Circulation, Vol 87, 1673-1686, Copyright © 1993 by American Heart Association
RA Cooper, CA Alferness, WM Smith and RE Ideker
BACKGROUND. The cardioversion efficacy of multiple defibrillation waveforms
and electrode systems was compared in a sheep model of atrial fibrillation.
METHODS AND RESULTS. Sustained atrial fibrillation could be induced with
rapid atrial pacing in 23 (55%) of the animals. This study was performed in
four parts. Six sheep with sustained atrial fibrillation were used for data
analysis for each part, except in part 4 where five sheep without sustained
atrial fibrillation were used. In part 1, four lead systems and four single
capacitor truncated exponential defibrillation waveforms (two monophasic
and two biphasic) were tested. In part 2, two transvenous lead systems were
compared; one was a right-to-left system with one electrode located in the
right side of the heart and the other electrode located in the left side of
the heart, and the other was a totally right-sided system with both
electrodes located in the right side of the heart. Eight (four monophasic
and four biphasic) waveforms were tested with each lead system. In part 3,
eight transvenous lead systems were compared, and two waveforms (one
monophasic and one biphasic) were tested with each lead system. For parts
1-3, probability of success curves were determined for each waveform/lead
system configuration using an up-down technique with 15 shocks per
configuration. In part 4, shocks were synchronized to the QRS and given
through two lead configurations during sinus rhythm in 20-V steps starting
with 40 and ending with 500 V, and two waveforms were tested with each lead
system (one monophasic and one biphasic). Ventricular fibrillation
thresholds were determined by giving shocks during the T wave of sinus
rhythm. For part 1, the three lead systems that used only intravenous
catheter electrodes had significantly lower defibrillation requirements
than the catheter-to- chest wall patch system. A 3/3-msec biphasic waveform
had significantly lower defibrillation requirements than any of the other
three waveforms in part 1. In part 2, the 3/3-msec biphasic waveform with a
right-to- left lead system configuration had significantly lower
defibrillation requirements than any other waveform lead system combination
tested, and for each waveform tested, the right-to-left configuration had
significantly lower requirements than the totally right-sided
configuration. In part 3, for each waveform the right-to-left configuration
had significantly lower voltage and energy requirements than the
corresponding totally right-sided configuration. Furthermore, in part 3,
waveform/lead configurations that probably generated high potential
gradients near the sinoatrial node and near the atrioventricular node
resulted in more postshock conduction disturbances. In part 4, there were
no episodes of ventricular arrhythmias with shocks synchronized to the QRS.
However, with synchronization to the T wave, ventricular fibrillation was
induced in all five animals with the minimum tested voltage, which was 40
V. CONCLUSIONS. This acute model yielded sustained atrial fibrillation in
approximately 55% of the animals. Cardioversion of atrial fibrillation in
sheep is possible with very low energy requirements using transvenous
electrode systems (50% successful energy of 1.3 +/- 0.4 J for the 3/3-msec
biphasic waveform with a right-to-left lead system). The biphasic waveform
had the lowest defibrillation requirements of any waveforms tested, and
right-to-left lead systems resulted in lower defibrillation requirements
than totally right-sided lead systems. Also, lead systems that probably
generated high potential gradients near the sinoatrial and atrioventricular
node areas resulted in more frequent episodes of postshock conduction
disturbances. Furthermore, synchronization of the shock to the QRS was
vital to avoid potentially lethal postshock ventricular arrhythmias...
ARTICLES
Internal cardioversion of atrial fibrillation in sheep
Department of Medicine, Duke University Medical Center, Durham, NC 27710.
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