Self-adhesive preapplied electrode pads for defibrillation and cardioversion

The efficacy of self-adhesive electrode pads for defibrillation and cardioversion was assessed in 80 patients who received 267 shocks from self-adhesive pads. In all but two patients, defibrillation or cardioversion was achieved at least once. The pads were equally effective when used in the apex-anterior or apex-posterior position. The transthoracic impedance using self-adhesive pads was 75 +/- 21 ohms (mean +/- standard deviation), which is similar to previously reported transthoracic impedance in defibrillation, using standard hand-held electrode paddles of 67 +/- 36 ohms. It is concluded that self-adhesive electrode pads are effective for defibrillation and cardioversion.     

Self-adhesive monitor/defibrillation pads improve prehospital defibrillation success

We compared self-adhesive, dual-function monitor/defibrillation electrode pads to standard chest monitoring leads and hand-held electrode paddles in the management of prehospital ventricular fibrillation in a single urban paramedic service. Shocks were delivered more quickly following paramedic arrival with self-adhesive pads than with hand-held paddles (1.6 vs 2.5 min; P less than .001). Ventricular fibrillation was terminated more frequently when shocks were delivered using the self-adhesive pads (55 of 58 patients, 95%) than when shocks were delivered using hand-held paddles (49 of 69 patients, 71%; P less than .005). Initial shocks delivered with self-adhesive pads were especially effective, converting 40 of 58 (69%) patients to an organized rhythm on the first or second shock; this was true of only 24 of 69 (35%) patients shocked with hand-held paddles (P less than .001). Patient survival to hospital admission improved when self-adhesive pads were used: 30 of the 58 (52%) patients shocked with self-adhesive pads achieved hospital admission, while only 21 of 69 patients (30%; P less than .025) survived to admission when hand-held paddles were used. In addition, electrical artifact that interfered with accurate rhythm interpretation was far more prevalent when standard monitoring electrodes were used, including artifact that resulted in inappropriate shock delivery (23% of patients monitored with standard electrodes vs 3% of patients monitored with self-adhesive pads; P less than .005). Self-adhesive monitor/defibrillation pads are superior to standard monitoring leads and hand-held electrode paddles in the management of prehospital ventricular fibrillation.     

Evaluation of a new defibrillation pathway: tongue-epigastric/tongue-apex route. II. Impedance characteristics in human subjects

An automated device for defibrillation using a vertical shock pathway (tongue-epigastric or tongue-apex) has been developed. The energy requirements for defibrillation using vertical pathways are uncertain and will be determined largely by the impedance of the pathway. The purpose of this study was to determine the impedance characteristics of vertical defibrillation pathways in human subjects. Twenty patients undergoing elective cardioversion of atrial fibrillation or atrial flutter, or both, were studied. Patients received shocks from electrodes placed in tongue-epigastric or tongue-cardiac apex positions. The tongue electrode was a 12 cm2 metal plate fixed to a standard plastic oropharyngeal airway. The epigastric or cardiac apex electrode was a 40 cm2 self-adhesive pad. The electrodes were connected to a standard damped-sinusoidal waveform defibrillator. It was found that the two vertical shock pathways had substantially higher impedance than the standard transthoracic pathway: tongue-epigastric pathway 130 +/- 11 omega (SD), tongue-apex pathway 115 +/- 12 omega, transthoracic pathway 68 +/- 11 omega (p less than 0.05). The higher impedance is probably due to the longer interelectrode distances of vertical pathways: tongue-epigastric 33 +/- 3 cm, tongue-apex 28 +/- 3 cm, transthoracic 23 +/- 3 cm (p less than 0.05). Vertical pathway shocks were successful in the cardioversion of 15 of 20 patients. Four of the five patients in whom vertical shocks were unsuccessful subsequently underwent successful cardioversion by transthoracic shocks; the transthoracic shocks achieved a higher current because of lower impedance of the transthoracic route.(ABSTRACT TRUNCATED AT 250 WORDS)     

