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Background. Potential gradient field determination may be a helpful means of describing the effects of
defibrillation shocks; however, potential gradient field requirements for defibnrllation with different
electrode configurations have not been established.
Methods and Results. To evaluate the field requirements for defibrillation, potential fields during
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defibrillation shocks and the following ventricular activations were recorded with 74 epicardial electrodes
in 12 open-chest dogs with the use of a computerized mapping system. Shock electrodes (2.64 cm2) were
attached to the lateral right atrium (R), lateral left ventricular base (L), and left ventricular apex (V).
Four electrode configurations were tested: single shocks of 14-msec duration given to two single
anode-single cathode configurations, R: V and L: V, and to one dual anode-single cathode configuration,
(R+L):V; and sequential 7-msec shocks separated by 1 msec given to R:V and L:V (R:V-*L:V).
Defibrillation threshold (DFT) current was significantly lower for R:V--L:V than for the other
configurations and markedly higher for L:V. Despite these differences, the minimum potential gradients
measured at DEFI were not significantly different (approximately 6-7 V/cm for each electrode configura-
tion). Potential gradient fields generated by the electrode configurations were markedly uneven, with a
15-27-fold change from lowest to highest gradient, with the greatest decrease in gradient occurring near
the shock electrodes. Although gradient fields varied with the electrode configuration, all configurations
produced weak fields along the right ventricular base. Early sites of epicardial activation after all
unsuccessful shocks occurred in areas in which the field was weak; 87% occurred at sites with gradients
less than 15 V/cm. Ventricular tachycardia originating in high gradient areas near shock electrodes
followed 11 of 67 successful shocks.
Conclusions. These data suggest that 1) defibrillation fields created by small epicardial electrodes are
very uneven; 2) achievement of a certain minimum potential gradient over both ventricles is necessary for
ventricular defibrillation; 3) the difference in shock strengths required to achieve this minimum gradient
over both ventricles may explain the differences in DIFTs for various electrode configurations; and 4) high
gradient areas in the uneven fields can induce ectopic activation after successful shocks. (Circuaion
1992;85:1510-1523)
KEY WORDS * defibrillation * fields, gradient
T odefibrillate with the least amount of energy, the myocardium; thus, potential gradients may explain the
potential field generated by the defibrillating relative efficacy of different electrode configurations.
shock must be optimized. The potential gradi- Though a few studies have measured potential gradients
ent has been reported to be closely related to the and gradient fields during electrical shocks in sinus
success or failure of defibrillation.' If a certain mini- rhythm or ventricular fibrillation,2-5 systematic evalua-
mum potential gradient is necessary over the myocar- tion of field requirements for multiple electrode config-
dium to achieve defibrillation, shocks that do not pro- urations to determine the minimum magnitude and
duce this minimum potential gradient will not be spatial requirements of potential gradient fields has not
successful. Furthermore, the defibrillation threshold been performed. In addition, mapping of potential
(DFT) should be determined by the shock strength gradient fields may help to explain the increased efficacy
required to obtain this minimum gradient across the of some sequential shock electrode configurations. The
All editorial decisions for this article, including selection of grants HL-17670, HL-28429, HL-33637, HL-07063, HL-44066,
reviewers and the final decision, were made by a guest editor. This and HL-42760; American Heart Association North Carolina Af-
procedure applies to all manuscripts with authors from the Uni- filiate grant-in-aid 1985-86 A-06; and a grant from the Fannie E.
versity of California San Diego or UCSD Medical Center. Ripple Foundation. J.M.W. received the North American Society
From the Departments of Medicine and Pathology (J.M.W., of Pacing and Electrophysiology Young Investigator Award for a
P.D.W., W.M.S., D.W.F., S.Y., N.D., R.E.I.), Duke University Med- presentation of a preliminary version of this article.
ical Center, Durham, N.C., and the Cardiology Division (P.-S.C.), Address for correspondence: J. Marcus Wharton, MD, PO Box
University of California Medical Center, San Diego, Calif. 3816, Duke University Medical Center, Durham, NC 27710.
Supported in part by National Institutes of Health research Received January 22, 1991; revision accepted November 21, 1991.
