JAM V.I. 23, No.
5
Apra 199e1141-5
Double Sequential External Shocks for Refractory
Ventricular FibrWation
DAVID H. HOCH, MD, PHD, FACC, WILLIAM P. BATSFORD . MD,'
STEVEN M . GREENBERG, MD, FACC. CRAIG M . MCPHERSON, MD, FACC.
LYNDA E . ROSENFELD, MD, FACC! MARK MARIEB . MD!
JOSEPH H. LEVINE, MD, FACC
Roslyn . New York and New Haven, Connecticut
Ohjseives. A technique for tsuinathrg refractory vatrleular
ibrillhallam. is described.
f fall, lilt all were sucre
RetrWuy venMrnYrse0tadea aneccurm up
to 1.1% it deehaplyyedolrgie studies, Auimd studies have charm
that rapid sequ iW shocks may redoce ventricular fibrillation
Mi .Flvepatimbef],990carecuivepatientsisa3yeas
period ezpeeleued retoetmy ventrimhr ibdpahandurhtg5 .450
ruaI e I I - . rile I III studies. MabIIIa shads were delivered
by amen at a defile L59- _I r. Double sequential shocks wen
delivered maternally 4 .5 to 4 $ r apart by mans of two detNr l a.
save wilk anpsmae pros of dettrodes .
Eleetrophyslologk resting is an accepted means of defining
lie nature of and beat therapy for ventricular arrhythmles .
Ono and point d the study is do induction of so-.mined
ventricular lachycardia. Usually, sustained ventricular
rachycari can be terminated with overdrive pacing, How-
ever. this may cause acceleration of the tachycardia or
ventricular fibrillation. External defibrillation is utilized rou.
tinely to terminate sustained ventricular mchyeardle or
fly In 10% to 30% otventiicular stimulation studies .
Despite its excellent a racy, reftectoey ventricular fibrilla-
tion can occur in up to 0.1% of cases (1.2).
When multiple tsrsthoracic ddlbrilletions have failed .
alternative approaches have been utiized . Emergency, tho-
racotmry with internal cardiopulmonary resuscitation and
delibriladon is ate such technique (3). However, it is
cmrbmaome. earring significst morbidity and requires sur-
gical expertise
fotraardiac; tausvcnoua cudioversion and defibrilalon
am terminate ventricular achyartfiythndas and has been
Pees St. Pence's Hawinl . C.dse Anhylln niO red Psaerao Cmtw,
Rostra, New York and 'Dep.mers o Cudmbey. W*-New Haven Hee-
piW, NO. Hmm,Caeacmcut
Namnergl meshed blush 25. 1993: mind aaonedps reCeiwd No-
ember If . M . Accepted November 17. IM
Dr. Dent H. Hack Cudae Arebyrhmu
mdDmemhCeter. St Funds Hoepird. I5Pet Wuhme0anauak std.
aodya, Now Yad 111!6.
0191 by ft Anne
., Coae0a dC.dloloa
1141
Reseal. In all patients, standard defihrduadon was uneuccesu.
rewacitatedusing the double sequen.
list shud,s .
Cancludom. This report stresses the impotence or en add!.
flood ddhrifstor bdsg radio available d ring etettropbysio-
lgtc testing. This ledmlqu of copal, double sequential entered
shade may have laced applicability, providing a simple and
potentially lifesaving approach to refractory ventricular
ibrigetioa.
(J Am Cog Carotol 1994;23:1141-5)
successful in refractory vcistiicular fibri llation during routine
electrophysiologic soldier (4-d)- A limitation of this tech-
nique is the time delay required to change the defibrillator
cue iguralion . In addition. mtracatdiac shocks may lead to
myocardial depression, cause new arrhylhmias and result in
cardiac perforation (5 .7) .
Animal studies (9) have suggested that rapid sequential
shocks may reduce ventricular defibrillation threshold, In
this report we describe our experience with five patients
among 2,990 consecutive patients studied during a 3-year
period at Yak-New Haven ad St . Francis Hospitals. These
patients experienced ventricular fibrillation refractory to
standard external defibrillation . All were successfully resus-
citated using two mod sequential shocks from two separate
defibrillators, thus averting the need for more aggressive
interventions.
Methods
There were 2.990 patients who underwent 5,450 electro-
physiologic studies during 3 consecutive years (1990 to 1992)
at Yale-New Haven and St. Francis Hospitals. Seventy
percent were men with an overall mean age of 60 years .
