Tunnel propagation following defibrillation with ICD shocks: hidden postshock activations in the left ventricular
Jason Constantino1, Yun Long, Takashi Ashihara
1Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA.
Background:
After near-defibrillation threshold (DFT) shocks from an implantable cardioverter-defibrillator (ICD), the first postshock activation that leads to defibrillation failure arises focally after an isoelectric window (IW). The mechanisms underlying the IW remain incompletely understood.
Objective:
The goal of this study was to provide mechanistic insight into the origins of postshock activations and IW after ICD shocks, and to link shock outcome to the preshock state of the ventricles. We hypothesized that the nonuniform ICD field results in the formation of an intramural excitable area (tunnel) only in the left ventricular (LV) free wall, through which both pre-existing and new shock-induced wavefronts propagate during the IW.
Methods:
Simulations were conducted using a realistic three dimensional (3D) model of defibrillation in the rabbit ventricles. Biphasic ICD shocks of varying strengths were delivered to 27 different fibrillatory states.
Results:
After near-DFT shocks, regardless of preshock state, the main postshock excitable area was always located within LV free wall, creating an intramural tunnel. Either pre-existing fibrillatory or shock-induced wavefronts propagated during the IW (duration of up to 74 ms) in this tunnel and emerged as breakthroughs on LV epicardium. Preshock activity within the LV played a significant role in shock outcome: a large number of preshock filaments resulted in an IW associated with tunnel propagation of pre-existing rather than shock-induced wavefronts. Furthermore, shocks were more likely to succeed if the LV excitable area was smaller.
Conclusion:
The LV intramural excitable area is the primary reason for near-DFT failure. Any intervention that decreases the extent of this area will improve the likelihood of defibrillation success.
Related Concept Videos
01:30Cardiac Action Potential
The cardiac action potential process involves a series of phases characterized by the movement of ions across the cardiac cell membranes, leading to the depolarization and repolarization of the cardiac myocytes.
Ionic Basis of Cardiac Action Potentials
01:23Propagation of Action Potentials
Neurons (nerve cells) have a resting membrane potential, with a slightly negative charge inside compared to outside. This is maintained by ion channels, such as sodium (Na+) and potassium (K+) channels, which control the flow of ions. When a stimulus, like a touch or a signal from another neuron, triggers the neuron, sodium channels open, allowing sodium ions to...
01:19Electrophysiology of Normal Cardiac Rhythm
01:25ECG Interpretation of Arrhythmias II: Atrial, Junctional and Ventricular Arrhythmias