Wharton et al Defibrillation Gradients 1511
present study was designed to 1) describe the potential lateral wall of the right atrium near the junction of the
and potential gradient fields generated by electrode superior vena cava (electrode R in Figures 1A and 1B),
configurations with different defibrillation efficacies; 2) the lateral free wall of the left ventricle adjacent to the
correlate the field characteristics with the efficacy of atrioventricular groove (electrode L), and the left ven-
each electrode configuration; 3) describe the field char- tricular apex (electrode V). The location of the L and V
acteristics necessary for defibrillation; and 4) define electrodes was varied slightly to avoid placement over or
further the relation of field strength to the site of initial near coronary arteries. Two pairs of stainless steel wires
ventricular activation after successful and unsuccessful were inserted into the right ventricular free wall approx-
defibrillation shocks. imately 1 cm apart for ventricular pacing and sensing.
electrodes (74 of which were on the ventricles). Ampli- resistor at the front end of the amplifier was simultane-
fier gains were set for each channel for optimal signal ously used with the other changes to reduce the elec-
recording. Electrogram signals were filtered to pass trode potential by a factor of 1,000. During the shock,
0.1-500 Hz before and after attempted defibrillation.13 epicardial potentials were measured by the 75 button
Ten milliseconds before a shock, recording was switched electrodes, which included the three electrodes located
to unipolar at a second set of gains (previously deter- beneath the shock electrodes. The potential delivered to
mined to be appropriate for the voltage of the shock to the shock electrodes was also directly measured. Cur-
be delivered) with a low-pass filter of 500 Hz and rent delivered to each electrode pair for single, com-
high-pass filter direct-current coupled14 (Figure 1C). bined, and sequential electrode configurations was mea-
Ten milliseconds allowed adequate time to establish a sured on an oscilloscope. The voltage attenuator was
baseline for measuring potentials generated by the switched off 1 msec after the shock, and recording of
shocks.14 A voltage attenuator produced by a 1-Gfl bipolar electrograms was resumed (Figure 1C).
Wharton et al Defibrillation Gradients 1513
After completion of the study, the dog was killed by Potential gradients were calculated as described pre-
induction of ventricular fibrillation. The button and shock viously.4 Briefly, the nearest neighbors of each recording
electrode locations were marked with color-coded pins. electrode were determined, and the interelectrode dis-
Their locations were subsequently transcribed to a com- tance of each electrode to its neighbors was calculated
from their x-y-z coordinates. From the potential differ-
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icantly different from R:V and (R+L):V. R:V and Table 1. There was a 19.5-+f13.2-, 27.6 + 17.7-,
(R+L): V were similar in terms of energy and voltage, 23.3 15.3-, and 15.7+4.4-fold change between the min-
but (R+L): V required significantly more current than imum and maximum measured potential gradient at the
R:V (p<0.05). On the other hand, L:V was markedly DFT for R: V, L: V, (R+L): V, and the composite field
worse in all parameters. At DFT, mean voltage and (see below) of (R: V)->(L: V), respectively. Paralleling
current for L:V were both approximately 1.5 times the changes seen in the potential fields, potential gra-
higher and energy was approximately three times higher dient decline was most rapid near the shock electrodes
than for the other electrode configurations (pc0.005 and more gradual at sites more distant from the shock
for all parameters). electrodes. Relatively weak potential gradient fields
There were 329 shocks delivered: 81 R:V, 114 L:V, (less than 10 V/cm) were produced across the base of
80 (R+L):V, and 54 R:V->L:V. The mean numbers of the right ventricle by all electrode configurations used.
shocks necessary to obtain DFT for each of these R: V also generated weak fields across most of the base
electrode configurations were 72, 102, 73, and of the left ventricle and L: V across the posterior base of
51, respectively. Determination of the DFT for L:V the left ventricle. For (R+L): V, the gradient field was
required a significantly greater number of shocks than less than 10 V/cm across the base of both ventricles
for the other electrode configurations. except for a relatively small area surrounding the L
electrode (Figure 3B). Except for the area enhanced by
Potential and Potential Gradient Fields the L anode, the gradient field was not greatly different
The potential fields, potential gradient fields, and the from that of R: V, which may explain their similar
postshock activation sequences were mapped for all DFTs. Figure 4 graphically illustrates the distribution of
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unsuccessful and successful shocks. For each electrode low gradient areas for each electrode configuration.
configuration, the potential and potential gradient fields As can be anticipated from the individual gradient
generated were similar among different experimental fields for R: V and L: V, neither component of the
animals. A representative example of maps of the sequential shocks obtained high gradients across the
potential field and potential gradient field for each right ventricular base or across portions of the base of
component of the sequential shock configuration is the left ventricle anteriorly and posteriorly near the
shown in Figure 2. Each component shock of right ventricle and distant from the L electrode. To
R:V->L:V was similar to R:V and L:V shocks of illustrate this, composite maps were generated by using
equivalent magnitude given singularly. Potential mea- the maximum gradient measured from either of the two
sured at the recording electrode immediately under- component shocks at each electrode site (Figure 2E).