Electrode pad size, transthoracic impedance and success of external ventricular defibrillation

Electrode pad size is an important determinant of transthoracic current flow during external countershock. Self-adhesive, dual function electrocardiogram/defibrillator pads were used to assess the effect of electrode pad size on defibrillation success with low energy (200 J) shocks. The study analyzed 123 cardiac arrests due to primary ventricular fibrillation (VF) in 105 patients (74 men, 31 women) ages 40 to 84 years (mean 64). Transthoracic impedance was measured before defibrillation using a low amplitude 30-kHz current passed through the chest by way of the electrocardiogram/defibrillator pads applied anteroanteriorly. Pad diameters were small (8/8 cm) in 26 cardiac arrests, intermediate (8/12 cm) in 63 arrests and large (12/12 cm) in 34 cardiac arrests. Transthoracic impedance decreased with increasing pad size (112 +/- 17 vs 92 +/- 22 vs 72 +/- 14 omega, respectively, p = 0.0001). Only the first episode of primary VF during a cardiac arrest was analyzed. A single shock of 200 J (delivered energy) was successful in 8 of 26 (31%) arrests using small pads, in 40 of 63 (63%) with intermediate pads and in 28 of 34 (82%) with large pads (p = 0.0003). A second 200-J shock increased the cumulative defibrillation rates to 12 of 26 (46%), 50 of 63 (79%) and 33 of 34 (97%), respectively (p less than 0.0001). In primary VF, larger self-adhesive electrocardiogram/defibrillator pads are associated with a lower transthoracic impedance and improved defibrillation success rates with low energy shocks.     

Disposable defibrillator electrodes

The transthoracic impedance to direct-current defibrillation discharge of the half-sinusoidal waveform was compared using recently marketed disposable defibrillator electrode pads (SAF-D-FIB and DEFIB-PADS) with electrode paste as the interfaces between the defibrillator paddle electrode and chest wall. Twenty-four mongrel dogs with an average weight of 17.3 kilograms were used. Half were shocked with the defibrillator meter setting at 100 watt-seconds (mean delivered energy, 59 watt-seconds) and half at 400 watt-seconds (mean delivered energy, 205 watt-seconds). Each animal received six shocks with both paste and one of the sets of disposable pads. The sequence of shocks was changed in alternate animals. At a meter setting of 100 watt-seconds, the mean impedance using SAF-D-FIB was 59 +/- 6 ohms compared to 46 +/- 6 ohms with paste (p less than 0.001), while that encountered with DEFIB-PADS was 57 +/- 5 ohms compared to 50 +/- 5 ohms with paste (p less than 0.01). At settings of 400 watt-seconds, the impedances encountered were also significantly higher with the disposable electrode (p less than 0.01). The output of many defibrillators in use today is inadequate for consistent defibrillation of adult patients weighing more than 50 to 80 kilograms. Since a minimal peak current per unit of body weight is required for ventricular defibrillation and since a higher transthoracic impedance results in a lower delivered peak current, one should use the paddle electrode-chest wall interface that results in the lowest impedance to defibrillator discharge. The impedance encountered with disposable electrodes is significantly higher than that encountered with electrode paste. Therefore, we do not recommend the use of these disposable electrodes for defibrillation or elective cardioversion.     

Defibrillator electrode-chest wall coupling agents: influence on transthoracic impedance and shock success

The purpose of this study was to determine if the difference in transthoracic impedance produced by different coupling agents affects the success of shocks for defibrillation. Three different coupling agents, Harco pads (Hewlett-Packard), Littman pads (3M) and Redux paste (Hewlett-Packard), were assessed in 10 anesthetized dogs in which ventricular fibrillation was induced by electrical stimulation of the right ventricle. Defibrillation was attempted 15 seconds later, using 50, 100 and 150 joules (selected energy). Actual delivered energy, current, impedance and the percent of the shocks that achieved defibrillation were determined for the three coupling agents. Redux paste gave significantly lower impedance and higher current than the two disposable performed coupling pads tested. Despite this, there were no significant differences in shock success among the three coupling agents. Thus, in this experimental model, over a three-fold energy range, disposable coupling pads were as effective as electrode paste for defibrillation despite the slightly higher impedance of the disposable pads.     

