Abstract
Introduction: Conventional implantable cardioverter defibrillators employ endocardial (shock) electrodes with a lead located in the right ventricular apex (RV) and a “hot-can” electrode located subcutaneously in the left pectoral region. In the event of a high defibrillation threshold (DFT) a third electrode is frequently employed in the superior vena cava (SVC). We report the comparison of conventional and novel locations of additional electrodes with the RV/Can configuration, in a porcine model.
Method: In 12 anesthetized pigs (30–45 kg), endocardial defibrillation electrodes were randomized to the following locations: RV/Can, RV/Can + SVC, RV/Can + main pulmonary artery (MPA) and RV/Can + left pulmonary artery wedge position (PAW), RV/Can + high inferior vena cava (HIVC), RV/Can + Low inferior vena cava (LIVC). Ventricular fibrillation (VF) was induced using 60 Hz alternating current. After 10 seconds VF a rectangular biphasic shock was delivered by the ARD9000 (Angeion Corp). The DFT was determined for each configuration using a modified four-reversal binary search. All configurations were compared using a repeated measures analysis of variance (ANOVA) statistical test and the five 3-electrode configurations were compared to the RV/Can position using a Dunnett test.
Results: Mean DFTs: RV = 21.5 ± 4.8 J, SVC = 16.8 ± 4.7 J (p < 0.05 vs. RV), HIVC = 21.1 ± 4.7 J (p <. 0.05), LIVC = 19.1 ± 5.7 J (p <. 0.05 vs. RV), MPA = 16.0 ± 5.8 J (p < 0.01), PAW = 17.5 ± 4.6 J (p < 0.05 vs. RV).
Conclusions: Relative to the RV/can configuration the addition of a third electrode in the PA, PAW or SVC significantly reduces the DFT in the pig. The addition of an electrode to the IVC did not significantly reduce the DFT in our model.
Similar content being viewed by others
References
Saksena S, Munsif A, Prakash A, Madan N. Future directions for implantable defibrillation. In: Lüderitz B, Saksena S, eds. Interventional Electrophysiology: A Textbook. Armonk, NY: Futura Publishing Company, 1996, 617–649.
Mouchawar GA, Wolsleger WK, Doan PD, Causey JD, Kroll MW. Does an SVC electrode further reduce DFT in a hotcan ICD system? Pacing Clin Electrophysiol 1997;20: 163–167.
Higgins SL, Alexander DC, Kuypers CJ, Brewster SA. The subcutaneous array: A new lead adjunct for the transvenous ICD to lower defibrillation thresholds. Pacing Clin Electrophysiol 1995;18:1540–1548.
Jordaens L, Vertongen P, van Belleghem Y. A subcutaneous lead array for implantable cardioverter defibrillators. Pacing Clin Electrophysiol 1993;16:1429–1433.
Kall JG, Kopp D, Lonchyna V, Blakeman B, Cadman C, O'Connor M, Kinder C, Gilkerson J, Avery R, Wilber D. Implantation of a subcutaneous lead array in combination with a transvenous defibrillation electrode via a single infraclavicular incision. Pacing Clin Electrophysiol 1995;18: 482–485.
Chen PS, Wolf PD, Claydon FJ, Dixon EG, Vidaillet HJ, Danieley ND, Pilkington TC, Ideker RE. The potential gradient field created by epicardial defibrillation electrodes in dogs. Circulation 1986;74:626–636.
Kontos MC, Ellenbogen KA, Wood MA, Damiano RJ, Akosah KO, Nixon JV, Stambler BS, KenKnight BH, Eyuboglu BM, Ideker RE. Factors associated with elevated impedance with a nonthoracotomy defibrillation lead system. Impedance to defibrillation countershock: Does an optimal impedance exist? Pacing Clin Electrophysiol 1995;18:2068–2087.
Kerber RE, Spencer KT, Kallok MJ, Birkett C, smith R, Yoerger D, Kieso RA. Overlapping sequential pulses. A new waveform for transthoracic defibrillation. Circulation 1994;89:2369–2379.
Fain ES, Sweeney MB, Franz MR. Sequential pulse internal defibrillation: Is there an advantage to “switched” current pathways? Am Heart J 1989;118:717–724.
Markewitz A, Kaulbach H, Mattke S, Dorwarth U, Hoffmann E, Weinhold C, Steinbeck G, Reichart B. The left subclavian vein as an alternative site for implantation of the second defibrillation lead. Pacing Clin Electrophysiol 1995;18:401–405.
Nitta J, Khoury DS. Role of proximal electrode position in transvenous ventricular defibrillation. Ann Biomed Eng 1996;24:418–423.
Stajduhar KC, Ott GY, Kron J, McAnulty JH, Oliver RP, Reynolds BT, Adler SW, Halperin BD. Optimal electrode position for transvenous defibrillation: A prospective randomized study. J Am Coll Cardiol 1996;27:90–94.
Trappe HJ, Pfitzner P, Fain E, Dresler C, Fieguth HG. Transvenous defibrillation leads: Is there an ideal position of the defibrillation anode? Pacing Clin Electrophysiol 1997;20:880–892.
