Effects of waveform and polarity on defibrillation thresholds in humans using a transvenous lead system

Minimizing defibrillation thresholds is important to allow for implantation of downsized pulse generators with reduced outputs while maintaining an adequate defibrillation safety margin. Recent studies have demonstrated a significant reduction in monophasic defibrillation thresholds with a transvenous lead when the polarity was reversed (proximal coil = cathode). However, conflicting data exist concerning the effect of polarity reversal on biphasic defibrillation thresholds. The present study was designed to evaluate prospectively the effect of waveform shape and polarity on defibrillation thresholds in humans. The group studied consisted of 26 patients undergoing cardioverter-defibrillator implantation for standard indications. All data were obtained with a transvenous lead alone configuration. Defibrillation thresholds were determined using a step-down protocol with the initial waveform and polarity randomized. Reversing polarity significantly decreased the delivered energy at defibrillation threshold with monophasic waveforms (14.8 +/- 7.1 vs 20.4 +/- 8.9 J; p < 0.001), but had no effect on the overall efficacy of biphasic waveforms (11.1 +/- 5.5 vs 12.2 +/- 6.5 J). In the subgroup of patients with high biphasic defibrillation thresholds (> or = 15 J), reversing polarity decreased the defibrillation threshold from 18.2 +/- 5.1 to 13.3 +/- 5.8 J (p < 0.001). Similarly, the improvement in defibrillation thresholds with reversing polarity of monophasic waveforms was confined to the subgroup of patients with higher defibrillation thresholds. Therefore, the lack of group effect of polarity on biphasic defibrillation thresholds may be simply due to the overall lowering of defibrillation thresholds by this waveform.