Determinants of successful transthoracic defibrillation and outcome in ventricular fibrillation

OBJECTIVE--To examine factors determining defibrillation success and outcome in patients with ventricular fibrillation. DESIGN--Observational prospective study of age, sex, transthoracic impedance, site of cardiac arrest, ventricular fibrillation duration and amplitude, primary or secondary ventricular fibrillation, aetiology, number of shocks to correct ventricular fibrillation, and drug treatment. SETTING--A teaching hospital and a mobile coronary care unit with a physician. PATIENTS--70 consecutive patients (50 male, 20 female) mean age 66.5 years. INTERVENTIONS--Before the first countershock was administered transthoracic impedance using a 30 kHz low amplitude AC current passed through 8 cm/12 cm self-adhesive defibrillator electrode pads applied in the anteroapical position was measured. The first two shocks were 200 J delivered energy (low energy) and further shocks of 360 J (high energy) were given if required. MAIN OUTCOME MEASURES--Countershock success and outcome from ventricular fibrillation. RESULTS AND CONCLUSIONS--First shock success was significantly greater in inhospital arrests (37/53) than in out-of-hospital arrests (5/17) and in those receiving antiarrhythmic treatment (13/15, 86.7%) v (27/51, 52.9%). Transthoracic impedance was similar in those who were successfully defibrillated with one or two 200 J shocks (98.7 (26) omega) and those who required one or more 360 J shocks (91.4 (23) omega). Success rates with two 200 J shocks were similar in those patients with "high" transthoracic impedance (that is, greater than 115 omega) and those with transthoracic impedance (less than or equal to 115 omega) (8/12 (67%) v 44/58 (76%]. Fine ventricular fibrillation was significantly more common in the patients with a transthoracic impedance of greater than 95 omega (41% (13/32] than in those with a transthoracic impedance less than or equal to 95 omega (13% (5/38]. Death during arrest was significantly more common in patients who needed high energy shocks (14/18 (78%] than in those who needed low energy shocks (16/52 (31%]. Multiple regression analysis identified ventricular fibrillation with an amplitude of greater than or equal to 0.5 mV, age less than or equal to 70 years, and arrests that needed less than or equal to two shocks for defibrillation, in rank order as independent predictors of survival to discharge.     

Determinants of successful transthoracic defibrillation and outcome in ventricular fibrillation.

OBJECTIVE--To examine factors determining defibrillation success and outcome in patients with ventricular fibrillation. DESIGN--Observational prospective study of age, sex, transthoracic impedance, site of cardiac arrest, ventricular fibrillation duration and amplitude, primary or secondary ventricular fibrillation, aetiology, number of shocks to correct ventricular fibrillation, and drug treatment. SETTING--A teaching hospital and a mobile coronary care unit with a physician. PATIENTS--70 consecutive patients (50 male, 20 female) mean age 66.5 years. INTERVENTIONS--Before the first countershock was administered transthoracic impedance using a 30 kHz low amplitude AC current passed through 8 cm/12 cm self-adhesive defibrillator electrode pads applied in the anteroapical position was measured. The first two shocks were 200 J delivered energy (low energy) and further shocks of 360 J (high energy) were given if required. MAIN OUTCOME MEASURES--Countershock success and outcome from ventricular fibrillation. RESULTS AND CONCLUSIONS--First shock success was significantly greater in inhospital arrests (37/53) than in out-of-hospital arrests (5/17) and in those receiving antiarrhythmic treatment (13/15, 86.7%) v (27/51, 52.9%). Transthoracic impedance was similar in those who were successfully defibrillated with one or two 200 J shocks (98.7 (26) omega) and those who required one or more 360 J shocks (91.4 (23) omega). Success rates with two 200 J shocks were similar in those patients with "high" transthoracic impedance (that is, greater than 115 omega) and those with transthoracic impedance (less than or equal to 115 omega) (8/12 (67%) v 44/58 (76%]. Fine ventricular fibrillation was significantly more common in the patients with a transthoracic impedance of greater than 95 omega (41% (13/32] than in those with a transthoracic impedance less than or equal to 95 omega (13% (5/38]. Death during arrest was significantly more common in patients who needed high energy shocks (14/18 (78%] than in those who needed low energy shocks (16/52 (31%]. Multiple regression analysis identified ventricular fibrillation with an amplitude of greater than or equal to 0.5 mV, age less than or equal to 70 years, and arrests that needed less than or equal to two shocks for defibrillation, in rank order as independent predictors of survival to discharge.     

