Europace Advance Access published online on May 30, 2008
Europace, doi:10.1093/europace/eun136
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Patient-tailored implantable cardioverter defibrillator testing using the upper limit of vulnerability: the TULIP protocol
1 Department of Cardiology and Angiology, Medical Clinic II, BG University Hospital, Bergmannsheil, Bochum, Germany; 2 Department of Cardiology and Angiology, Internal Medicine Department III, Luedenscheid Clinic, Paulmannshoeher Strasse 14, D-58515 Luedenscheid, Germany; 3 Second Department of Cardiology, Medical University of Gdansk, Poland; 4 Cardiology Department, Carl-Thiem Clinic, Cottbus, Germany; 5 Cardiology Department, German Heart Centre, Berlin, Germany; 6 University Hospital Hamburg-Eppendorf, Germany; 7 Centre for Clinical Research and Scientific Studies, Biotronik GmbH & Co. KG, Hartmannstrasse 65, 91052 Erlangen, Germany
Aims: We evaluated the feasibility of the TULIP (Threshold test using Upper Limit during ImPlantation) protocol, which was designed to provide a confirmed, low defibrillation energy value during implantable cardioverter defibrillator (ICD) implantation with only two induced ventricular fibrillation (VF) episodes.
Methods and results: Ninety-eight patients (62 ± 12 years, 86 male) from 13 clinical centres underwent an active can ICD implantation. A single coupling interval derived from electrocardiogram lead II during ventricular pacing was used for VF induction shocks at 13, 11, 9, and 6 J in a step-down manner until the upper limit of VF induction (ULVI) was determined. If ULVI 
9 J, a defibrillation energy of ULVI + 4 J was tested. For ULVI <9 J, the defibrillation test energy was 9 J. In 79/98 patients (80.6%), two induced VF episodes were sufficient to obtain confirmed defibrillation energy of 11.1 ± 3.3 J. The mean strength of the successful VF induction shock was 6.8 ± 4.3 J, the coupling interval was 303 ± 35 ms, and the number of delivered induction shocks until the first VF induction was 3.9 ± 1.6.
Conclusion: TULIP is a safe and simple device testing procedure allowing the determination of confirmed, low defibrillation energy in most patients with two VF episodes induced at a single coupling interval.
Key Words: Implantable cardioverter defibrillator, Defibrillation threshold, Upper limit of vulnerability, Ventricular fibrillation, Implantation
* Corresponding author. Tel: +49 2351 46 3326; fax: +49 2351 46 3275. E-mail address: bernd.lemke{at}rub.de
Manuscript submitted 19 November 2007. Accepted after revision 24 April 2008.