Ventricular tachyaodia or fibrillation was induced in -30%
of the studies. All patients were studied in the electrophys-
iology laboratory in the postabsorptive state . Three hundred
fifty studies involved testing of implantable caedioverter
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JACC Vol . 23. No. 5
Apia 1991 :1 NI-5
Figure I . Six surface leads 1 .
aVF. sYR, V,, V1 and V6 ate
shown in Patient 2. Seven prevl-
am shacks were unsuccessful.
Two sequential shacks (*S. *91
shown were successful in car
veiling to canal sinus rhythm .
Shack 8 appears to have yield a
slower tachycardia transiently .
which any have improved nOt-
cacy of the nubaiqaniat shads tone
Discussion). DCCV = direct car-
tent cardioversioo.
OCC- P - }607
SEQIIM '_naxe
In all of these patients, no pharmacologic agents were
adndnistered between the initial unsuccessful attempts at
defibrillation and final application of the successful sequen-
tial shock.
Discussion
The main finding of this study is that double sequential
shacks can result in successful defibrillation in pmiems with
ventricular fibrillation refractory to standard defibrillation
techniques. These patients underwent 7 to 20 unsuccessful
defibrillation attempts. In all cases two defibrillators were
used individually without success. Using both defibrillators
in each of Were patientsl two sequential shacks delivered 0 .5
to 4.5 a apart and from different defibrillation electrodes
resulted in successful conversion to normal sinus rhythm on
the first mtempL Thus, all five patients with refractory
ventricular fibrillation were successfully resuscitated using
double sequential shocks delivered 0 .5 to 4.5 s apart .
During electrophysiologic studies ventricular tachycardia
and fibrillation are frequently produced. Defibrillation mp-
idly delivered through pad decuodes (R,) already in place
successfully terminates most episodes with one or two
shocks. We report an incidence of refractory ventricular
fibrillation requiring mare than seven shocks in 0.2% of
patients and 0.1% of eleclrophysiologic studies . All patients
were successfully resuscitated with double sequential
shocks using two separate defibrillators (external in four,
imcrnalkxtetaal in one). This technique of rapid, double
defibrillation is relatively easy, requiring only the availability
of a second defibrillator. This approach may avert more
lengthy or unsuccessful resuscitations and more aggressive
interventions such as endacardial or internal defibrillation .
D ots thresholds are known to be affected by
HOCIH Er AL 1143
DOUBLE SHOCKS FOR VEN R1CULAR FIBRILLATION
navy 19 . 3501
multiple factors . including obesity, chronic lung disease,
antiarrhythmic agents, especially amiodarone and class IC
agents, as well as the position and polarity of electrodes
(9-18). The presence of implanted internal defibrillator
patches (Patient 5) may also alter external defibrillation
thresholds . ?articularfy if the patches are placed parallel to
the transthomcic electrode axis (14). Patients 1, 3 and 4 were
obese and might have bad incremed tmnsthmacic imped-
ances . Patients 3 and 5 were taking medications that might
also increase deflbt0lation thresholds- Patient 2 had a dilated
heart with a markedly depressed ejection fraction, which
may have contributed to the difficulty of his defibrillation .
Potential medmahms . The mechanism of the effect of
sequential extemul dellhrillatiuns is unknown . Animal stud-
ies (19-221 have shown that rapid . sequential shocks reduce
ventricular defibrillation thresholds . In most studies sequen-
tial shocks separated by I to 10 ms have been examined . A
recent study examined the effect of pulse separation between
sequential shocks and ventricular defibrillation efficacy. In
this series the optimal interval between shocks was 510 ms
or between 75 and 123 ma (23). Intervals X125 ms have not
been fully evaholed. A marked increase in defibrillation
threshold at a delay of 25 to 50 ms has been found. The
investigators of this series suggest that this time scale is
consistent with the known relative refractory period of
ventricular muscle, which is 50 to 70 ma. This period might
be one of particular vulnerability m the reinduction of
ventricular flbrlllatfon . In our series, the time between
sequential shocks is not only longer then this relative refrac-
tory period. but also longer than those reported in animal
studies . It is possible, however, that the mechanisms are
similar once the relative refractory periods have been ex-
ceeded .
Transthoraae impedance is another factor known to be


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JACC Vol. 23. No. 5
ApeS 1991:11415
10
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