Circulation, Vol 89, 413-422, Copyright © 1994 by American Heart Association
GM Ayers, CA Alferness, M Ilina, DO Wagner, WA Sirokman, JM Adams and JC Griffin
BACKGROUND: Synchronized cardioversion is generally accepted as safe for
the treatment of ventricular tachycardia and atrial fibrillation when
shocks are synchronized to the R wave and delivered transthoracically.
However, others have shown that during attempted transvenous cardioversion
of rapid ventricular tachycardia, ventricular fibrillation (VF) may be
induced. It was our objective to evaluate conditions (short and irregular
cycle lengths [CL]) under which VF might be induced during synchronized
electrical conversion of atrial fibrillation with transvenous electrodes.
METHODS AND RESULTS: In 16 sheep (weight, 62 +/- 7.8 kg), atrial
defibrillation thresholds (ADFT) were determined for a 3-ms/3-ms biphasic
shock delivered between two catheters each having 6-cm coil electrodes, one
in the great cardiac vein under the left atrial appendage and one in the
right atrial appendage along the anterolateral atrioventricular groove. A
hexapolar mapping catheter was positioned in the right ventricular apex for
shock synchronization. In 8 sheep (group A), a shock intensity 20 V less
than the ADFT was used for testing, and in the remaining 8 sheep (group B),
a shock intensity of twice ADFT was used. With a modified extrastimulus
technique, a basic train of eight stimuli alone (part 1) and with single
(part 2) and double (part 3) extrastimuli were applied to right ventricular
plunge electrodes. Atrial defibrillation shocks were delivered synchronized
to the last depolarization. In part 4, shocks were delivered during atrial
fibrillation. The preceding CL was evaluated over a range of 150 to 1000
milliseconds. Shocks were also delayed 2, 20, 50, and 100 milliseconds
after the last depolarization from the stimulus (parts 1 through 3) or
intrinsic depolarization (part 4). The mean ADFT for group A was 127 +/- 48
V, 0.71 +/- 0.60 J and for group B, 136 +/- 37 V, 0.79 +/- 0.42 J (NS, P
> .15). Of 1870 shocks delivered, 11 episodes of VF were induced. Group
A had no episodes of VF in part 1, two episodes of VF in part 2 (CL, 240
and 230 milliseconds with 2-millisecond delay), and one episode each in
parts 3 (CL, 280 milliseconds with 2-millisecond delay) and 4 (CL, 240
milliseconds with 100-millisecond delay). Group B had two episodes in part
1 (CL, 250 and 300 milliseconds with 20-millisecond delay), three episodes
in part 2 (CL, 230, 230, and 250 milliseconds with 2- millisecond delay),
and one episode each in parts 3 (CL, 260 milliseconds with 2-millisecond
delay) and 4 (198 milliseconds with 100- millisecond delay). No episodes of
VF were induced for shocks delivered after a CL > 300 milliseconds.
CONCLUSIONS: Synchronized transvenous atrial defibrillation shocks
delivered on beats with a short preceding ventricular cycle length (<
300 milliseconds) are associated with a significantly increased risk of
initiation of VF. To decrease the risk of ventricular proarrhythmia, short
CLs should be avoided.
ARTICLES
Ventricular proarrhythmic effects of ventricular cycle length and shock strength in a sheep model of transvenous atrial defibrillation
InControl, Inc, Redmond, Wash. 98052.
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