© 2002 by European Society of Cardiology
DEFIBRILLATORS
What is the optimal electrode configuration for atrial defibrillators in man?
Department of Cardiology, Eastbourne General Hospital Eastbourne, U.K.
Manuscript submitted 10 January 2001. Accepted after revision 17 October 2001.
Correspondence: Dr Andrew Mitchell, Department of Cardiology, Eastbourne General Hospital, King's Drive, Eastbourne, BN21 2UD, U.K. E-mail: mitcharj{at}doctors.org.uk
Key Words: Atrial defibrillator, electrode configuration, atrial defibrillation threshold
Aims
To compare the atrial defibrillation threshold (DFT) for two electrode configurations in patients with drug refractory persistent atrial fibrillation (AF).
Methods and Results
11 patients, 73% male, mean age 60·9 (range 38 to 83), underwent implantation of a Medtronic Jewel®AF dual chamber defibrillator (model 7250). A step-up atrial DFT was performed in a randomized sequence for two electrode configurations: (1) Right atrial to distal coronary sinus electrode (RA>CS) and (2) defibrillator can to right ventricular and right atrial electrodes (CAN>RV+RA). The RA>CS configuration restored SR in 10 patients (91%). The CAN>RA+RV configuration restored SR in four patients (36%). The mean atrial DFT was significantly lower for the RA>CS than CAN>RA+RV configuration (10±7 Joules vs 25±6 Joules), P< 0·01. At 3 months post implantation, AF was reinduced and the protocol was repeated for the optimal electrode configuration. There was no significant difference in the atrial DFT compared with that at implant.
Conclusion
The right atrium to coronary sinus electrode configuration significantly reduces the atrial DFT. The atrial DFT also remains stable at 3 months post-implantation. Patients with persistent AF undergoing insertion of an atrial defibrillator should have a coronary sinus electrode implanted.
References
[1] Furberg CD, Psaty BM, Manolio TA, Gardin JM, Smith VE, Rautaharju PM. Prevalence of atrial fibrillation in elderly subjects (the Cardiovascular Health Study). Am J Cardiol 1994; 74: 236–241.[CrossRef][Web of Science][Medline]
[2] Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991; 22: 983–988.
[3] Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med 1982; 306: 1018–1022.[Abstract]
[4] Alpert JS, Petersen P, Godtfredsen J. Atrial fibrillation: natural history, complications, and management. Annu Rev Med 1988; 39: 41–52.[CrossRef][Web of Science][Medline]
[5] Petersen P and Godtfredsen J. Atrial fibrillation — a review of course and prognosis. Acta Med Scand 1984; 216: 5–9.[Web of Science][Medline]
[6] Brand FN, Abbott RD, Kannel WB, Wolf PA. Characteristics and prognosis of lone atrial fibrillation. 30-year follow-up in the Framingham Study. JAMA 1985; 254: 3449–3453.
[7] Donaldson P and Kavanagh-Gray D. Electrical cardioversion of atrial fibrillation: a one-year follow-up study. Can Med Assoc J 1969; 100: 370–373.[Medline]
[8] Coplen SE, Antman EM, Berlin JA, Hewitt P, Chalmers TC. Efficacy and safety of quinidine therapy for maintenance of sinus rhythm after cardioversion. A meta-analysis of randomized control trials [published erratum appears in Circulation 1991; 83: 714]. Circulation 1990; 82: 1106–1116.
[9] Crijns HJ, Van Gelder IC, Van Gilst WH, Hillege H, Gosselink AM, Lie KI. Serial antiarrhythmic drug treatment to maintain sinus rhythm after electrical cardioversion for chronic atrial fibrillation or atrial flutter. Am J Cardiol 1991; 68: 335–341.[CrossRef][Web of Science][Medline]
[10] Gosselink AT, Crijns HJ, Van Gelder IC, Hillige H, Wiesfeld AC, Lie KI. Low-dose amiodarone for maintenance of sinus rhythm after cardioversion of atrial fibrillation or flutter. JAMA 1992; 267: 3289–3293.
[11] Flaker GC, Blackshear JL, McBride R, Kronmal RA, Halperin JL, Hart RG. Antiarrhythmic drug therapy and cardiac mortality in atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators. J Am Coll Cardiol 1992; 20: 527–532.[Abstract]
[12] Cooper RA, Alferness CA, Smith WM, Ideker RE. Internal cardioversion of atrial fibrillation in sheep. Circulation 1993; 87: 1673–1686.
