Electrotherapy of cardiac arrhythmias

Anwar C Varghese

History
Early in the 20th century, the Consolidated Edison Electrical Company of New York, concerned by accidental electrocutions of its line workers, supported research on the mechanisms and treatment of electrical accidents. Investigators at Johns Hopkins Hospital developed techniques of defibrillationthe termination of ventricular fibrillationby an electrical shock in the 1930s. The first human defibrillation in the operating room was performed by Claude Beck in 1947.

 Transchest defibrillation using alternating current became a clinical reality when introduced by Paul Zoll in 1956, and direct current defibrillation was pioneered by Bernard Lown in 1962. The work of Zoll and Lown, in combination with the description of closed-chest cardiac massage by Jude and colleagues in 1960, has formed the foundation of cardiopulmonary resuscitation from cardiac arrest for 50 years.

Mechanisms of Defibrillation and Cardioversion

The critical mass hypothesis suggests that some proportion of the myocardium (not necessarily all) must be depolarized, so that the remaining muscle is inadequate to maintain the arrhythmia. The upper limit of vulnerability hypothesis argues that a sufficient current density throughout the ventricle must be achieved lest fibrillation be reinitiated by a subthreshold current density. Jones' group hypothesized that defibrillating shocks must achieve an extension of refractoriness in sufficient myocardium to terminate VF.

Techniques of Cardioversion and Defibrillation

Anesthesia elective cardioversion should be performed under anesthesia conscious sedation is often inadequate, with the patient experiencing and remembering severe discomfort.

Synchronization
It is essential to synchronize the electrical discharge on the R wave of the QRS complex; If the shock falls in the vulnerable period of the cardiac cycle, VF may be induced. This is the most frequent serious complication of elective cardioversion of atrial arrhythmias and usually results from the operator's failure to enable properly the synchronizing device or to verify that the R wave of the ECG lead chosen is sufficiently tall to be recognized by the synchronizer.

 Recognition of the R wave of ventricular tachycardia is sometimes difficult owing to the morphology of the arrhythmia. If the patient is hemodynamically unstable owing to rapid ventricular tachycardia, unsynchronized shocks may be necessary; if VF results from the first shock, an immediate second shock is administered to terminate the VF. The operator must be prepared, in such circumstances, to quickly disable the synchronizing setting; if this is not done the defibrillator will not identify an R wave (which is not present in VF) and will not deliver a shock.

Electrodes
Electrode placement on the chest is important to maximize current flow through the heart, which is what actually terminates the arrhythmia. Only a small proportionas low as 4%of the total transchest current flow actually traverses the heart. Numerous pathways have been used successfully, including apexhigh right parasternal, anteroposterior, and apex right infrascapular . The apexhigh right parasternal is most frequently used. Although it has been difficult to demonstrate the superiority of any pathway over others in clinical studies, one pathway might prove superior in the individual patient.

Move the electrodes to an alternate pathway when a patient whose atrial arrhythmia is expected to respond to elective cardioversion fails to convert with the initial shocks.

 Electrodes should not be placed directly over the site of implanted pacemaker or defibrillator generators. Although manufacturers commonly mark electrodes to indicate the location of chest placement, electrode polarity does not seem to influence shock success, either for monophasic or biphasic waveforms

 Electrode size influences the impedance of the chest; larger electrodes yield lower impedance and thereby increase transchest current flow. The Association for the Advancement of Medical Instrumentation recommends a minimum electrode contact area of 50 cm2 for each electrode. The total area of both electrodes should be at least 150 cm2. Smaller pediatric paddles have been manufactured for children, but adult-size paddles should be used for children weighing more than 10 kg (~1-year-old). This minimizes transthoracic impedance

 Gels or pastes should not be smeared across the chest between paddle electrodes; the electrical current may follow the low-impedance pathway created by the paste, deflecting current away from the heart. In women, the apex electrode should be placed adjacent to or under the breast; placement on the breast results in a high transthoracic impedance and degrades current flow

 Cutaneous erythema after shocks is often noted at the location of the electrode placement. Skin biopsies have shown that these are first-degree burns. Because there is preferential current flow at the edges of these electrodes, the erythema typically is most intense at the edges of the electrode location, outlining the electrode shape. Self-adhesive electrode pads constructed to have increased impedance at the pad edges allow more homogeneous current flow and may minimize these burns.

 Self- Adhesive electrode pads for defibrillation have other advantages. They allow continuous monitoring of cardiac rhythm before and after the shock. They promote more physical separation of the operator from the patient, thus reducing the chance of the operator inadvertently receiving a shock. However, measurements of current passing through the body of an operator deliberately placed in the current path of a cardioversion performed with selfadhesive pads showed that only trivial amounts of current actually flowed through the operator's body.

