Skip to main content
SpringerLink
Log in

How to Manage a High Defibrillation Threshold in ICD Patients: and Does it Really Matter?

  • Arrhythmia (B Stambler, Section Editor)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Opinion statement

In the 30 years since its introduction, implantable cardioverter defibrillator (ICD) hardware and programming has evolved greatly. Coupled with a better understanding of how patient factors and anti-arrhythmic drug therapy affect ICD function, these changes have resulted in a modern ICD system which is highly effective at terminating ventricular arrhythmias. This has led to a marked decrease in the conduct of intraoperative defibrillation testing. Still, clinicians are faced with patients who have had unsuccessful intraoperative defibrillation testing or who have experienced one or more failed clinical shocks for ventricular arrhythmias. Thus, clinicians caring for ICD patients must understand the expected performance of modern ICD systems, understand the issues with intraoperative defibrillation testing, and have a strategy for dealing with patients when their ICD has failed to terminate a clinical or induced ventricular arrhythmia. This review will focus on the clinical approach to such patients, including trouble-shooting and system revision.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Connolly SJ, Hallstrom AP, Cappato R, et al. Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. Eur Heart J. 2000;21:2071–8.

    Article  PubMed  CAS  Google Scholar 

  2. Nanthakumar K, Epstein AE, Kay GN, Plumb VJ, Lee DS. Prophylactic implantable cardioverter-defibrillator therapy in patients with left ventricular systolic dysfunction: a pooled analysis of 10 primary prevention trials. J Am Coll Cardiol. 2004;44(11):2166–72.

    Article  PubMed  Google Scholar 

  3. Yee R, Klein GJ, Leitch JW, Guiradon GM, Guiradon CM, Jones DL, et al. A permanent transvenous lead system for an implantable pacemaker cardioverter-defibrillator. Nonthoracotomy approach to implantation. Circulation. 1992;85(1):196–204.

    Article  PubMed  CAS  Google Scholar 

  4. Gold M, Val-Mejias J, Leman RB, Tummala R, Goyal S, Kluger J, et al. Optimization of superior vena cava coil position and usage for transvenous defibrillation. Hear Rhythm. 2008;5(3):394–9.

    Article  Google Scholar 

  5. Seow SC, Tolentino CS, Zhao J, Lim TW. Azygous vein coil lowers defibrillation threshold in patients with high defibrillation threshold. Europace. 2011;13(6):825–8.

    Article  PubMed  Google Scholar 

  6. Wilczek R, Swiatkowski M, Czepiel A, Sterlinski M, Makowska E, Kulakowski P. Implantation of additional defibrillation lead into the coronary sinus: an effective method of decreasing defibrillation threshold. Kardiol Pol. 2011;69(12):1308–9.

    PubMed  Google Scholar 

  7. Osswald BR, De Simone R, Most S, Tochtermann U, Tanzeem A, Karck M. High defibrillation threshold in patients with implantable defibrillator: how effective is the subcutaneous finger lead? Eur J Cardiothorac Surg. 2009;35(3):489–92. Very large registry reporting the value of adding a subcutaneous shock electrod.

    Article  PubMed  Google Scholar 

  8. Winkle RA, Mead RH, Ruder MA, Gaudiani V, Buch WS, Pless B, et al. Improved low energy defibrillation efficacy in man with the use of a biphasic truncated exponential waveform. 117 1989;1(122):127.

  9. Hohnloser SH, Dorian P, Roberts RS, Gent M, Israel CW, Fain E, et al. Effect of amiodarone and sotalol on ventricular defibrillation threshold: the optimal pharmacological therapy in cardioverter defibrillator patients (OPTIC) trial. Circulation. 2006;114(2):104–9.

    Article  PubMed  CAS  Google Scholar 

  10. Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002;346(12):877–83.

    Article  PubMed  Google Scholar 

  11. Kolb C, Tzeis S, Zrenner B. Defibrillation threshold testing: tradition or necessity? Pacing Clin Electrophysiol. 2009;32(5):570–2.

