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Is the determination of the defibrillation threshold in patients with an implantable cardioverter–defibrillator still required?

Wird die Bestimmung der Defibrillationsschwelle bei Patienten mit implantierbarem Kardioverter/Defibrillator noch benötigt?

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Abstract

Background

Intraoperative testing of implantable cardioverter–defibrillators (ICDs) is time consuming and associated with risks. In the present study, we elucidated whether the initial implantation of an ICD with high energy output makes intraoperative defibrillation threshold testing (DFTT) unnecessary even though antiarrhythmic (AA) therapy is needed in the future.

Methods

A total of 111 patients (94 men, 17 women) receiving an ICD with subsequent AA therapy (mexiletine, amiodarone, sotalol, flecainide) were analyzed retrospectively. DFT was performed during ICD implantation and after AA drug therapy. In a second step, DFT results from the study cohort were analyzed for implantation of virtual ICDs with either low (≤ 30 J, LOD), intermediate (34 J, IOD), or high energy output (36 J, HOD).

Results

In the study cohort, all patients reached the safety margin (SM) of 10 J between DFT and maximal shock energy of the ICD. After loading of AA agents, 6 patients (12%) with a LOD, 3 patients (11%) with an IOD, and 3 (13%) patients with a HOD failed the 10 J SM. Using virtual ICDs, 6 (5.5%) patients with a LOD, 1 patient (1%) with an IOD, and no patients with a HOD would have failed the 10 J SM. After loading of AA agents, 18 patients (16%) with a virtual LOD, 12 patients (10.8%) with an IOD, and still 9 patients (8%) with a HOD would have failed the 10 J SM.

Conclusion

Our results demonstrate that the 10 J SM would have been achieved intraoperatively in all patients with virtual HOD ICDs. Thus, determination of the DFT during implantation does not seem to be obligatory. However, in patients receiving AA agents, DFT testing is still required.

Zusammenfassung

Hintergrund

Die intraoperative Testung von implantierbaren Kardioverter/Defibrillatoren (ICD) ist personalintensiv und mit Komplikationen vergesellschaftet. In der vorliegenden Studie untersuchten wir, ob bei ICD-Implantationen mit unterschiedlicher maximaler Energieabgabe eine intraoperative Testung inklusive der Induktion von Kammerflimmern (DFT) notwendig gewesen wäre.

Material und Methoden

In einer retrospektiven Studie erhielten 111 Patienten (94 männlich, 17 weiblich) einen ICD. Nach Auftreten von ventrikulären Tachyarrhythmien wurden im weiteren Verlauf alle Patienten mit antiarrhythmischen Substanzen aufgesättigt (Mexiletin, Amiodaron, Sotalol, Flecainid). DFT-Testungen wurden intraoperativ und nach Aufsättigung mit antiarrhythmischen Substanzen durchgeführt. In einem zweiten Schritt wurden die DFT-Resultate der Studienkohorte analysiert hinsichtlich virtueller ICDs mit unterschiedlicher maximaler Energieabgabe ≤ 30 J (LOD), 34 J (IOD) oder 36 J (HOD).

Ergebnisse

Während Implantation erreichten alle Patienten die Sicherheitsmarge von 10 J (10-J-SM) zwischen maximaler Energieabgabe und DFT. Nach Aufsättigung mit antiarrhythmischen Substanzen verpassten 6 Patienten (12%) mit LOD, 3 Patienten (11%) mit IOD und 3 Patienten (13%) mit HOD die 10-J-Sicherheitsmarge. Hätte man für die Kohorte virtuelle ICDs mit LOD, IOD oder HOD implantiert, so hätten sechs (5,5%), ein (1%) bzw. kein Patient(en) (0%) die 10-J-SM nicht erreicht. Im Falle einer Aufsättigung der Studienkohorte mit antiarrhythmischen Substanzen hätten 18 (16%), 12 (10,8%) bzw. 9 (8%) der Patienten mit virtuellen ICDs (LOD/IOD/HOD) die 10-J-SM verpasst.

Schlussfolgerung

Die vorliegende Studie zeigt, dass intraoperativ bei allen Patienten mit virtuellem HOD-ICD die 10-J-SM erreicht worden wäre, jedoch nicht nach Aufsättigung mit antiarrhythmischen Substanzen. Eine intraoperative Testung aller Patienten mit HOD scheint entsprechend verzichtbar, solange keine Aufsättigung mit einem Antiarrhythmikum erfolgt.

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The corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Innere Medizin 1, Diakonieklinikum Schwäbisch Hall, Diakoniestr. 10, 74523, Schwäbisch Hall, Germany

    L. Jahn &  A. Bauer

  2. Abteilung für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Germany

    M. Licka, K. Kelemen, F. Voss, K. Trappe, R. Becker, O. Bikou, M. Hauck, M. Koch & H.A. Katus

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  1. M. Licka
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  2. L. Jahn
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  3. K. Kelemen
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  8. M. Hauck
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  11. A. Bauer
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Correspondence to A. Bauer.

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*The first two authors contributed equally to this work.

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Licka, M., Jahn, L., Kelemen, K. et al. Is the determination of the defibrillation threshold in patients with an implantable cardioverter–defibrillator still required?. Herzschr. Elektrophys. 22, 209–213 (2011). https://doi.org/10.1007/s00399-011-0150-1

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