[13] Alferness C, Ayers GM, Cooper RA, Ideker RE. Lead systems for atrial defibrillation. Pacing Clin Electrophysiol 1994; 17: 1043–1047.[CrossRef][Medline]
[14] Fotuhi PC, Cooper RA, Sreenan CM, Rollins DL, Smith WM, Ideker RE. Can early timed internal atrial defibrillation shocks reduce the atrial defibrillation threshold? Pacing Clin Electrophysiol 1999; 22: 1179–1185.[CrossRef][Medline]
[15] Cooklin M, Olsovsky MR, Brockman RG, Shorofsky SR, Gold MR. Atrial defibrillation with a transvenous lead: a randomized comparison of active can shocking pathways. J Am Coll Cardiol 1999; 34: 358–362.
[16] Chaudhry GM, Warman E, Casavant D, et al. Optimization of atrial defibrillation pathways without use of coronary sinus leads in patients receiving Medtronic 7250 dual chamber defibrillator (Jewel AF). J Am Coll Cardiol 2000; 35: 104.
[17] Gallik DM, O'Conner ME, Warman E, Swerdlow CD. Optimal defibrillation pathway for an implantable atrial defibrillator without a coronary sinus lead. Pacing Clin Electrophysiol 1999; 22: 826 (Abstract).
[18] Cooper RA, Plumb VJ, Epstein AE, Kay GN, Ideker RE. Marked reduction in internal atrial defibrillation thresholds with dual-current pathways and sequential shocks in humans. Circulation 1998; 97: 2527–2535.
[19] Harbinson MT, Allen JD, Imam Z, et al. Rounded biphasic waveform reduces energy requirements for transvenous catheter cardioversion of atrial fibrillation and flutter. Pacing Clin Electrophysiol 1997; 20: 226–229.[CrossRef][Medline]
[20] Murgatroyd FD, Slade AK, Sopher SM, Rowland E, Ward DE, Camm AJ. Efficacy and tolerability of transvenous low energy cardioversion of paroxysmal atrial fibrillation in humans. J Am Coll Cardiol 1995; 25: 1347–1353.[Abstract]
[21] Ammer R, Alt E, Ayers G. Pain threshold for low energy intracardiac cardioversion of atrial fibrillation with low or no sedation. Pacing Clin Electrophysiol 1997; 20: 230–236.[CrossRef][Medline]
[22] Lok NS, Lau CP, Tse HF, Ayers GM. Clinical shock tolerability and effect of different right atrial electrode locations on efficacy of low energy human transvenous atrial defibrillation using an implantable lead system. J Am Coll Cardiol 1997; 30: 1324–1330.[Abstract]
[30] Santini M, Pandozi C, Toscano S, et al. Low energy intracardiac cardioversion of persistent atrial fibrillation. Pacing Clin Electrophysiol 1998; 21: 2641–2650.[CrossRef][Medline]
[23] Boriani G, Biffi M, Camanini C, et al. Internal atrial cardioversion: predictors of atrial defibrillation threshold. Europace Suppl 2000; 1: D324.
[24] Capucci A, Villani G, Piepoli M, Rusticali G, et al. Reproducibility of atrial defibrillation threshold in patients with induced or chronic atrial fibrillation. J Am Coll Cardiol 2000; 35: 106 (Abstract).
[25] Venditti FJ, John RM, Hull M, Tofler GH, Shahian DM, Martin DT. Circadian variation in defibrillation energy requirements. Circulation 1996; 94: 1607–1612.
[26] Levy S, Ricard P, Lau CP, et al. Multicenter low energy transvenous atrial defibrillation (XAD) trial results in different subsets of atrial fibrillation. J Am Coll Cardiol 1997; 29: 750–755.[Abstract]
[27] Timmermans C, Rodriguez LM, Ayers GM, Lambert H, Smeets J, Wellens HJ. Effect of electrode length on atrial defibrillation thresholds. J Cardiovasc Electrophysiol 1998; 9: 582–587.[Web of Science][Medline]
[28] Tse H, Timmermans C, Rodriguez L, et al. Incorporation of a coronary sinus lead in a standard ICD lead configuration: impact on atrial defibrillation threshold in humans. Europace Suppl 2000; 1: D322.
[29] Benser ME, Walcott GP, Killingsworth CR, et al. Atrial defibrillation thresholds of electrode configurations available to an atrioventricular defibrillator. J Cardiovasc Electrophysiol 2001; 12: 957–964.[CrossRef][Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||