    Article  PubMed  Google Scholar 

  12. Pires LA, Johnson KM. Intraoperative testing of the implantable cardioverter defibrillator: How much is enough? J Cardiovasc Electrophysiol. 2006;17:140–5.

    Article  PubMed  Google Scholar 

  13. Russo AM, Sauer W, Gerstenfeld EP, et al. Defibrillation threshold testing: is it really necessary at the time of implantable cardioverter-defibrillator insertion? Hear Rhythm. 2005;2(5):456–61.

    Article  Google Scholar 

  14. Gold MR, Higgins S, Klein R, et al. Efficacy and temporal stability of reduced safety margins for ventricular defibrillation: primary results from the Low Energy Safety Study (LESS). Circulation. 2002;105(17):2043–8.

    Article  PubMed  Google Scholar 

  15. Shorofsky SR, Peters RW, Rashba EJ, Gold MR. Comparison of step-down and binary search algorithms for determination of defibrillation threshold in humans. Pacing Clin Electrophysiol. 27 2004;2(218):220.

    Google Scholar 

  16. Healey JS, Dorian P, Mitchell LB, Talajic M, Philipon F, Simpson C, et al. Canadian Registry of ICD Implant Testing Procedures (CREDIT): current practice, risks and costs of intraoperative defibrillation testing. J Cardiovasc Electrophysiol. 2010;21(2):177–82.

    Google Scholar 

  17. Birnie D, Tung S, Simpson C, Crystal E, Exner D, Ayala Paredes FA, et al. Complications associated with defibrillation threshold testing: the Canadian experience. Hear Rhythm. 2008;5(3):387–90.

    Article  Google Scholar 

  18. Healey JS, Birnie DH, Lee DS, Chen Z, Krahn AD, Crystal E, et al. Defibrillation testing at the time of ICD insertion: an analysis from the Ontario ICD registry. J Cardiovasc Electrophysiol. 2010;21(12):1344–8. Large, regional registry documenting current practice of defibrillation testing.

    Article  PubMed  CAS  Google Scholar 

  19. Brignole M, Occhetta E, Bongiorni MG, Proclemer A, Favale S, Iacopino S, et al. Clinical evaluation of defibrillation testing in an unselected population of 2120 consecutive patients undergoing first implantable cardioverter-defibrillator implant. J Am Coll Cardiol. 2012;60(11):981–7. Very large regional registry documenting current practice of defibrillation testing.

    Article  PubMed  Google Scholar 

  20. Rattes MF, Jones DL, Sharma AD, Klein GJ. Defibrillation threshold: a simple and quantitative estimate of the ability to defibrillate. Pacing Clin Electrophysiol. 1987;10(1 Pt 1):70–7.

    Article  PubMed  CAS  Google Scholar 

  21. Kroll MW, Tchou PJ. Testing and programming of implantable defibrillator functions at implantation. In: Ellenbogen KA, Kay GN, Lau CP, Wilkoff BL, editors. Clinical cardiac pacing, defibrillation and resynchronization therapy. 4th edition ed. Philadelphia: Saunders; 2007. p. 531–57.

  22. Swerdlow CD, Shehata M, Chen PS. The dilemma of ICD implant testing. Pacing Clin Electrophysiol. 2007;30(2):258–70.

    Article  PubMed  Google Scholar 

  23. Epstein AE, Ellenbogen KA, Kirk KA, Kay GN, Dailey SM, Plumb VJ. Clinical characteristics and outcome of patients with high defibrillation thresholds. A multicenter study. Circulation. 1992;86(4):1206–16.

    Article  PubMed  CAS  Google Scholar 

  24. Guenther M, Rauwolf T, Bruggemann B, et al. Pre-hospital discharge testing after implantable cardioverter defibrillator implantation: a measure of safety or out of date? Europace. 2012;14(2):217–23.

