Transvenous Biventricular Defibrillation Halves Energy Requirements in Patients

Abstract

Background-Defibrillation thresholds (DFT) with standard implantable cardioverter-defibrillator leads in the right ventricle (RV) may be determined by weak shock field intensity in the myocardium of the left ventricle (LV). Adding a shocking electrode in a coronary vein on the middle of the LV free wall, thereby establishing biventricular defibrillation, substantially reduced defibrillation requirements in animals. We investigated the feasibility of this approach in 24 patients receiving an implantable cardioverter-defibrillator using a prototype over-the-wire temporary LV defibrillation lead. Methods and Results-The LV lead was inserted through the coronary sinus, using a guide catheter and guidewire, into a posterior or lateral coronary vein whose location was determined by retrograde venography. Paired DFT testing compared a standard system (RV to superior vena cava plus can emulator [SVCϩCan], 60% tilt biphasic shock) to a system including the LV lead. The biventricular system was tested with a dual-shock waveform (20% tilt monophasic shock from LV3 SVCϩCan, then 60% tilt biphasic shock from RV3 SVCϩCan). Twenty patients completed DFT testing. Venography and LV lead insertion time was 46Ϯ40 minutes. The biventricular system reduced mean DFT by 45% (8.9Ϯ1.1 J versus 4.9Ϯ0.5 J, PϽ0.001). Twelve patients (60%) had a standard system DFT Ն8 J, and the biventricular system gave a lower DFT in all patients. There were no adverse events related to the use of the LV lead, which was removed after testing. Conclusions-Internal defibrillation using a transvenously inserted LV lead is feasible, produces significantly lower DFTs, and seems safe under the conditions tested. Biventricular defibrillation may be a useful option for reducing DFTs or could be added to an LV pacing lead for heart failure.

“Cold Can for a Hot Case”: Use of a Coronary Sinus Shocking Lead in Association with Cold Can to Achieve Successful Defibrillation

“…The use of CS coil placement allows utilization of a different vector encompassing the left ventricle. This has been previously described in the context of a biventricular device by our group and others 1–3 . In previous cases, the use of this configuration using a “hot can” was successful but in this case despite these measures we were still unable to achieve adequate defibrillation.…”

Coronary Sinus Shocking Lead As Salvage In Patients with Advanced CHF and High Defibrillation Thresholds

“…This appears to be a requirement for optimal defibrillation of the left ventricle during ventricular fibrillation 29 . When this area (posterior LV) is included in the shock field, DFTs are reduced 30 . We believe our patients displayed significant reduction in DFTs after CS shocking electrode placement because we were able to depolarize the posterior LV by employing the CS coil in the shocking/defibrillating configuration to include the posterior LV.…”

A Biventricular ICD System with Biventricular Defibrillation

“…Roberts et al demonstrated in pigs a 56% reduction in DFTs utilizing a shocking coil placed in the middle cardiac vein 6 . Significant reduction in DFTs has also been demonstrated in humans using a temporary transvenous shocking electrode placed in a posterior or lateral coronary vein tested at the time of a standard ICD implant 7 . Snow et al reported a case of high DFTs encountered in a single‐chamber ICD system resolved by the placement of a shocking coil in the coronary sinus 8 .…”