neath the shock electrode was approximately two thirds This is justifiable because both 7- and 14-msec trun-
of the measured delivered potential for both compo- cated exponential shocks occur on the relatively flat
nents of the sequential shock. Mean potential decrease portion of the strength-duration curve10 and presum-
at the electrode-myocardial interface ranged from 27% ably should have approximately the same potential
to 29% of the applied potential for all of the electrode gradient field requirements for defibrillation. Such com-
configurations tested. Decline in potential across the posite maps demonstrated that neither of the sequential
myocardium was relatively symmetrical with respect to shocks created potential gradients greater than 10 V/cm
the interelectrode axis of each configuration and was across the base of the right ventricle. In some experi-
most rapid near the shock electrodes. As can be seen in ments, gradients greater than 10 V/cm were also not
Figures 2A and 2B, potential change was small across created by the sequential shocks across the anterior
the base of the right ventricle for both R: V and L: V. and/or posterior base of the left ventricle. However,
Potential change was also small across the entire base of 52+19% of recording electrodes with gradients less
the left ventricle with R: V shocks and across the than or equal to 10 V/cm during the R: V component of
posterior left ventricular base with L: V shocks. the sequential shock at DFT recorded gradients greater
When the combined anodal configuration (R+L):V than 10 V/cm during the L:V component. The mini-
was used, the potential field was similar to R: V except mum gradient for each component of the sequential
for a rapidly decreasing component which rapidly de- shock at DFT was 5.3+0.8 V/cm and 4.40.9 V/cm,
creased with distance from the left ventricular anode respectively. These were significantly less (p=0.012)
(Figure 3A). From the rule of superposition, the poten- than the minimum gradient of 6.61.8 V/cm for the
tial field generated by (R+L): V should be equal to the composite field. The ability of two sequential fields of
sum of the potential fields generated by R: V and L: V lower minimum gradient to generate a composite field
if current flow were equal between each component of with higher minimum gradient presumably accounts for
(R+L): V and the corresponding R: V and L: V shocks. the greater efficacy of the sequential shock compared
Equal currents (0.1 A) among all necessary compo- with either component alone. The minimum gradients
nent shocks were available for four shock strengths in at DFT for the R: V and L: V components of the
two dogs. The correlation between the actually mea- sequential shock were significantly less (p<0.01) than
sured (R+L): V potential field and the field calculated for those at DFI' for the respective single 14-msec
from superpositioning equicurrent R: V and L: V fields shocks. However, the minimum gradients at DFT for
for these four shocks was excellent (r=0.993-0.998). the composite field of the sequential shock and for the
The small size of the shock electrodes resulted in very fields of the single R: V and L: V shocks were similar.
inhomogeneous potential gradient fields (Figures 2C
and 2D). The unevenness of the potential gradient fields Minimum Gradient and Defibrillation Parameters
for each electrode configuration is quantitated by com- R:VL:V required significantly less and L: V re-
parison of minimum and maximum gradients at DFT in quired significantly more current to defibrillate than
Wharton et al Defibrillation Gradients 1515
A B
R:V -.L:V R:V -* L: V
+27
3
-II
6 -5 i`ij
10
-ill 14
a -B
24 1 - 25
7--0 -
_e X7/ -'37~
~ ~ ~ ~ ~
RI5-81
POTENTIAL FIELD POTENTIAL FIELD
2? 29 26 26
C S 467 -
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E
18
41T
Io
1~ ~ ~ ~ ~ ~
1~~~~~~~~~~~~~~~~~~~~I
II
'43~ ~~lr
A. c
R R:V R (R+L):V
D
B. R R:V -> L:V
L :V
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v v
FIGURE 4. Maps indicate sites of epicardial activation after all unsuccessful shocks between 4 J and the highest subthreshold
shockforR: V (single anode-single cathode configuration) (panel A), L: V (single anode-single cathode configuration) (panel B),
(R+L): V (dual anode-single cathode configuration) (panel C), and R: V-L: V (sequential 7-msec shocks separated by 1 msec
given to R: Vand L: V) (panel D). Relative locations of shock electrodes are indicated by double cross-hatched oval areas. Site(s)
of earliest activation are indicated with filled circles; other sites of early activation are indicated with filled triangles. Small branch
arteries are for illustrative purposes only and do not correspond to actual location of branch arteries. Cross-hatched and stippled
areas on each figure represent epicardial surface in which gradients less than 10 V/cm were measured during the highest
subthreshold shocks for the majority (greater than six) and the minority (less than or equal to six) of experimental animals,
respectively. Solid line represents border of area in which at least one dog had gradients less than 10 V/cm for the initial 4-J shocks.