    Article  PubMed  CAS  Google Scholar 

  25. Cheng Z, Turakhia M, Lo R, et al. Incidence and clinical predictors of low defibrillation safety margin at time of implantable defibrillator implantation. J Interv Card Electrophysiol. 2012;34(1):93–100.

    Article  PubMed  Google Scholar 

  26. Raitt MH, Johnson G, Dolack GL, et al. Clinical predictors of the defibrillation threshold with the unipolar implantable defibrillation system. J Am Coll Cardiol. 1995;25(7):1576–83.

    Article  PubMed  CAS  Google Scholar 

  27. Kkalighi K, Daly B, Beino EV, et al. Clinical predictors of transvenous defibrillation energy requirements. Am J Cardiol. 1997;79(2):150–3.

    Article  Google Scholar 

  28. Shukla HH, Flaker GC, Jayam V, Roberts D. High defibrillation thresholds in transvenous biphasic implantable defibrillators: clinical predictors and prognostic implications. Pacing Clin Electrophysiol. 2003;26(1 pt 1):44–8.

    Article  PubMed  Google Scholar 

  29. Leong-Sit P, Gula LJ, Diamantouoros P, Krahn AD, Skanes AC, Yee R, et al. Effect of defibrillation testing on management during implantable cardioverter-defibrillator implantation. Am Heart J. 2006;152:1104–8.

    Article  PubMed  Google Scholar 

  30. Mainigi SK, Cooper JM, Russo AM, et al. Elevated defibrillation thresholds in patients undergoing biventricular defibrillator implantation: incidence and predictors. Hear Rhythm. 2006;3(9):1010–6.

    Article  Google Scholar 

  31. Hodgson DM, Olsovsky MR, Shorofsky SR, Daly B, Gold MR. Clinical predictors of defibrillation thresholds with an active pectoral pulse generator lead system. Pacing Clin Electrophysiol. 2002;25(4 Pt 1):408–13.

    Article  PubMed  Google Scholar 

  32. Nagai T, Kurita T, Satomi K, et al. QRS prolongation is associated with high defibrillation thresholds during cardioverter-defibrillator implantations in patients with hypertrophic cardiomyopathy. Circ J. 2009;73(6):1028–32. Nice observational study examining the predictors of high defibrillation thresholds.

    Article  PubMed  Google Scholar 

  33. Gold MR, Khalighi K, Kavesh NG, et al. Clinical predictors of transvenous biphasic defibrillation thresholds. Am J Cardiol. 1997;79(12):1623–7.

    Article  PubMed  CAS  Google Scholar 

  34. Schuger C, Ellenbogen KA, Faddis M, et al. Defibrillation energy requirements in an ICD population receiving cardiac resynchronization therapy. J Cardiovasc Electrophysiol. 2008;7(3):247–50.

    Google Scholar 

  35. Healey JS, Gula LJ, Birnie DH, Sterns L, Connolly SJ, Sapp J, et al. A randomized-controlled pilot study comparing ICD implantation with and without intraoperative defibrillation testing in patients with heart failure and severe left ventricular dysfunction: a sub-study of the RAFT trial. J Cardiovasc Electrophysiol. 2012;23(12):1313–6. First small randomized trial of defibrillation testing.

    Article  PubMed  Google Scholar 

  36. Val-Mejias JE, Oza A. Does defibrillation threshold increase as left ventricular ejection fraction decrease? Europace. 2010;12(3):385–8.

    Article  PubMed  Google Scholar 

  37. Kroll MW, Tchou PJ. Testing and programming of implantable defibrillator functions at implantation. Pacing Clin Electrophysiol. 2007;531–57.

  38. Kroll MW, Efimov IR, Tchou PJ. Present understanding of shock polarity for internal defibrillation: the obvious and nonobvious clinical implications. Pacing Clin Electrophysiol. 2006;29(8):885–91.

    Article  PubMed  Google Scholar 

  39. Denman RA, Umesan C, Martin PT, et al. Benefit of millisecond waveform durations for patients with high defibrillation thresholds. Hear Rhythm. 2006;3(5):536–41.