Energy, current, and success in defibrillation and cardioversion: clinical studies using an automated impedance-based method of energy adjustment

The purposes of this study were two. First, we wanted to evaluate in patients a technique for automated adjustment of selected energy for defibrillation or cardioversion based on transthoracic impedance. Second, we wanted to define the relationship of peak current and shock success in various arrhythmias. Applying a previously validated method of predicting transthoracic impedance in advance of any shock, we modified defibrillators to automatically double the operator-selected energy if the predicted impedance exceeded 70 omega. Success rates of shocks given for ventricular and atrial arrhythmias from these modified energy-adjusting defibrillators were compared with success rates for shocks given from standard defibrillators. We prospectively collected data on 347 patients who received a total of 1009 shocks. Low-energy (100 J) shocks given to high-impedance (greater than or equal to 70 omega) patients had a poor success rate; in such high-impedance patients significant improvement in shock success rate was achieved by the energy-adjusting defibrillators. For example, when 100 J shocks were selected for high-impedance patients in ventricular fibrillation the energy-adjusting defibrillators achieved a shock success rate of 75%, whereas standard defibrillators achieved a shock success rate of only 36% (p less than .01). Similar improvements were seen for ventricular tachycardia and atrial fibrillation. Thus, automated energy adjustment based on transthoracic impedance is a beneficial approach to defibrillation and cardioversion. For ventricular fibrillation, atrial fibrillation, and atrial flutter there was a clear relationship between peak current and shock success.(ABSTRACT TRUNCATED AT 250 WORDS)     

Low Energy Intracardiac Cardioversion After Failed Conventional External Cardioversion of Atrial Fibrillation

Objectives. This study was designed to evaluate the efficacy of intracardiac cardioversion in patients with chronic atrial fibrillation after unsuccessful external cardioversion.Background. Previous studies in patients with atrial fibrillation undergoing intracardiac cardioversion have suggested that intracardiac cardioversion is highly effective and safe. However, the characteristics of patients who benefit most from this invasive technique are unknown.Methods. We prospectively studied 25 consecutive patients with chronic atrial fibrillation (11 ± 9 months). All patients had undergone at least three attempts at conventional external transthoracic cardioversion by means of paddles in an anteroposterolateral position applying energies up to 360 J without success. Intracardiac shocks were delivered by an external defibrillator through defibrillation electrodes placed in the right atrium and coronary sinus or in the right atrium and left pulmonary artery. After conversion, all patients were treated orally with sotalol (mean 194 ± 63 mg/day).Results. Internal cardioversion was successful in 22 of 25 patients at a mean defibrillation threshold of 6.5 ± 3.0 J. Mean lead impedance was 56.4 ± 7.4 Ω. No severe complications were observed. At a mean follow-up of 15 ± 12 months, 12 (55%) of the patients treated successfully remained in sinus rhythm.Conclusions. In patients with failed external cardioversion, internal cardioversion offers a new option for restoring sinus rhythm. Intracardiac cardioversion is an effective and safe method and can be easily performed in patients with minimal sedation.     

Transesophageal low-energy synchronous cardioversion of atrial flutter/fibrillation in the dog.