Distance between solid line and apical border ofstippled area illustrates decrease in low gradient area needed to reach the highest
subthreshold shock. The much greater difference for L: Vshocks (panel B) than for other configurations between the solid line (4-I
shocks) and apical border of the stippled area (highest subthreshold shocks) is because of the much greater defibrillation threshold
for L: Vshocks. Figures graphically illustrate that early sites of activation for all electrode configurations occur mainly in areas in
which gradients are less than 10 V/cm and demonstrate similarity of generated fields with each electrode configuration within all
experimental animals. Note that despite the fact that L: Vhad the highest defibrillation threshold, epicardial surface area of lowest
gradients is smallest. Also note that for R: V shocks (panel A) but not (R+L): V shocks (panel C) that gradients are frequently
somewhat greater than 10 V/cm on the posterior right ventricle and that early sites of activation do not occur in this area for R: V
shocks but do for (R+L): V shocks. This is less clearly demonstrated for R: V-L: V shocks (panel D) perhaps because the
compositefield is used to generate the figure. Occurrence of several early sites of activation outside of cross-hatched or stippled areas
is caused primarily by their occurrence after shocks of considerably less total delivered potential (and larger area of low gradient)
than the highest subthreshold shock.
ectopic activity, there were 94 early sites or a mean of One episode occurred approximately 8 seconds after a
1.70.8 per successful shock. Ninety (96%) of these successful type B shock, with 6.5 seconds of intervening
early sites occurred in areas in which the gradient was sinus rhythm before the initiation of ventricular tachy-
weak; however, four (4%) occurred in high gradient cardia. The remaining two episodes occurred 81 and 328
areas (mean gradient, 7140 V/cm) at the perimeter of msec after type A defibrillating shocks. All episodes of
a shock electrode after L:V defibrillations only. Mean ventricular tachycardia arose from or near the perime-
gradient at the site of origin of epicardial activity after ter of ventricular shock electrodes in which gradients
all successful shocks followed by ectopic activity was were high (Figure 6). Mean gradient at the site of
15.4+15.4 V/cm (12.9+6.9 V/cm if the four high gradi- earliest epicardial activation of these ventricular tachy-
ent sites are omitted). cardias was 47.3+15.5 V/cm. Evidence supporting mac-
Eleven episodes of nonsustained, monomorphic ven- roreentry was not identified for any of these episodes of
ventricular tachycardia.
tricular tachycardia occurred after defibrillating shocks.
Eight of these episodes occurred after a pause of Myocardial and Electrode Impedance
167-852 msec after one to seven postshock, ectopic Electrode impedance accounted for approximately
activations originating in low gradient areas (Figure 6). one third to one fourth of total impedance for all
1518 Circulation Vol 85, No 4 April 1992
TABLE 2. Potential Gradients and Number of Sites of Initial Activation for Subthreshold Shocks 10% or Less Than
Defibrillation Threshold Energy
R:V L:V (R+L):V R:V->L:V
Minimum gradient (V/cm) 5.81.6 7.31.6 5.71.5 6.61.7*
Number of early sites 1.90.9 1.40.5 2.21.0 2.00.6
Gradient at sites of 9.04.5 12.26.7 11.85.9 12.66.7*
initiation (V/cm)
Maximum gradient (V/cm) 105.966.0 181.897.1t 130.197.5 99.352.4*
R:V and L:V, single anode-single cathode configurations; (R+L):V, dual anode-single cathode configuration;
R V-L: V, sequential 7-msec shocks separated by 1 msec given to R: V and L: V.
*Represents field parameter from maximum combined gradient field (see text).
tp<0.05 with respect to R:V-*L:V.
electrode configurations. The mean electrode, cardiac, from multiple sites, which was not done in the above
and total impedance at DFT was generally less with studies. Chen et a14 have attempted to directly measure
(R+L):V compared with the other configurations (Ta- the distribution of potentials generated across most of
ble 3), although the impedance for (R+L):V was the ventricles by defibrillation electrodes; however, the
indirectly calculated (see "Methods"). The smaller elec- fields recorded were from 1-2-V shocks delivered dur-
trode impedance for (R+L): V was presumably due to ing the fully repolarized period of sinus rhythm. Com-
the larger combined anodal surface area. At DFT, parison of the potential gradient field generated by the
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electrode, cardiac, and total impedance were similar low-voltage shocks with the activation sequences re-
between R: V and the R: V component of the sequential corded immediately after high-voltage defibrillation
shock; however, all components of impedance were shocks showed that the continuation of ventricular
significantly higher for the L: V component of the fibrillation after unsuccessful shocks arose in areas in
sequential shock than for L: V shocks alone (p<O.O5). which the field was weak during low-voltage shocks.