    Article  Google Scholar 

  40. Gold MR, Val-Mejias J, Cuoco F, Siddiqui M. Comparison of fixed tilt and tune defibrillation waveforms. J Cardiovasc Electrophysiol. 2013;24:323–7. Excellent evaluation of the role of adjustable defibrillation waveform on clinical success.

    Article  PubMed  Google Scholar 

  41. Kroll MW, Shwab JO. Achieving low defibrillation thresholds at implant: pharmacological influences, RV coil polarity and position, SVC coil usage and positioning, pulse width settings, and the azygous vein. Fundam Clin Pharmacol. 2010;24(5):561–73.

    Article  PubMed  CAS  Google Scholar 

  42. Yang F, Patterson R. Optimal transvenous coil position on active-can single coil ICD defibrillation efficacy: a simulation study. Ann Biomed Eng. 2008;36(10):1659–67.

    Article  PubMed  Google Scholar 

  43. Roberts PR, Allen S, Betts T. Increased defibrillation threshold with right-sided active pectoral can. J Interv Card Electrophysiol. 2000;4(1):245–9.

    Article  PubMed  CAS  Google Scholar 

  44. Healey JS, Nair GM, Connolly SJ, Morillo CA. A rare cause of implantable cardioverter-defibrillator failure: short-circuiting via an unused pace/sense lead. Hear Rhythm. 2010;7(11):1630–1.

    Article  Google Scholar 

  45. De Lurgio DB, Sathavorn C, Mera F, Leon A, Walter PF, Langberg JJ. Incidence and implications of abrasion of implantable cardioverter-defibrillator leads. Am J Cardiol. 1997;79(10):1409–11.

    Article  PubMed  Google Scholar 

  46. Simon RD, Sturdivant JL, Leman RB, Wharton JM, Gold MR. The effect of dofetilide on ventricular defibrillation thresholds. Heart Lung. 2009;7(1):67–71.

    Google Scholar 

  47. Dorian P, Newman D, Sheehan R, et al. d-Sotalol decreases defibrillation energy requirements in humans: a novel indication for drug therapy. J Cardiovasc Electrophysiol. 1996;7(10):952–61.

    Article  PubMed  CAS  Google Scholar 

  48. Zhou L, Chen BP, Kluger J, et al. Effects of amiodarone and its active metabolite desethylamiodarone on the ventricular defibrillation threshold. J Am Coll Cardiol. 1998;31(7):1672–8.

    Article  PubMed  CAS  Google Scholar 

  49. Christ G, Becker R, Voss F, Kelemen K, Senges-Becker J, Hauck M, et al. Indications for predismissal testing with arrhythmia-inducation in patients receiving an implantable cardioverter defibrillator. Clin Res Cardiol. 2007;96:613–20.

    Article  PubMed  CAS  Google Scholar 

Download references

Conflict of Interest

Dr. Maria Vittoria Matassini reported no potential conflicts of interest relevant to this article.

Dr. Jeff S. Healey reported receiving grants from Boston Scientific and St. Jude Medical.

Author information

Authors and Affiliations

  1. Polytechnic University of Marche, Ancona, Italy

    Maria Vittoria Matassini MD

  2. Population Health Research Institute, McMaster University, Room C3-121, DBCVSRI Building, Hamilton Health Sciences, General Site, Hamilton, Ontario, Canada, L8L 2X2

    Maria Vittoria Matassini MD & Jeff S. Healey MD, MSc

Authors
  1. Maria Vittoria Matassini MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jeff S. Healey MD, MSc
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jeff S. Healey MD, MSc.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Matassini, M.V., Healey, J.S. How to Manage a High Defibrillation Threshold in ICD Patients: and Does it Really Matter?. Curr Treat Options Cardio Med 15, 497–505 (2013). https://doi.org/10.1007/s11936-013-0244-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11936-013-0244-7

Keywords

Search

Navigation