The purpose of this study was to determine the feasibility and efficacy of terminating atrial flutter/fibrillation using low-energy synchronous shocks delivered through a transesophageal catheter in dogs with talc-induced pericarditis. Atrial flutter/fibrillation was induced by employing the pulse train method. The minimum effective cardioversion energy level was compared for three different methods--method A, delivery between a distal esophageal electrode and a proximal esophageal electrode; method B, delivery of shocks through a distal esophageal electrode and a plate placed on the chest; method C, transthoracic cardioversion. The minimum effective cardioversion energy level did not differ significantly between methods A and B (1.30 +/- 0.46 joules versus 1.29 +/- 0.35 joules). Transesophageal cardioversion decreased the defibrillation threshold three- to fourfold from that of conventional transthoracic cardioversion. There were no complications of heart block, ventricular fibrillation, or any pathologic evidence of esophageal injury. Thus transesophageal low-energy synchronous cardioversion is considered a feasible and effective method for the treatment of atrial flutter/fibrillation.     

Automated impedance-based energy adjustment for defibrillation: experimental studies

In defibrillation, current flow depends on the energy selected and the transthoracic impedance. If transthoracic impedance is high, current flow may be inadequate to defibrillate. We developed a method by which high transthoracic impedance is automatically compensated for by an increase in operator-selected energy when impedance is high. Transthoracic impedance was predicted in advance of the first shock by passing a low-level current between the defibrillator electrodes during the defibrillator charge cycle; a microprocessor monitored current flow and determined impedance. In 28 mongrel dogs we manipulated transthoracic impedance by placing glycerin-soaked gauze pads between the paddle electrodes and the chest. If the predicted impedance exceeded a preset value, the delivered energy was automatically increased by 40% or 100%. Using this impedance-based energy adjustment technique, we found significant improvements in current flow and success rate of shocks when energy was automatically increased to compensate for high transthoracic impedance. The use of transthoracic impedance as a basis for energy adjustment appears a promising technique to minimize the hazards of high electrical energy; it allows low-energy shocks in most patients while avoiding inappropriate low energies in patients with high impedance. Clinical trials are justified.     

Transthoracic defibrillation: effect of sternotomy on chest impedance.

The purpose of this study was to determine the effect of sternotomy on transthoracic impedance, a major determinant of current flow and defibrillation success. Transthoracic impedance was determined by using a validated test-pulse technique that does not require actual shocks. Seventeen patients undergoing median sternotomy were studied prospectively. Transthoracic impedance was determined before operation, 3 to 5 days after operation and (in eight patients) greater than or equal to 1 month after operation. When measured using paddle electrodes placed in the standard apex-right parasternal defibrillating position, transthoracic impedance declined after sternotomy in all patients, from 77 +/- 18 to 59 +/- 17 omega (p less than 0.01); smaller declines were demonstrated by using other electrode positions. Transthoracic impedance remained below the preoperative level in the eight patients who underwent a second set of measurements at least 1 month after operation. Six normal subjects not undergoing sternotomy underwent serial transthoracic impedance measurements at least 5 days apart; mean transthoracic impedance did not change. It is concluded that transthoracic impedance declines after sternotomy. At any operator-selected energy level a higher current flow will result after sternotomy; this may facilitate postoperative defibrillation.     

Transthoracic defibrillation of short-lasting ventricular fibrillation: a randomised trial for comparison of the efficacy of low-energy biphasic rectilinear and monophasic damped sine shocks