Because impedance decreased as shock strength was Because recordings were not made during high-voltage
increased (see "Appendix"), the lower mean imped- shocks, quantitative field requirements for defibrillation
ances for the L: V shocks, compared with the L: V could not be defined. Furthermore, impedance and the
component of the sequential shock, may simply reflect fraction of delivered potential appearing across the
the larger shock strength at DFT for the single L: V ventricles are markedly different for 1-2-V shocks than
shocks. When L V shocks of similar voltage to the L: V for shocks of hundreds of volts (see "Appendix").
component of the sequential shock were compared, Mapping system modifications now allow the mea-
impedances were not significantly different. surement of high-voltage defibrillation shocks as well as
myocardial activation before and after shocks.5"4 Using
Discussion such a device, Witkowski et a15 recently showed that
Defibrillation presumably depends on achieving a sites of early activation after unsuccessful high-voltage
sufficient transsarcolemmal potential change across all, shocks occurred in areas in which the field is weak. By
or most, of the ventricular myocardium. The transsar-
colemmal potential change should be related to the
.rfl-1
extracellular potential gradient or current density.120 140
There is some indirect evidence to support the theory
that a minimum potential gradient or current density is
required across all or most of the myocardium to 120
achieve defibrillation. The efficacy of different paddle
sizes in transchest defibrillation and of two different
external shock electrode locations was shown to be
) uu
innj
r
proportional to the generated intracardiac potential u- 80)I
0
U)
gradients.2'3 However, the limited number of electrodes W
used in these studies did not allow determination of the :~> 60
myocardial distribution of gradients or of the possibility z
of a minimum gradient necessary for defibrillation.
Geddes et al,2' using a presumed uniform current 40
density field across an excised, perfused, whole heart in
vitro, showed that DFTs in terms of current density 20
were similar for three different waveforms of equal
duration. From these studies, Geddes et al estimated V_ W
0 41
A
8 12
1-
16 20 24
^ .
>28
-
(R+L):V shocks, vector components of current flow plained by a number of factors, such as measurement
between the R and V electrodes and the L and V error and the lack of intramyocardial and endocardial
electrodes were oppositely directed, particularly be- recording sites.
tween the two anodes in the area of the atrioventricular Another factor explaining why earliest activation
groove, and that this may have resulted in vector after an unsuccessful shock is not always in the region
cancellation of these components. exposed to the weakest potential gradient is variation in
Sequential shocks with short shock separation times the electrophysiological state of the myocardium at the
to two electrode configurations using an intravascular time of the shock. Besides the spatial distribution of
catheter and patch-electrode configuration or a three- potential gradients and the temporal waveform of the
patch-electrode configuration have been shown to have shock, major determinants of the effect of a shock are
greater efficacy than shocks to single pairs of elec- probably the state of myocardial activation, refractori-
trodes.9'22-24 However, not all sequential shock elec- ness, and wavefront propagation at the time of the
trode configurations significantly alter the energy re- shock. Such factors may prevent the postshock appear-
quirements for defibrillation.22,25'26 The present study ance of ventricular fibrillation activation fronts at many
confirmed the greater efficacy of sequential shocks to sites whether or not the potential gradient of the shock
two different epicardial electrode configurations. The exceeds a minimum threshold. For example, when the
mechanism by which sequential shocks may lower the region in which the shock field is weakest is in its
DFI' is presumably due to improvement in the distribu- absolute refractory period at the time of the shock,
tion of potential gradients across the ventricles. The fibrillation will not reappear from this region even when
L: V component of the sequential shocks at the DFT the potential gradient is below threshold. At another
significantly decreased (by 52%) the number of record- point in time during fibrillation, this region may not be
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ing electrodes that measured a gradient less than or absolutely refractory, and fibrillation activation fronts
equal to 10 V/cm during the preceding R: V component may originate from this region after the shock,19'27
of the sequential shock. Thus, the overall surface area of assuming that adjacent sites are capable of conducting
the ventricles that was exposed to a weak gradient field the impulse and that surrounding wavefronts do not
during the sequential shocks was substantially de- collide and terminate the reentrant circuit. Consider-
creased compared with the R: V shock alone. There was ation of these interactions may help to explain the
no evidence that the initial R: V shock changed imped- observation that there exists a range of voltages or
ance to the subsequent L: V shock to enhance current energies near threshold in which defibrillation is best
delivery of the latter. However, the minimum gradients described in terms of a probability function.28'29 The
of the composite gradient field of the sequential shocks occurrence of a shock strength with which defibrillation
were greater than the minimum gradients of each is always achieved and an upper limit of shock strength
component shock but were similar to the minimum that will not induce fibrillation no matter when it is
gradients produced by all of the other single-shock introduced into the vulnerable period27'30'31 suggests
electrode configurations at the DFT. This again suggests that there should exist a potential gradient above which
the necessity of obtaining a certain minimum gradient fibrillation will be terminated regardless of the state of
over all of the heart for defibrillation. Greater increases the myocardium. However, because the shock strength
in defibrillation efficacy may be obtained by designing that is always successful is usually greater than that at
electrode configurations in which one shock field is the DFT,28,29,31 the minimum gradient measured in this
strong where the other is weak, and neither is weak in study is probably less than that required to always
the same area. defibrillate.
