rate pacing with alternating current. The device was then allowed to detect and treat VF. The induction was repeated for each patient at each programmed setting so that all patients were tested at both programmed settings. Paired analysis was performed. Patient characteristics were a mean age of 69 +/- 11 years, 78% were men, coronary artery disease was present in 85%, and a mean left ventricular ejection fraction of 0.34 +/- 0.11. Fifty-two episodes of VF were induced in 26 patients. Despite the high pacing rate, all VF episodes were appropriately detected. The mean VF detection time was 2.4 +/- 1.0 seconds during DDD pacing and 2.9 +/- 1.9 seconds during DDDR pacing (P = NS). DDD and DDDR programming resulted in appropriate detection of all episodes of VF with similar detection times despite the "worst case scenario" tested. Delays in detection may be seen with long programmed ventricular refractory periods which shorten the VF sensing window and may be avoided with dynamic ventricular refractory period shortening.
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Affiliation(s)
- K A Ellenbogen
- Medical College of Virginia (Virginia Commonwealth University), Richmond 23298-0053, USA.
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26
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Lai LP, Lin JL, Lien WP, Tseng YZ, Huang SK. Intravenous sotalol decreases transthoracic cardioversion energy requirement for chronic atrial fibrillation in humans: assessment of the electrophysiological effects by biatrial basket electrodes. J Am Coll Cardiol 2000; 35:1434-41. [PMID: 10807444 DOI: 10.1016/s0735-1097(00)00597-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study was undertaken to assess the effects of sotalol on the transthoracic cardioversion energy requirement for chronic atrial fibrillation (AF) and on the atrial electrograms during AF recorded by two basket electrodes. BACKGROUND The effects of sotalol infusion on transthoracic electrical cardioversion for chronic atrial fibrillation in humans have not been well investigated. METHODS We included 18 patients with persistent AF for more than three months. Atrial electrograms were recorded by two basket electrodes positioned in each atrium respectively. Transthoracic cardioversion was performed before and after sotalol 1.5 mg/kg i.v. infusion. RESULTS In the 14 patients whose AF could be terminated by cardioversion before sotalol infusion, the atrial defibrillation energy was significantly reduced after sotalol infusion (236 +/- 74 jules [J] vs. 186 +/- 77 J; p < 0.01). Atrial fibrillation was refractory to cardioversion in four patients at baseline and was converted to sinus rhythm by cardioversion after sotalol infusion in two of them. We further divided the patients into two groups. Group A consisted of 10 patients in whom the energy requirement was decreased by sotalol while group B consisted of eight patients in whom the energy requirement was not decreased. The mean A-A (atrial local electrogram) intervals during AF were significantly increased after sotalol infusion in both groups, but the increment of A-A interval was significantly larger in group A than it was in group B patients (36 +/- 13 ms vs. 22 +/- 8 ms for the right atrium; 19 +/- 7 ms vs. 9 +/- 7 ms for the left atrium; both p < 0.05). The spatial and temporal dispersions of A-A intervals were not significantly changed after sotalol infusion in both atria in both groups. CONCLUSIONS Sotalol decreases the atrial defibrillation energy requirement by increasing atrial refractoriness but not by decreasing the dispersion of refractoriness.
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Affiliation(s)
- L P Lai
- Department of Internal Medicine, National Taiwan University Hospital, Taipei
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27
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Marchlinski FE, Zado ES, Deely MP, Saligan J, Ashar M, Nayak H. Concomitant device and drug therapy: current trends, potential benefits, and adverse interactions. Am J Cardiol 1999; 84:69R-75R. [PMID: 10568663 DOI: 10.1016/s0002-9149(99)00705-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Antiarrhythmic drug therapy in patients with implantable cardioverter defibrillators (ICDs) has decreased over the last 10 years. This trend, primarily seen with class I agents, has occurred mainly in patients with a cardiac arrest. However, despite this overall decrease, antiarrhythmic drug therapy remains an important adjuvant to ICD therapy. In addition to primary prevention of ventricular tachycardia and supraventricular tachycardia, antiarrhythmic drug therapy may potentiate tachycardia rate slowing and make ventricular tachycardia more tolerated hemodynamically and possibly more amendable to pacing therapy. Some of the class III antiarrhythmic drugs may actually lower defibrillation threshold. Unfortunately, these drugs may have adverse interactions with ICDs. An increase in defibrillation threshold or rate-dependent increase in pacing threshold may interfere with the effectiveness of device therapy. Proarrhythmic effects of antiarrhythmic drugs may enhance the frequency of device use. The bradycardic effects of antiarrhythmic drug therapy may similarly enhance the requirements for persistent bradycardia pacing and lead to early battery depletion and other adverse consequences. An awareness of potential benefits and adverse effects of antiarrhythmic drug therapy along with careful electrophysiologic assessment are necessary for optimum combination drug and device therapy.