BACKGROUND: Biphasic rectilinear shocks are more effective than monophasic shocks for transthoracic atrial defibrillation and for ventricular arrhythmias during electrophysiological testing.We undertook the present study to compare the efficacy of 100 J rectilinear biphasic waveform shocks with 150 J monophasic damped sine waveform shocks for transthoracic defibrillation of true ventricular fibrillation during defibrillation threshold testing (DFT).The second aim of the study was to analyse the influence of patch positions on the efficacy of defibrillation. METHODS: 50 episodes of 14 patients (age ranging from 37 to 82 years) who underwent DFT testing were randomised for back-up shocks with either a sequence of 100 and 200 J biphasic waveform, or a sequence of 150 and 360 J conventional monophasic shocks. A binary search protocol was used at implantation and before hospital discharge. Patients were also randomised to an anteroposterior position versus a right-anterior-apical position. A crossover was performed between implantation and pre-hospital discharge for biphasic versus monophasic sequence as well as for the 2 different positions. RESULTS: After failed internal shocks, 27 episodes were treated with biphasic, and 23 with monophasic shocks.The first attempt by the external device did not terminate II episodes (2 biphasic, 9 monophasic).The first shock efficacy was significantly greater with biphasic than with monophasic shocks (p < 0.02).The overall success rate was 93% with biphasic shocks and 64% with monophasic shocks. In multivariate regression analysis including patch position, arrhythmia duration, type of waveform, testing order and session, only waveform was associated with successful defibrillation (p < 0.02). CONCLUSION: For transthoracic defibrillation of ventricular fibrillation, low-energy rectilinear biphasic shocks are more effective than monophasic shocks.The position of the defibrillation shock pads has no influence on the biphasic shock efficacy, but anteroposterior pad position is more effective using monophasic shocks.     

Randomised comparison of electrode positions for cardioversion of atrial fibrillation

OBJECTIVE: To compare the relative efficacy of anteroanterior v anteroposterior electrode pad positions for external cardioversion of atrial fibrillation. DESIGN: Prospective randomised trial. SETTING: Tertiary referral cardiology centre in the United Kingdom. PATIENTS: 90 patients undergoing elective cardioversion for atrial fibrillation. INTERVENTIONS: Cardioversion was attempted with self adhesive electrode pads with an area of 106 cm2 placed either in the anteroanterior (AA) or anteroposterior (AP) positions. Initial shock was 100 J which, if unsuccessful, was followed by 200 J, 300 J, and 360 J if required. Peak current and transthoracic impedance were measured. MAIN OUTCOME MEASURES: Cardioversion success rate and energy requirements. RESULTS: Cardioversion was successful in 81% of the patients (73/90). There was no statistically significant difference in the cardioversion success rate (AA 84%, 38/45 patients; AP 78%, 35/45 patients; p = 0.42) or mean (SD) energy requirement for all patients (AA 223 (96.1) J; AP 232 (110) J) or for patients who were successfully cardioverted (AA 197.9 (82.4) J; AP 195.4 (97.2) J; p = 0.9) between the two pad positions. The mean transthoracic impedance (TTI) for the first shock (AA 77.5 (18.4) ohms; AP 73.7 (18.7) ohms; p = 0.34) was not significantly different between the two groups. TTI correlated significantly with body mass index, percentage body fat, and chest AP diameter. There was a progressive decrease in TTI with serial shocks. While aetiology and TTI were the two independent significant predictive factors for energy requirement, duration of atrial fibrillation was the only independent predictor of cardioversion success in a multivariate analysis. CONCLUSIONS: Electrode pad position is not a determinant of cardioversion success rate or energy requirement.     

Evaluation of a new defibrillation pathway--the tongue-epigastric route. I. Experimental studies in dogs

The purpose of this study was to determine the efficacy of a tongue-epigastric defibrillation route in anesthetized dogs. Ventricular fibrillation was induced by rectangular pulses passed down a transvenous catheter into the right ventricle. Three groups of dogs were studied. Group I (15 dogs) received shocks from a 12 cm2 tongue electrode, a 50 cm2 circular, gelled self-adhesive electrode pad placed on the epigastrium and standard transthoracic defibrillator paddle electrodes. Shocks were given at energy levels of 50 to 460 joules (delivered energy, 50 ohm resistance). The success of the tongue-epigastric shocks in achieving defibrillation, and the resistance and current flow were determined at each energy level and compared with the same energy shocks from the standard transthoracic electrodes. In Group II (five dogs), comparisons were made between the 12 cm2 tongue electrode used in the first group of dogs and a larger tongue electrode of 40 cm2. In Group III (five dogs), intracardiac current flow (potential gradient) with tongue-epigastric and standard transthoracic electrodes was studied. In Group I, defibrillation success with the tongue-epigastric electrodes ranged from no success at 50 to 100 joules to 83% success at 460 joules. With standard transthoracic electrodes, success rates ranged from 65% at 50 joules to 100% at 300 joules. At all energies tested, the resistance was significantly higher and current significantly lower using tongue-epigastric compared with transthoracic electrodes. The higher tongue-epigastric resistance is probably related to the longer interelectrode distance; the correlation between interelectrode distance (x, in centimeters) and resistance (y, in ohms) in these dogs was y = 2.2x + 29.6, r = 0.78.(ABSTRACT TRUNCATED AT 250 WORDS)     