Bardy GH, Dolack GL, Kudenchuk PJ, Pooole JE, Mehra R, Johnson G. Prospective, randomized comparison in humans of a unipolar defibrillation system with that using an additional superior vena cava electrode. Circulation 1994;89:1090–1093.
Bardy GH, Allen MD, Mehra R, Johnson G. An effective and adaptable transvenous defibrillation system using the coronary sinus in humans. J Am Coll Cardiol 1990;16:887–895.
Bardy GH, Allen MD, Mehra R, Johnson G, Feldman S, Greene HL, Ivey TD. Transvenous defibrillation in humans via the coronary sinus. Circulation 1990;81:1252–1259.
Kudenchuk PJ, Bardy GH, Dolack GL, Poole JE, Mehra R, Johnson G. Efficacy of a single-lead unipolar transvenous defibrillator compared with a system employing an additional coronary sinus electrode. A prospective, randomized study. Circulation 1994;89:2641–2644.
Levy S, Ricard P, Gueunoun M, Yapo F, Trigano J, Mansouri C, Paganelli F. Low-energy cardioversion of spontaneous atrial fibrillation. Immediate and long-term results. Circulation 1997;96:253–259.
Alt E, Schmitt C, Ammer R, Plewan A, Evans F, Paquantonio J, Ideker T, Lehmann G, Putter K, Schomig A. Effect of electrode position on outcome of low-energy intracardiac cardioversion of atrial fibrillation. Am J Cardiol 1997;79:621–625.
Mouchawar GA, Schmidth JA, Johnson CR. Where and how long should the venous electrode be for lead only defibrillation? Circulation 1996;94:I-131 (abstract).
Austin E, Singer I. Operative techniques for implantation and testing of implantable cardioverter-defibrillators. In: Singer I, ed. Implantable Cardioverter-Defibrillator. Armonk, NY: Futura Publishing Company, 1994, 327–355.
Kallok MJ, Marcaccini S. Efficacy of two transvenous electrode systems for sequential pulse defibrillation. In: Gomez FP, ed. Cardiac Pacing: Electrophysiology. Tachyarrhythmias. Madrid: Editorial Grouz, 1985, 1497–1504.
Hillsley RE, Wharton JM. Implantable atrial defibrillators. J Cardiovasc Electrophysiol 1995;6:634–648.
Alferness C, Ayers GM, Cooper RA, Ideker RE. Lead systems for atrial defibrillation. Pacing Clin Electrophysiol 1994;17:1043–1047.
Cooper RA, Smith WM, and Ideker RE. Internal cardioversion of atrial fibrillation: Marked reduction in defibrillation threshold with dual current pathways. Circulation 1997;96(8):2693–2700.
Guse PA, Walcott GP, Rollins DL, Smith WM, Ideker RE. Defibrillation electrode configurations developed from cardiac mapping that combine biphasic shocks with sequential timing. Am Heart J 1992;124:1491–1500.
Singer I, Goldsmith J, Maldonado C. Transseptal defibrillation is superior for transvenous defibrillation. Pacing Clin Electrophysiol 1995;18:229–232.
Zipes DP, Fischer J, King RM, Nicoll AdeB, Jolly WW. Termination of ventricular fibrillation in dogs by depolarizing a critical amount of myocardium. Am J Cardiol 1975;36:37–44.
Chen PS, Wolf PD, Ideker RE. Mechanism of cardiac defibrillation. A different point of view. Circulation 1991;84:913–919.
Tang AS, Wolf PD, Afework Y, Smith WM, Ideker RE. Three-dimensional potential gradient fields generated by intracardiac catheter and cutaneous patch electrodes. Circulation 1992;85:1857–1864.
Kallok MJ. Pathways for Defibrillation Current. In: Kroll MW, Lehman MH, eds. Implantable Cardioverter Defibrillator Therapy: The Engineering-Clinical Interface. Kluwer Academic Publishers, 1993;105–119.
Bardou AL, Chesnais JM, Birkui PJ, Govaere MC, Auger PM, Von Euw D, Degonde J. Directional variability of stimulation threshold measurements in isolated guinea pig cardiomyocytes: Relationship with orthogonal sequential defibrillating pulses. Pacing Clin Electrophysiol 1990;13:1590–1595.
Tung L, Sliz N, Mulligan MR. Influence of electrical axis of stimulation on excitation of cardiac muscle cells. Circ Res 1991;69:722–730.
Gold JH, Schuder JC, Stoeckle H. Ventricular defibrillation with myocardial electrodes in the dog, calf, pony, and pig. Med Instrum 1980;14:19–22.
Crick SJ, Sheppard MN, Ho SY, Gebstein L, Anderson RH. Anatomy of the pig heart: Comparisons with normal human cardiac structure. J Anat 1998;105–119.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Roberts, P.R., Allen, S., Smith, D.C. et al. A Systematic Evaluation of Conventional and Novel Transvenous Pathways for Defibrillation. J Interv Card Electrophysiol 3, 231–238 (1999). https://doi.org/10.1023/A:1009895623802
Issue Date:
DOI: https://doi.org/10.1023/A:1009895623802