Improved internal defibrillation with twin pulse sequential energy delivery to different lead orientations in pigs

Internal cardiac defibrillation with an intravascular catheter was compared with a new method for internal cardiac defibrillation using 2 pulses delivered in sequence directly to the myocardium. For the sequential pulses, the first pulse was passed through an intravascular catheter (Medtronic 6880), between the anode in the superior vena cava-atrial junction region and the cathode in the apex of the right ventricle. The second pulse was delivered between the catheter tip in the right ventricular apex as cathode and an oval plaque electrode (Medtronic TX-7) secured on the epicardium of the left ventricular free wall as anode. Defibrillation pulses were of truncated, trapezoidal waveform (65% tilt), separated by 1, 10 and 100 ms. Using the catheter alone, 36 normal pig hearts could be defibrillated by 44 J. However, 22 pig hearts (60%) could not be defibrillated with energies below 35 J. Defibrillation threshold was improved with sequential twin pulses, the improvement being dependent on pulse separation (42, 34 and 19 J, at 100-, 10- and 1-ms separation, respectively; F = 14.6, df = 2.29, p less than 0.01). In conclusion, sequential twin pulse defibrillation provides a considerable reduction in energy necessary for defibrillation in comparison to single pulses using the catheter alone. In this study, the optimal separation was 1 ms.