External cardioversion of atrial fibrillation: comparison of biphasic vs monophasic waveform shocks.

AIMS: It is well established in transthoracic ventricular defibrillation that biphasic truncated waveform shocks are associated with superior defibrillation efficacy when compared with damped sine wave monophasic waveform shocks. The aim of this study was to explore whether biphasic waveform shocks were superior to monophasic waveform shocks for external cardioversion of atrial fibrillation (AF). METHODS AND RESULTS: Fifty-seven patients in whom cardioversion of AF was indicated were randomized in this prospective study, to transthoracic cardioversion with either monophasic damped sine waveform shocks or biphasic impedance compensating waveform shocks. In the group randomized to monophasic waveform shocks (27 patients), a first shock of 150 J was delivered, followed (if necessary) by a 360 J shock. In the biphasic waveform group (30 patients), the first shock had an energy of 150 J and (if necessary) a second 150 J was delivered. All shocks were delivered in the anterolateral chest pad position. Sinus rhythm was restored in 16 patients (51%) with the first monophasic shock and in 27 patients (86%) with the first biphasic shock. The difference was statistically significant (P=0.02). After the second shock, sinus rhythm was obtained in a total of 24 patients (88%) with monophasic shocks and in 28 patients (93%) with biphasic shocks. No complication was observed in either group and cardiac enzymes (CK, CKmb, troponin I, myoglobin) did not show any significant changes. CONCLUSION: This study suggests that at the same energy level of 150 J, biphasic impedance compensating waveform shocks are superior to monophasic damped sine waveform shocks cardioversion of atrial fibrillation.     

Encircling overlapping multipulse shock waveforms for transthoracic defibrillation

Objectives. This study was performed to determine the efficacy of new encircling overlapping multipulse, multipathway waveforms for transthoracic defibrillation.

Background. Alternative waveforms for transthoracic defibrillation may improve shock success.

Methods. First, we determined the shock success achieved by three different waveforms at varying energies (18–150 J) in 21 mongrel dogs after short-duration ventricular fibrillation. The waveforms tested included the traditional damped sinusoidal waveform, a single pathway biphasic waveform, and a new encircling overlapping multipulse waveform delivered from six electrode pads oriented circumferentially. Second, in 11 swine we compared the efficacy of encircling overlapping multipulse shocks given from six electrode pads and three capacitors versus encircling overlapping shocks given from a device utilizing three electrodes and one capacitor.

Results. In the first experiment, the encircling overlapping waveform performed significantly better than biphasic and damped sinusoidal waveforms at lower energies. The shock success rate of the overlapping waveform (six pads) ranged from 67 ± 4% (at 18–49 J energy) to 99 ± 3% at ≥150 J; at comparable energies biphasic waveform shock success ranged from 26 ± 5% (p < 0.01 vs. encircling overlapping waveforms) to 99 ± 5% (p = NS). Damped sinusoidal waveform shock success ranged from 4 ± 1% (p < 0.01 vs. encircling overlapping waveform) to 73 ± 9% (p = NS). In the second experiment the three electrode pads, one capacitor encircling waveform achieved shock success rates comparable with the six-pad, three-capacitor waveform; at 18–49 J, success rates were 45 ± 15% versus 57 ± 12%, respectively (p = NS). At 100 J, success rates for both were 100%.

