The development of implantable cardioversion defibrillation systems: the clinical chronicle of defibrillation leads

Clinical experience suggests that there is a significant advantage from both the standpoint of survival and thoracotomy morbidity in the use of cardioverter defibrillator implantation strategies with transvenous and subcutaneous leads. Bioengineering achievements making the latter possible remains somewhat preliminary in comparison with the highly advanced analytic technology from which the leads for bradycardia pacing have issued. Accordingly, a good deal remains to be accomplished in the technology evolution of leads for implantable cardioverter defibrillators (ICDs). While second- and third-generation leads have proved to be clinically useful, their development remains far from complete. To date most lead studies have focused on endocardial shock pathways, waveforms, and the linkage thereof affecting defibrillation thresholds. Experience suggests that asymmetric biphasic waveforms that use dual pathways (versus monophasic unidirectional shocks) yield a greater margin of safety for effective control of arrhythmias with existing ICD systems. The critical mass and region of myocardium encompassed by energy pathways, the simultaneous versus sequential pulsing of ICD antiarrhythmic discharges, as well as electrode combinations, locations, and polarity, remain under study. Although final adjudication of the superiority of endocardial systems that exclude the need for thoracotomy over those that use epicardial electrodes remains to be determined by further observational and randomized trials, it is reasonable to conclude at this juncture that ICDs with endocardial leads are feasible and facile, providing a highly promising alternative to other antiarrhythmic strategies.