title: ICD patients with elevated defibrillation threshold: clinical behavior and therapeutic alternatives.
abstract: BACKGROUND
  The ideal programming of the implantable cardioverter defibrillator (ICD) shock energy should be at least 10J above the defibrillation threshold (DFT), requiring alternative techniques when the DFT is elevated.
  
  
  OBJECTIVE
  To assess the clinical behavior of ICD patients with DFT>25J and the efficacy of the chosen therapy.
  
  
  METHODS
  Patients who had undergone ICD implantation between Jan/00 and Aug/04 (prospective database) and presented intraoperative DFT>25J were selected. The analyzed variables were: clinical characteristics, LVEF, rescue of arrhythmic events from ICD and causes of deaths.
  
  
  RESULTS
  among 476 patients, 16 (3.36%) presented DFT>25J. The mean age was 56.5 years, and 13 patients (81%) were men. According to the baseline cardiomyopathy, 09 patients had Chagas' disease, 04 had ischemic cardiomyopathy and 03 had idiopathic cardiomyopathy. Mean LVEF was 0.37 and amiodarone was used by 94% of the patients. Mean follow-up (FU) period was 25.3 months. DFT was higher than maximum energy shock (MES) in 2 patients and it was necessary to implant an additional shock electrode (array). It was programmed MES in ventricular fibrillation zone of ICD therapy in the other patients. In the FU, 03 patients had 67 successful appropriate shock therapies (AST). There were 05 noncardiac and 02 heart failure deaths. The patients who died showed higher DFT levels (p=0.044) without correlation with death because there wasn't unsuccessful AST.
  
  
  CONCLUSIONS
  In this cohort of ICD patients, the occurrence of elevated DFT (>25J) was low, leading to alternative therapies. There was an association with severe ventricular dysfunction, although without correlation to the causes of death.
authors.affiliation: Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Unidade de Estimulação Cardíaca Artificial, São Paulo, SP - Brazil. carlos.lima@cardiol.br
authors.forename: Carlos Eduardo Batista de
authors.initials: CE
authors.lastname: Lima
authors.forename: Martino
authors.initials: M
authors.lastname: Martinelli Filho
authors.forename: Rodrigo Tavares
authors.initials: RT
authors.lastname: Silva
authors.forename: Wagner Tetsuji
authors.initials: WT
authors.lastname: Tamaki
authors.forename: Júlio Cesar de
authors.initials: JC
authors.lastname: Oliveira
authors.forename: Daniela Cabral
authors.initials: DC
authors.lastname: Martins
authors.forename: Silvana Angelina D'Orio
authors.initials: SA
authors.lastname: Nishióka
authors.forename: Anísio Alexandre Andrade
authors.initials: AA
authors.lastname: Pedrosa
authors.forename: Sérgio Freitas
authors.initials: SF
authors.lastname: Siqueira
authors.forename: Roberto
authors.initials: R
authors.lastname: Costa
mesh_terms: D000638:Amiodarone / Q000627:therapeutic use; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001145:Arrhythmias, Cardiac / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D016757:Death, Sudden, Cardiac / Q000209:etiology / Q000517:prevention & control; D017147:Defibrillators, Implantable / Q000592:standards; D004056:Differential Threshold; D004554:Electric Countershock / Q000592:standards; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D017180:Tachycardia, Ventricular / Q000628:therapy; D014693:Ventricular Fibrillation / Q000628:therapy
chemical_list: D000889:Anti-Arrhythmia Agents; D000638:Amiodarone