Conclusions. We conclude that encircling overlapping multipulse multipathway waveforms facilitate transthoracic defibrillation at low energies. These waveforms can be generated from a device that requires only three electrodes and one capacitor.     

Effect of application of force to self-adhesive defibrillator pads on transthoracic electrical impedance and countershock success.

STUDY OBJECTIVE: To examine the effect of the application of force to self-adhesive defibrillator pads on transthoracic electrical impedance and countershock success. METHODS: A prospective, randomized, controlled pilot study was carried out in an experimental animal laboratory, involving 32 mixed-breed swine weighing 36.5 to 55.7 kg each. Ventricular fibrillation (VF) was induced, and the animals were randomly allocated to 1 of 4 groups, with 8 animals per group. Animals in groups I and II remained in VF for 30 seconds; those in groups III and IV remained in VF for 5 minutes. At the end of the VF period, up to 3 countershocks were given. In groups I and III, countershocks were delivered through the self-adhesive defibrillator pads alone; in groups II and IV, they were delivered through the defibrillator pads with 25 lb of applied force. Any animal without return of spontaneous circulation after 3 countershocks was given epinephrine after 1 minute of CPR, followed by 1 additional minute of CPR and 1 additional countershock if required. RESULTS: The main measurements included baseline and countershock transthoracic impedance, cumulative countershock success rate, and 30-minute survival rate. Application of 25 lb of force to the defibrillator pads significantly decreased transthoracic impedance, compared with baseline values (group II, 15. 1% decrease; group IV, 16.1% decrease). The first-shock success rate was higher when force was applied during the countershock (87.5% versus 50% for groups II and I, respectively; 62.5% and 37.5% for groups IV and III, respectively). In the animals who experienced 5 minutes of VF, there were greater rates of success after the second, third, and fourth countershocks when force was applied (group IV) than when no force was applied (group III). Groups I and II (VF for 30 seconds) demonstrated 100% survival at 30 minutes. Group IV had a higher 30-minute survival rate (3/8 animals) than did group III (1/8). However, the rates of countershock success and 30-minute survival were not statistically different among the groups. CONCLUSION: Application of force to self-adhesive defibrillator pads decreases transthoracic impedance during countershock. This effect may contribute to improving the countershock success rate.     

Ambulatory electrocardioversion of atrial fibrillation by means of biphasic versus monophasic shock delivery. A prospective randomized study

Transthoracic electrical cardioversion using a monophasic waveform is the most common method converting persistent atrial fibrillation into sinus rhythm. Recently, cardioversion with a new biphasic waveform has shown promising results for treatment of atrial fibrillation. We undertook a randomized prospective trial comparing the efficacy and safety of the two waveforms for ambulatory cardioversion of atrial fibrillation. A total of 118 consecutive patients (mean age 62 years [SD 11]) presenting with persistent atrial fibrillation (mean duration 8 months [SD 11]) for ambulatory electrical cardioversion were randomized to receive either monophasic (n = 57) or biphasic shocks (n = 61). We used a standardized step-up protocol with increasing shock energies (100-360 joules) in either group. In all patients an anterior-posterior shock electrode position was used. If sinus rhythm was not achieved with the third (360 joules) shock, cardioversion was repeated with the opposite waveform. The two groups did not differ in demographic or disease-related data. The success rate was 100% for the biphasic and 73.7% for the monophasic waveform (p < 0.001). Biphasic patients required fewer shocks (1.5 versus 2.9) and a lower mean cumulative energy (203 versus 570 joules) (p < 0.001). Twelve out of 15 unsuccessfully treated monophasic patients were converted with biphasic shocks. The success rate for all 118 patients was 97.5%. No major acute complications were observed. For ambulatory transthoracic cardioversion of persistent atrial fibrillation biphasic shocks are of greater efficacy and require less energy than monophasic shocks. The procedure can be performed ambulatory and is safe regardless of shock waveform used.