title: Predictors of successful defibrillation threshold test during CRT-D implantation.
abstract: BACKGROUND
  The assessment of defibrillation energy requirement (DER) is a standard practice during cardioverter-defibrillator (ICD) implantation. It is recommended to assure that the energy at least 10 J below the maximal energy deliverable by the implanted device successfully converts the induced ventricular fibrillation (VF). The cardiac resynchronisation therapy with defibrillator (CRT-D) recipients are at increased risk of developing serious complications due to repeated VF induction.
  
  
  OBJECTIVE
  To define the prevalence of high DER among CRT-D recipients and to determine the factors which allow to obtain defibrillation safety margin.
  
  
  METHODS
  We examined all patients who underwent CRT-D implantation between June 2006 and June 2009 in our institution. The verification of the DER required at least one termination of the induced VF with the energy at least 10 J below the maximal energy deliverable by the implanted device.
  
  
  RESULTS
  The CRT-D was implanted in 65 patients. The first defibrillation test was successful in 57 (88%) patients. In the remaining 8 patients (12%), the defibrillation test was unsuccessful. These patients required system revision: reprogramming shocking polarity (2), reversing polarity and adjusting waveform (3), lead repositioning (1) and adding a subcutaneous lead (2). The use of high output devices (maximal energy > 30 J) and dual-coil leads was associated with a significantly (p < 0.05) lower rate of high DER, although high DER occurred in one patient implanted with the high output device. There was a correlation between the probability of successful defibrillation and renal function. It was less likely to obtain successful defibrillation safety margin in patients with creatinine > 175 micromol/L. During the follow up, ventricular tachyarrhythmia detected in the VF detection zone occurred in 13 (20%) patients, including two patients, who required system modification during implantation. In both cases, VF was terminated by the first defibrillation with the maximal energy of the implanted devices.
  
  
  CONCLUSIONS
  High DER occurred in a significant number of CRT-D recipients. There is a correlation between high DER and impaired renal function. The use of high output devices significantly decreases the number of patients who required system modification in order to obtain an adequate defibrillation safety margin.
authors.affiliation: Cardinal Stefan Wyszyński Institute of Cardiology, Warsaw, Poland. aprzybylski@ikard.pl
authors.forename: Andrzej
authors.initials: A
authors.lastname: Przybylski
authors.forename: Artur
authors.initials: A
authors.lastname: Oreziak
authors.forename: Zbigniew
authors.initials: Z
authors.lastname: Lewandowski
authors.forename: Andrzej
authors.initials: A
authors.lastname: Hasiec
authors.forename: Michał
authors.initials: M
authors.lastname: Orczykowski
authors.forename: Franciszek
authors.initials: F
authors.lastname: Walczak
mesh_terms: D000368:Aged; D001145:Arrhythmias, Cardiac / Q000453:epidemiology / Q000628:therapy*; D002304:Cardiac Pacing, Artificial / Q000379:methods / Q000706:statistics & numerical data*; D015897:Comorbidity; D016757:Death, Sudden, Cardiac / Q000517:prevention & control; D017147:Defibrillators, Implantable / Q000706:statistics & numerical data*; D004554:Electric Countershock / Q000295:instrumentation*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012684:Sensory Thresholds; D016896:Treatment Outcome; D014693:Ventricular Fibrillation / Q000453:epidemiology / Q000517:prevention & control*