title: Combination biphasic waveform plus sequential pulse defibrillation improves defibrillation efficacy of a nonthoracotomy lead system.
abstract: OBJECTIVE
  We hypothesized that combining biphasic waveform and sequential pulse defibrillation techniques would lower the defibrillation threshold of a nonthoracotomy lead system in humans below that obtained with biphasic or sequential pulse defibrillation alone.
  
  
  BACKGROUND
  Previous studies have shown that sequential pulse monophasic shocks and biphasic waveform shocks are more effective than single monophasic shocks for ventricular defibrillation.
  
  
  METHODS
  Thirteen patients aged 48 to 71 years undergoing nonthoracotomy defibrillation lead testing participated in the study. Transvenous electrodes were positioned in the right ventricular apex, superior vena cava and coronary sinus. A cutaneous patch electrode was placed on the left chest wall. All electrodes were connected to an external defibrillator. In random order, defibrillation threshold measurements were made for biphasic defibrillation alone, sequential defibrillation alone and combined biphasic plus sequential defibrillation.
  
  
  RESULTS
  The mean defibrillation threshold-delivered energy was 18.0 +/- 11.9 J for biphasic defibrillation and 16.3 +/- 9.0 J for sequential defibrillation. Biphasic plus sequential defibrillation significantly reduced the threshold energy to 10.2 +/- 5.3 J (p < 0.001). Threshold peak voltage and current values showed corresponding reductions. The combined waveform resulted in a greater reduction in defibrillation threshold in patients with threshold energies > 18 J versus those with threshold values < or = 18 J for sequential (p = 0.001) or biphasic (p < 0.01) waveform alone. The nonthoracotomy lead implantation rate was improved from 62% with each of the single techniques (biphasic waveform or sequential pulse defibrillation) to 85% with the combined waveform.
  
  
  CONCLUSIONS
  Adding biphasic waveform to sequential pulse defibrillation significantly reduced the defibrillation threshold compared with either technique alone, and nonthoracotomy lead system implantation can be enhanced by this combined technique.
authors.affiliation: Department of Medicine, University of Western Ontario, London, Canada.
authors.forename: D
authors.initials: D
authors.lastname: Exner
authors.forename: R
authors.initials: R
authors.lastname: Yee
authors.forename: D L
authors.initials: DL
authors.lastname: Jones
authors.forename: G J
authors.initials: GJ
authors.lastname: Klein
authors.forename: R
authors.initials: R
authors.lastname: Mehra
mesh_terms: D000368:Aged; D002304:Cardiac Pacing, Artificial; D017147:Defibrillators, Implantable; D004554:Electric Countershock / Q000379:methods*; D004567:Electrodes, Implanted; D004867:Equipment Design; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D017180:Tachycardia, Ventricular / Q000628:therapy*; D013908:Thoracotomy; D014693:Ventricular Fibrillation / Q000628:therapy*