Shock on T Versus Direct Current Voltage for Induction of Ventricular Fibrillation:

Abstract

VF is induced during ICD implantation to determine efficacy of therapy. Establishing the best clinical method of induction of VF would potentially be beneficial in reducing the number of induction attempts and reducing the frequency of inadvertent induction of VT. Commonly used methods to induce VF include shock in the T wave vulnerable period (T shock) and high frequency stimulation. This study compared the efficacy of T shock with a new induction method using a 9-V DC pulse. The study was a randomized, prospective, case crossover trial in patients receiving ICDs. VF was induced by T shock and DC in a randomized sequence during an ICD implant. VF was induced at least four times in each patient (two T shocks and two DC inductions) and with each induction; attempts were continued with modifications until successful. A paired evaluation between the T shock/DC induction was performed in 37 patients (28 men, age 64 +/- 12 years) with a left ventricular ejection fraction of 0.40 +/- 0.20. Arrhythmia indications were VT (n = 23), VF (n = 10), and VT/VF (n = 4). Drug therapy included amiodarone (n = 10), metoprolol (n = 6), digoxin (n = 1), and lidocaine (n = 1). The average T shock voltage was 207.0 +/- 16.1 V. The S1 cycle drive length was consistently 400 ms, and the mean S2 coupling interval was 317.8 +/- 19.6 ms. The length of time DC applied averaged 3.8 +/- 1.4 seconds. A total of 148 episodes of VF were included in the analysis. T shock induced VF with a cycle length of 213.5 +/- 35.1 ms, and DC induced VF with a cycle length of 214.6 +/- 34.5 ms (P = 0.86). Although VF was eventually induced for each randomization, the number of attempts required were dependent on the method of induction. The successful DC first attempt VF induction rate was 96%, with three patients requiring two attempts during one of the DC inductions. T shock had a 68% first attempt success rate with 21 patients requiring multiple T shocks to induce VF. All nine female patients had at least one unsuccessful first attempt T shock, which contributed to an overall unsuccessful first attempt induction rate significantly higher in women then men (36.1% vs 12.5%, P = 0.001). A constant DC voltage induction of VF may be more effective than T shock for induction of VF in a clinical setting because it reduces the number of attempts required to induce VF. By either method, VF appears to be more difficult to induce in women. DC induction has the advantage of simple programming of only duration of stimulation. These findings have implications particularly for ICD implantation with conscious sedation.

Mechanisms of superiority of ascending ramp waveforms: new insights into mechanisms of shock-induced vulnerability and defibrillation

“…During ICD implantation, VF is commonly induced using T shock. Sharma et al (35) compared the efficacy of T shock with a new induction method using a 9-V direct current pulse. The rate of first-attempt VF induction rate using a 9-V pulse (96%) was much higher than the T shock method (68%).…”

A Rare Cause of Ventricular Fibrillation Confirmed by Speckle-Tracking Imaging

“…Electrical shock may cause direct myocardial necrosis or cardiac arrhythmias, and asystole and VF are the most severe arrhythmic complications of electrical injury. 7,8 Increased cardiac sodium/potassium pump activities and an increase of serum potassium concentration may trigger arrhythmias after electrical injury. Even though electrocution has been recognized and studied for over a century, many secrets remain about the mechanism of occurrence of ventricular arrhythmias.…”

Essentials of low-power electrocution: Established and speculated mechanisms

“…A shock of appropriate charge during the T-wave leads instantly to VF from reentry. 17 That is why the T-wave is referred to as the "vulnerable" portion of the heartbeat. For blunt trauma, mechanical energy delivered into the T-wave can also induce VF with a condition referred to as "commotio cordis."…”