None of the electrode configurations examined in this The occurrence of a minimum gradient at the DFT is
study produced adequate fields along the right ventric- most consistent with either the total ventricular depo-
ular base, especially along the right ventricular outflow larization (or extinction) hypothesis of defibrillation32 or
tract. One explanation for this finding is that the three the upper limit of vulnerability hypothesis,19'27'30 be-
electrodes describe a plane that is located posteriorly cause both theories predict a minimum required poten-
(Figure 1B), so that the right ventricular outflow tract, tial gradient across all of the ventricular myocardium.
which bulges anteriorly, lies the greatest distance from The finding of a required minimum gradient across all
this plane to produce an area in which the field is weak. of the ventricular myocardium is less consistent with the
This effect may not be as pronounced in the human critical mass hypothesis.18'33 The latter hypothesis pre-
heart because the right ventricular outflow tract does dicts that the minimum necessary gradient for different
not project as far anteriorly relative to this plane. electrode configurations should be equal, not over the
The present study confirms and expands on the entire ventricular myocardium but at the boundary
finding that ventricular fibrillation first appears after enclosing the critical mass. The absolute minimum
unsuccessful shocks in areas in which the field is weak, gradient would not necessarily have to be equal for
regardless of the electrode configuration used.4'5 different electrode configurations, because it would
Eighty-seven percent of gradients at the sites of early depend only on the rate of decline in the gradient field
epicardial activation after unsuccessful shocks were less beyond the border of the critical mass. The critical mass
than 15 V/cm, and 52% were within 1 V/cm of the for defibrillation has been estimated to be approxi-
minimum measured gradient. Sites of initiation of ven- mately 75% of the ventricular myocardium with pro-
tricular fibrillation in high gradient areas after unsuc- longed depolarization with potassium administration.33
cessful shocks were not seen. The lack of a closer If so, equal potential gradients should be found at the
correlation between the absolute minimum potential border of the regions enclosing 75% of the ventricular
gradient generated by a field and the gradient at the site myocardium for different electrode configurations, not
of resumption of ventricular fibrillation may be ex- at the minimum gradient value over all of the ventricles.
Wharton et al Defibrillation Gradients 1521
The findings in this study that 1) the L: V shock had a ventricles have the same field requirements were not
smaller surface area of low gradients compared with the assessed in this study.
other shocks (Figure 4), despite the fact that it was When only a certain minimum gradient is needed for
markedly less efficient in defibrillation, and 2) the defibrillation, electrode configurations that must gener-
minimum potential gradients are not significantly differ- ate very high gradients near the shock electrodes to
ent for the different lead configurations both run con- achieve this minimum gradient distantly not only waste
trary to the predictions of the critical mass hypothesis. energy but increase the risk of inducing variable degrees
However, because endocardial and septal gradient mea- of myocardial injury. High potential gradients may
sures are not available for determination of the three- cause cell injury and death, decreased contractility,
dimensional potential gradient field, it is possible that asystole, conduction block, and dysrhythmias.'37-42 Ex-
intramyocardial potential gradient distributions do not tremely high gradients may even generate intractable
parallel in a relatively symmetrical manner the distribu- ventricular fibrillation secondary to induced injury.30,40
tion measured on the epicardium and that a critical Despite the great unevenness of the fields generated by
the electrode configurations used in this study, post-
mass less than 100% existed but was not identified in shock arrhythmias occurred relatively infrequently.
