Plateau Waveform Shape Allows a Much Higher Patient Shock Energy Tolerance in AF Patients

Boriani, Giuseppe; Edvardsson, Nils; Biffi, Mauro; Silvestri, Paolo; Martignani, Cristian; Valzania, Cinzia; Diemberger, Igor; Moulder, John C.; Mouchawar, Gabriel; Poçi, Dritan; Branzi, Angelo; Kroll, Mark W.

doi:10.1111/j.1540-8167.2007.00846.x

Cited by 7 publications

(6 citation statements)

References 33 publications

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“…11,13,18–21 Shock warning systems were developed in conjunction with biphasic shocks because uncertainty of when a shock would occur was a common stressor, 22 but the psychological effect of expectation has been shown to worsen the perception of shocks. 23,24 Further, additional shocks given within minutes tend to hurt more than initial shocks.…”

Section: Discussionmentioning

confidence: 99%

Tetanizing prepulse: A novel strategy to mitigate implantable cardioverter-defibrillator shock-related pain

et al. 2016

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Background Skeletal muscle activation has been implicated as the source of pain associated with ICD shocks. We hypothesized that the skeletal muscle response to defibrillatory shocks could be attenuated with a tetanizing pre-pulse immediately prior to biphasic shock delivery. Objectives The purpose of this study was to test the ability of tetanizing pre-pulses to reduce the skeletal muscle activation associated with defibrillation. Methods Seven adult pigs were studied. A left ventricular coil and subcutaneous dummy can in the right thorax were used to deliver either pure biphasic waveforms or test waveforms consisting of a tetanizing pulse of high-frequency alternating current (HFAC) ramped to an amplitude of 5–100 V over 0.25 to 1 s, immediately followed by a biphasic shock of approximately 9 J (ramped HFAC and biphasic, or rHFAC+B). We used limb acceleration and rate of force development (RoFD) as surrogate measures of pain. Test and control waveforms were delivered in sinus rhythm and induced VF to test defibrillation efficacy. Results Defibrillation threshold energy was indistinguishable between rHFAC+B and pure biphasic shocks. Peak acceleration and RoFD were reduced by 72%±7% and 71%±22%, respectively with a 25 V 1 s rHFAC+B waveform compared with pure biphasic shocks. Notably, rHFAC+B with a 9 J biphasic shock produced significantly less skeletal muscle activation than a 0.1J pure biphasic shock. Conclusion A putative source of ICD shock-related pain can be mitigated using a tetanizing pre-pulse followed by biphasic shock. Human studies will be required to assess true pain reduction with this approach.

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Section: Discussionmentioning

confidence: 99%

Tetanizing prepulse: A novel strategy to mitigate implantable cardioverter-defibrillator shock-related pain

et al. 2016

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“…The results of the study indicated that peak voltage (rather than shockwave rounding or shape) is the major determinant of shock‐induced discomfort. This observation suggests that development of a waveform allowing voltage reduction could improve tolerability 58 …”

Section: The Issue Of Shock‐induced Discomfortmentioning

confidence: 96%

“…This observation suggests that development of a waveform allowing voltage reduction could improve tolerability. 58 (3) Modulation of shock perception: Patients' perception of discomfort from atrial defibrillator shocks could be mitigated in various ways. Shockinduced discomfort is not just a matter of pain: it is a complex phenomenon involving many facets, one of the most important of which is the anticipation of the shocks and their unpredictability.…”

Section: The Issue Of Shock-induced Discomfortmentioning

confidence: 99%

How, Why, and When May Atrial Defibrillation Find a Specific Role in Implantable Devices? A Clinical Viewpoint

Boriani¹,

Diemberger²,

Biffi³

et al. 2007

Pacing Clinical Electrophis

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This viewpoint article discusses the potential for incorporation of atrial defibrillation capabilities in modern multi-chamber devices. In the late 1990s, the possibility of using shock-only therapy to treat selected patients with recurrent atrial fibrillation (AF) was explored in the context of the stand-alone atrial defibrillator. The failure of this strategy can be attributed to the technical limitations of the stand-alone device, low tolerance of atrial shocks, difficulties in patient selection, a lack of predictive knowledge about the evolution of AF, and, last but not least, commercial considerations. An open question is how atrial defibrillation capability may now assume a specific new role in devices implanted for sudden death prevention or cardiac resynchronization. For patients who already have indications for implantable devices, device-based atrial defibrillation appears attractive as a "backup" option for managing AF when preventive pharmacological/electrical measures fail. This and several other personalized hybrid therapeutic approaches await exploration, though assessment of their efficacy is methodologically challenging. Achievement of acceptance by patients is an essential premise for any updated atrial defibrillation strategy. Strategies that are being investigated to improve patient tolerance include waveform shaping, pharmacologic modulation of pain, and patient-activated defibrillation (patients might also perceive the problem of discomfort somewhat differently in the context of a backup therapy). The economic impact of implementing atrial defibrillation features in available devices is progressively decreasing, and financial feasibility need not be a major issue. Future studies should examine clinically relevant outcomes and not be limited (as occurred with stand-alone defibrillators) to technical or other soft endpoints.

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“…Evaluation of shock tolerability in a clinical perspective must consider the multiple complexities of pain evaluation in humans. It is a common clinical experience that the discomfort associated with an electrical shock varies considerably from patient to patient and is affected by many factors related to individual features, clinical and arrhythmic profile, shock characteristics, delivery modality, and concurrent treatments 1,2,9–11 . These factors have emerged from experiences of patients implanted with an ICD or undergoing internal atrial cardioversion.…”

Section: Editorial Commentmentioning

confidence: 99%

Painless Shock Therapy: More Than Just an Attempt to Square the Circle?

Boriani

Biffi

Martignani

2007

Cardiovasc electrophysiol

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Plateau Waveform Shape Allows a Much Higher Patient Shock Energy Tolerance in AF Patients

Abstract: A plateau shaped biphasic waveform resulted in significantly increased shock energy pain tolerances. Controlling for session sensitization, patients tolerated over three times as much energy for the same verbally reported discomfort score.

Cited by 7 publications

References 33 publications

Tetanizing prepulse: A novel strategy to mitigate implantable cardioverter-defibrillator shock-related pain

Tetanizing prepulse: A novel strategy to mitigate implantable cardioverter-defibrillator shock-related pain

How, Why, and When May Atrial Defibrillation Find a Specific Role in Implantable Devices? A Clinical Viewpoint

Painless Shock Therapy: More Than Just an Attempt to Square the Circle?

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