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Affiliation(s)
- F E Marchlinski
- University of Pennsylvania Health System, Philadelphia 19104, USA
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28
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Gallardo I, Paydak H, Narra L, Ezri M, Maheshwari P, Telfer EA, Wang T, Zheutlin T, Kehoe RF, Nazari J. Repetitive ICD discharges during an ambulance ride: an unusual pacemaker-ICD interaction. Pacing Clin Electrophysiol 1999; 22:1680-2. [PMID: 10598973 DOI: 10.1111/j.1540-8159.1999.tb00389.x] [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] [Indexed: 11/30/2022]
Affiliation(s)
- I Gallardo
- Cardiac Electrophysiology Service, Illinois Masonic Medical Center, Chicago 60657, USA
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29
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Affiliation(s)
- J R Zaidan
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30021, USA
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30
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Abstract
Multiple technologic advances in the implantable cardioverter defibrillator (ICD) have resulted in smaller size, easier implantation, and improved detection, therapy, and stored diagnostic information. Advanced dual-chamber ICDs are currently available that allow dual-chamber rate-responsive pacing with mode switching, enhanced detection algorithms, antitachycardia pacing, low-energy cardioversion, high-energy shocks, and extensive diagnostics. Based on improvements in lead systems and improved energy waveforms, almost all devices are being implanted with nonthoracotomy leads in the pectoralis area. The results of recent clinical trials have expanded indications for the ICD for primary and secondary prevention of sudden cardiac death. With advances in capacitor and battery technology coupled with improved lead systems and waveform resulting in lower defibrillation thresholds, it is likely that lower-output, smaller devices will be developed. In the future, ICDs may have expanded indications and may incorporate physiologic sensors to access hemodynamic significance of arrhythmias and algorithms for prediction and prevention of cardiac arrhythmias.
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Affiliation(s)
- C A Swygman
- New England Medical Center, Boston, MA 02111, USA
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31
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Winecoff Miller AP, Sims JJ, McSwain R, Ujhelyi MR. Lidocaine's effect on defibrillation threshold are dependent on the defibrillation electrode system: epicardial versus endocardial. J Cardiovasc Electrophysiol 1998; 9:312-20. [PMID: 9554736 DOI: 10.1111/j.1540-8167.1998.tb00916.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Epicardial and endocardial defibrillation electrode systems affect myocardial electrophysiology and sympathetic function differently. Thus, we postulate that antiarrhythmic drugs will interact with these electrode systems differently. METHODS AND RESULTS Defibrillation energy requirements (DER) at 20% (ED20), 50% (ED50), and 80% (ED80) success were measured at baseline and during lidocaine (10 mg/kg per hour) or D5W treatment for epicardial and endocardial electrodes. Pigs were randomized to treatment (lidocaine or D5W) and electrode system, which resulted in four experimental groups: (1) epicardial electrode + D5W; (2) epicardial electrode + lidocaine; (3) endocardial electrode + D5W; and (4) endocardial electrode + lidocaine. ED50 DER (mean +/- SEM) values at baseline for groups 1-4 were 10.6+/-1, 8.5+/-1, 12.6+/-1, and 12.3+/-1 J, respectively. DER values for groups 1 and 3 during D5W were similar to baseline. Conversely, lidocaine increased ED50 DER values from 8.5+/-1 to 13.5+/-2 J (P < 0.05) in group 2 animals (epicardial electrodes). When lidocaine was administered to group 4 animals (endocardial electrodes), however, ED50 DER values remained similar to baseline values (12.3+/-1 to 14.3+/-2 J, P = NS). Lidocaine increased ED50 DER values by 59% with the epicardial electrode system, which was significantly greater than the 16% increase with the endocardial electrode system (P < 0.05). Electrophysiologic response and electrode impedance were similar between electrode systems. CONCLUSION Lidocaine increases DER values to a greater extent when using epicardial versus endocardial electrode system. Thus, drug-device interactions are dependent on the electrode system. These data suggest that the electrophysiologic milieu created by endocardial defibrillation mitigates the effects that lidocaine has on DER values.
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Affiliation(s)
- A P Winecoff Miller
- The University of Georgia College of Pharmacy, Augusta VA Medical Center, USA
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