Termination of sustained atrial flutter and fibrillation using low-voltage multiple-shock therapy

Heart Rhythm. 2011 Jan;8(1):101-8. doi: 10.1016/j.hrthm.2010.10.018. Epub 2010 Oct 19.


Background: Defibrillation therapy for atrial fibrillation (AF) and flutter (AFl) is limited by pain induced by high-energy shocks. Thus, lowering the defibrillation energy for AFl/AF is desirable.

Objective: In this study we applied low-voltage multiple-shock defibrillation therapy in a rabbit model of atrial tachyarrhythmias comparing its efficacy to single shocks and antitachycardia pacing (ATP).

Methods: Optical mapping was performed in Langendorff-perfused rabbit hearts (n = 18). Acetylcholine (7 ± 5 to 17 ± 16 μM) was administered to promote sustained AFl and AF, respectively. Single and multiple monophasic shocks were applied within 1 or 2 cycle lengths (CLs) of the arrhythmia.

Results: We observed AFl (CL = 83 ± 15 ms, n = 17) and AF (CL = 50 ± 8 ms, n = 11). ATP had a success rate of 66.7% in the case of AFl, but no success with AF (n = 9). Low-voltage multiple shocks had 100% success for both arrhythmias. Multiple low-voltage shocks terminated AFl at 0.86 ± 0.73 V/cm (within 1 CL) and 0.28 ± 0.13 V/cm (within 2 CLs), as compared with single shocks at 2.12 ± 1.31 V/cm (P < .001) and AF at 3.46 ± 3 V/cm (within 1 CL), as compared with single shocks at 6.83 ± 3.12 V/cm (P =.06). No ventricular arrhythmias were induced. Optical mapping revealed that termination of AFl was achieved by a properly timed, local shock-induced wave that collides with the arrhythmia wavefront, whereas AF required the majority of atrial tissue to be excited and reset for termination.

Conclusion: Low-voltage multiple-shock therapy terminates AFl and AF with different mechanisms and thresholds based on spatiotemporal characteristics of the arrhythmias.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Animals
  • Atrial Fibrillation / therapy*
  • Atrial Flutter / therapy*
  • Electric Countershock / methods*
  • Electrodes, Implanted
  • Pain Measurement
  • Rabbits
  • Voltage-Sensitive Dye Imaging