From Defibrillation Theory to Clinical Implications

Background: Our defibrillation theory claims that the mean voltage threshold is a hyperbolic function of pulse duration and that voltages below rheobase should be avoided as being counterproductive. Truncation of the pulse just at rheobase level yields minimal stored energy thresholds. To verify or falsify this theory, animal experiments were carried out. Material and Methods: In two animal experiments, 212 defibrillation thresholds in 22 swine were determined with different biphasic pulses of which 92 were optimally truncated in phase 1. Step‐up test procedure was used with the first successful shock defined as “threshold.” Results: Experimental proof is gained that truncation according to “rheobase condition” shows lowest stored energy. A ranking order of stored energy thresholds demonstrates that (1) lower output capacitances reduce needed energy, and (2) pulse durations shorter or longer than optimal increase needed energy. The voltage–pulse‐content threshold is linearly correlated with pulse duration. Conclusions: Truncation above or below rheobase increases the stored energy threshold. Voltage averaged during pulse duration is a hyperbolic function of pulse duration. The stored energy is reduced with decreasing output capacitance. The experimental results do not only fully verify our theory, they also suggest clinical implications: (1) the current usage of the “constant tilt concept” in implantable cardioverter defibrillator (ICD) should be abandoned in favor of “optimal truncation concept,” (2) an algorithm developed for calculating optimal truncation proved to be useful so that incorporation into ICD for automatic adjustment is recommended, and (3) the output capacitance should be reduced from about 100 μF to 60 to 70 μF. (PACE 2010; 33:814–825)