this study. We hope that further developments in the There was no evidence that the high gradients at the
calculation of gradients across the entire volume of the shock electrodes directly initiated ventricular fibrillation
heart will help to resolve this issue.34 after unsuccessful shocks, although repetitive activity
A potential gradient greater than approximately 5 occurred infrequently in high gradient areas after suc-
V/cm for a 3-msec, low-tilt, monophasic shock delivered cessful shocks. Specifically, this occurred only after
during the relative refractory period of a passing wave- successful L: V shocks, which generated the highest
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front induces conduction block, presumably by prolong- gradients for defibrillation, perhaps reaching a specific
ing refractoriness; gradients less than this do not pro- injury threshold. High-voltage shock induction of ven-
duce conduction block.35 This critical interaction tricular fibrillation (type II ventricular fibrillation)
between refractoriness and decreasing field strength probably requires voltages higher than those used in this
may lead to the induction of reentry and ventricular study.3040 Although shock-induced arrhythmias may oc-
fibrillation. According to the upper limit of vulnerability cur clinically41 and have been shown to occur more
hypothesis, subthreshold shocks will halt all fibrillation frequently after high-voltage shocks in vitro,'37'40 the
wavefronts but reinitiate ventricular fibrillation, pre- present study is the first to map the origin of postshock
sumably by a mechanism similar to that just described.19 ventricular tachycardia from the site of the shock elec-
The similarity between the minimum gradient of 6-7 trode, which in all cases was recorded from electrodes at
V/cm for defibrillation found in this study and the the perimeter of the shock electrode possibly reflecting
critical gradient of 5 V/cm for electrical induction of the higher current density at the electrode edge.43 The
fibrillation in the vulnerable period of regular rhythm is mechanism of the postshock ventricular tachycardia
consistent with but does not prove this hypothesis. seen in this study could not be ascertained; evidence of
There are several limitations to this study. Wave- epicardial macroreentry was not seen.
forms of depolarization are obscured during defibrilla- The ability to measure shock potentials also allows
tion by the shock and immediately after the shock by the measurement of various components of impedance,
baseline deflection generated by switching off the map- such as that at the electrode-myocardial interface or
ping system modification; thus, depolarization during or across the heart itself (see "Appendix"). The imped-
immediately after the shock cannot be identified or ance measured in this study is generally greater than
mapped. Furthermore, the lack of septal, intramyocar- that reported by others for transmyocardial shocks,44,45
dial, and endocardial recording sites limits the resolu- presumably reflecting the small size of the shock elec-
tion of the mapping and the determination of all trodes used in this study. Unlike a previous study,27 the
components of the gradients. Specifically, the lack of present study did not show significant changes in im-
transmural recordings may decrease the absolute value pedance with increasing shock voltage for R: V,
of the measured gradients. For low-voltage shocks to an (R+L): V, or the components of R:V-L: V. This may
electrode array resembling R: V, transmural gradients be due to the random sequence of shock delivery and/or
in the right ventricular outflow tract are approximately to the relatively small range of shock voltages delivered
half the tangential gradient.4 The exposure of the to these configurations. There was a significant change
anterior surface of the heart to air in the open-chest dog with L: V, which, because of its decreased efficacy,
preparation may increase the anterior gradient mea- required a larger number of shocks over a greater range
surements due to a boundary effect; however, the of voltages to achieve a DFT. When R: V shocks were
greater tangential current flow would improve gradient given over a greater range of voltages, marked changes
calculation using epicardial recording electrodes. Mea- in impedance were noted (see "Appendix"). However,
surement of rapidly changing gradients near shock Lawrence et al44 were not able to show a change in
electrodes requires small interelectrode distances to impedance between shocks of different strengths when
maintain accuracy; irregularities in high gradient areas more than 5 minutes elapsed between shocks and
in this study may reflect inadequate spacing of recording showed only a very small change when the shocks were
electrodes or inhomogeneous current distribution separated by a few seconds.
around the perimeter of the shock electrode. Depolar- The ability to map the potential gradient field gener-
ization of ventricular myocardium is dependent on fiber ated by shock electrodes should lead to marked im-
orientation relative to the vector of the potential gradi- provements in their design and function. If the desired
ent.36 Whether fiber orientation affects the field require- goal is a uniform field slightly exceeding a certain
ments for defibrillation or whether different areas of the minimum gradient, the possible electrode combinations
1522 Circulation Vol 85, No 4 April 1992
VOLTAGE (V)
ated with defibrillation shocks.