New Waveforms for Defibrillation and Cardioversion

Truncated exponential biphasic waveforms have replaced damped sinusoidal monophasic waveforms for defibrillation. Their superiority for transthoracic defibrillation and cardioversion has been demonstrated in the operating room and electrophysiology laboratory, where VF is deliberately induced, and during out-of-hospital cardiac arrest. They are also superior for the electrical cardioversion of atrial arrhythmias. At any energy level, these biphasic waveforms yield higher rates of arrhythmia termination than damped sinusoidal monophasic waveforms.

 This has resulted in lower energy recommendations for biphasic defibrillation and cardioversion; however, clinical considerations (left atrial size, duration of arrhythmia) may suggest higher or lower energies. The American Heart Association recommends that when a monophasic defibrillator is used, the energy should be 360 J for all shocks; if a biphasic defibrillator is used, the initial energy recommendation is 150 to 200 J

 Smart" biphasic waveform defibrillators incorporate technology to measure transthoracic impedance during the shock and instantaneously alter the waveform duration and/or voltage to compensate for impedance. Still other available defibrillators use a rectilinear near-rectangular fixed-pulse-duration waveform. Any of these biphasic waveform variants will be superior to the traditional damped sinusoidal monophasic waveform.

 New waveforms for defibrillation have been investigated in animal models. These include sawtooth-shaped biphasic waveforms and multipulse multipathway shocks. These have not yet been used for transthoracic defibrillation in humans. Triphasic and quadriphasic waveforms do not require additional capacitors or elaborate circuitry; these have shown superiority in animal studies. Pulsed biphasic waveforms have recently been evaluated

Myocardial Damage from Defibrillation and Cardioversion

Although a lifesaving technique, direct current shocks may cause myocardial damage, especially when repeated high-energy discharges are administered. Shocks cause mitochondrial dysfunction and free radical generation in the myocardium proportional to the energy used. Antioxidant strategies to minimize shock-induced cardiac damage have been investigated in experimental animals. Reducing shock energy/current as well as minimizing the number of shocks delivered will likely limit shockinduced myocardial damage

 Some clinicians delay repeating a failed shock (for atrial fibrillation) for 1 or 2 minutes in the hope of preventing damage, but there is no convincing evidence for this approach; the author's practice is to repeat shocks for cardioversion of atrial fibrillation as necessary without delay. In contrast, when attempting to defibrillate VF, the American Heart Association recommends immediate resumption of CPR for 2 minutes after the shock before pausing briefly to reassess the postshock rhythm. The intent is to minimize long periods of no compression/no myocardial perfusion.

Automated External Defibrillators and Public Access Defibrillation

In the 1980s, efforts to reduce the mortality associated with out-of-hospital cardiac arrest emphasized training of emergency medical technicians to recognize VF and to defibrillate using traditional manual defibrillators. Subsequently, automated external defibrillators (AEDs) were introduced; these small, light, and relatively inexpensive devices acquire an ECG via self-adhesive monitor-defibrillator pads applied to the cardiac arrest victim's thorax. A microprocessor in the defibrillator analyzes the ECG thus acquired; if the algorithm for VF is satisfied, the device sounds a warning and then delivers a shock.

 The ease of application and use of these devices make training requirements minimal, and biphasic waveforms in presently available units enhance the effectiveness of these AEDS. Many communities are now equipping "first responders," such as police officers, firefighters, and security guards, with AEDs. Placement of AEDs in areas known to have a high rate of cardiac arrestairports, prisons, gymsis an appropriate and cost-effective strategy. Controlled trials of this strategy have shown its effectiveness.

Defibrillation at Home
Although widespread placement of AEDs in public spaces will improve survival after cardiac arrest, it is known that over two-thirds of cardiac arrests occur at home. Initial experience with AED use at home suggested that in an emergency, spouses, often elderly, may forget to retrieve their AED and/or be unable to apply and use it correctly. More recently, the "HAT" trial of 7001 patients reported no increased survival from cardiac arrest even when there was access to a home AED.

 One potential solution to this problem is the recent development of a wearable defibrillator. The patient wears a vest in which electrodes are incorporated and an ECG is fed to a defibrillator that is worn in a holster-like device . The ECG is continuously analyzed; if the VF algorithm is satisfied, the device initially delivers an audible and tactile alarm. If VF is not actually present (eg, if one of the ECG leads in the vest loses skin contact and the resultant artifact simulates VF), the patient has approximately 30 seconds to disable the device; if it is not disabled during the alert period, the defibrillator charges and then automatically delivers a biphasic shock. Initial clinical experience has been favorable.

This device has frequently been used in patients awaiting cardiac transplantation; such patients have a high risk of sudden cardiac death.