Sequential or single pulse defibrillation? Investigations towards energy reduction in experimental animals

With introduction of the automatic implantable cardioverter-defibrillator for treatment of medically refractory ventricular arrhythmias, many investigations are focussing on possibilities of reducing the energy necessary for defibrillating the heart to obtain a more adequate size and a longer durability of the generator. Several studies favour the sequential pulse delivery, using three electrodes, either endocardial, epicardial or subcutaneous plates, to improve defibrillation performance of low energy shocks. However, the validity of this conclusion remains equivocal since two different electrode configurations were used for single and sequential defibrillation. In the present study the influence of sequential pulse delivery, pulse sequence and resultant current pathways on defibrillation energy requirements were examined in comparison with single-shocks between the same epicardial electrode configuration as well as four orthogonally positioned patches. The energy requirement for 100% efficiency could be reduced by sequential pulsing with a time interval of 1 msec thus yielding significant superiority compared to single pulse defibrillation using three electrodes. The same reliable defibrillation and reduced threshold has been obtained by using four electrodes and one single shock. The addition of a third electrode alone had no influence on the energy requirements. Therefore, we have to discuss a different electrophysiological mechanism for sequential defibrillation than for single shocks with an extended current distribution over the heart using four electrodes. Possibly the action potential of the single cell of the fibrillating heart is of interest in reflecting the efficiency of sequential pulse defibrillation. By influencing the action potential pharmacologically in some animals, the optimal time interval for double shocks could be extended up to 7 msec.(ABSTRACT TRUNCATED AT 250 WORDS)