FIGuRE 7. Graph of calculated total impedance or mean
Appendix change in potential divided by total delivered current between
Effect of Shock Strength on Impedance successive rows of electrodes across the ventricles as a function
In an earlier study4 with low-voltage shocks from 1 to 2 V of logarithm of delivered potential from R: V (single anode-
Downloaded from http://circ.ahajournals.org/ by guest on January 6, 2017
given to R:V using 4.5-cm2 titanium mesh electrodes, only single cathode configuration) shocks of 1-1,000 Logarith- V
173% of the delivered shock potential was measured on the mic scale wasused to emphasize abrupt changes at low
ventricles, whereas in the present study, recorded myocardial delivered potential. Line labeled "Total" represents relation of
potential was 76.46.3% of that delivered with 2.64-cm2 total impedance and delivered potential. Lines labeled 1-7
electrodes. The addition of recording electrodes beneath the represent changes between successive rows of electrodes pro-
shock electrodes and inclusion of the voltage drop across the gressively cephalad to apical shock electrode. Thus, line 1
atria in this study may explain some but not all of this
difference. To see if part of this discrepancy was caused by represents impedance between shock electrode and recording
differences in impedance for low- and high-voltage shocks, an electrode immediately underneath (row 1). Line 2 represents
additional dog was studied with the same surgical preparation estimated impedance changes between recording electrode un-
as described in "Methods." However, 4.5-cm2-round titanium derneath apical shock electrode and ring of electrodes at
mesh shock electrodes with a recording button electrode perimeter of apical shock electrode (row 2). Lines 3-7 represent
underneath were attached in an R: V configuration. Shocks of estimated impedance changes between successive rows progres-
14-msec duration were delivered once each at increasing sively cephalad to recording electrodes at perimeter of shock
strengths as follows: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12.5, 15, 20, 25, electrode. For further discussion, see 'Appendix."
50, 75, 100, 150, 200, 300, 400, 500, 750, and 1,000 V. Shocks
from 1 to 25 V were delivered by a constant voltage device and
from 25 to 1,000 V by the device used in the present study. Two
calibrated input dynamic ranges (10 V and 500 V) to the diately encircling (row 2) the apical shock electrode, respec-
amplifiers were used to record potentials. Current was mea- tively, and the electrode beneath the right atrial anode. These
sured on an oscilloscope. measurements were not significantly changed at 4 V and were
With 1-4-V shocks, total impedance increased markedly from in accordance with the previous study.4 As delivered potential
254 to 434Q1, decreased abruptly to 273Q1 at 5 V, and then increased from 5 V, 25 V, 100 V, and 1,000 V, the percent of
gradually declined with increasing potential down to 106 fl at delivered potential measured in row 1 steadily increased to
1,000 V. A plot of the logarithm of potential delivered versus the 48%, 66%, 73%, and 75% and in row 2 from 20%, 32%, 34%,
calculated total impedance illustrates the marked change in and 43%, respectively.
impedance at low voltages (Figure 7). Beyond approximately 10 The current waveform for shocks less than V showed a 5
V, the relation between impedance and the logarithm of deliv- logarithmic increase in current flow during the period of the
ered voltage became more linear. shock, suggesting a large contribution of capacitance to the
To define where the change in impedance occurred, mean overall impedance. This capacitive element may explain the
differences in potential between successive rows of electrodes initial increase in total impedance. As potential was increased
starting at the apical shock electrode were calculated and above 5 V, the current waveform showed progressively less
divided by the total measured current as an estimate of distortion and impedance decreased, primarily at or near the
effective impedance of the layers of ventricular myocardium electrode-myocardial interface. This strong capacitive element
between each row of electrodes. The greatest impedance was to impedance may be generated to some extent by electrode
calculated between the shock electrode and the recording polarization at the myocardial interface during low-voltage
electrode underneath it (row 1) for shocks of 1-20 V (Figure shocks. However, the occurrence of similar changes in esti-
7). At 25 V, however, the impedance at row 1 and the next mated impedance distant to the apical shock electrode implies
most cephalad row (row 2) equalized with further increases in myocardial changes occurring as a function of increasing
delivered potential causing the greatest impedance change at potential delivered. This capacitive component of impedance
row 2, principally because impedance at row 1 continued to progressively decreased with increasing delivered potential so
decrease, whereas it was relatively stable at row 2. The marked that in the range of potentials necessary for defibrillation with
increase in impedance at 4 V is reflected in the impedance epicardial electrodes, impedance appears to be primarily
curves at all levels of the ventricles, although most of this resistive, confirming the work of others.45
occurs in the apical third of the myocardium in rows 1-3
(Figure 7). Acknowledgments
For a 1-V R: V shock, 36% and 15% of delivered potential We would like to thank Joseph C. Greenfield Jr. for his
was measured between electrodes beneath (row 1) and imme- support and advice; and Ellen G. Dixon, Sharon B. Melnick,
Wharton et al Defibrillation Gradients 1523
Yohannes Afework, Alton T. Ledford, and Cloyce M. Lassiter 23. Jones DL, Klein GJ, Guiraudon GM, Sharma AD, Kallok MJ,
for their technical assistance. Bourland JD, Tacker WA Jr: Internal cardiac defibrillation in man:
Pronounced improvement with sequential pulse delivery to two
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Circulation. 1992;85:1510-1523
doi: 10.1161/01.CIR.85.4.1510
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