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J Thorac Cardiovasc Surg 1996;111:392-398
© 1996 Mosby, Inc.

SURGERY FOR ACQUIRED HEART DISEASE

SUCCESSFUL ATRIAL DEFIBRILLATION WITH VERY-LOW-ENERGY SHOCKS BY MEANS OF TEMPORARY EPICARDIAL WIRE ELECTRODES

Cleveland, Ohio, and Redmond, Wash.

Supported in part by a grant from InControl, Incorporated, Redmond, Wash.

Address for reprints: Brian L. Cmolik, MD, University Hospitals of Cleveland, 11100 Euclid Ave., Cleveland, OH 44106.

Abstract

Sustained atrial fibrillation is very common after cardiac surgical procedures. We hypothesized that atrial defibrillation could be accomplished consistently and safely by means of low-energy shocks delivered by temporary stainless steel wire electrodes placed at the time of the operation. Sterile pericarditis was created in five mongrel dogs (20.9 ± 2.1 kg), and pairs of standard temporary stainless steel wire electrodes were placed on the right atrial appendage, on Bachmann's bundle, and on the right ventricular apex for pacing, sensing, and recording. Temporary stainless steel wire electrodes, insulated except for the distal 6 cm and used to deliver defibrillation shocks, were placed adjacent to both atrial free walls and secured to the pericardium. All electrodes were brought out through the skin, and the sternotomy was closed. Dogs were tested in the conscious state on postoperative day 2. Sustained atrial fibrillation was induced by rapid atrial pacing. A customized software program was used to control the defibrillator, which delivered R wave–synchronous biphasic shocks to the atria through the temporary defibrillation electrodes. The shock intensity began at 50 volts and was increased by 10-volt increments until atrial fibrillation was terminated. Atrial fibrillation was terminated in all dogs at 112 ± 7 volts, with an energy of 0.42 ± 0.07 joule and an impedance of 67.8 ± 4 ohms (all values mean ± standard error of the mean). The mean percent success for atrial defibrillation at this minimal threshold was 49%. Thus at low-threshold voltages atrial fibrillation could be terminated with every other shock. A 25% increase in the minimal threshold voltage improved the conversion rate to 73% (mean energy 0.66 ± 0.19 joule and mean impedance of 67 ± 3.8 ohms). No complications were detected with the use of the electrodes or after their removal on the seventh postoperative day. One instance of electrode migration on the right atrial free wall was detected by roentgenography, but this did not adversely affect atrial defibrillation threshold. No ventricular arrhythmias or hemodynamic complications were noted during shock delivery. We conclude that successful conversion of atrial fibrillation to sinus rhythm can be achieved consistently with shock energies below 0.5 joule delivered with temporary epicardial defibrillation wire electrodes in this canine pericarditis model. These results suggest that this approach to the management of sustained atrial tachyarrhythmias has considerable promise in the management of atrial fibrillation in patients who have had cardiac operations. (J THORAC CARDIOVASC SURG 1996;111:392-8)

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