Multistage electrotherapy delivered through chronically-implanted leads terminates atrial fibrillation with lower energy than a single biphasic shock

J Am Coll Cardiol. 2014 Jan;63(1):40-8. doi: 10.1016/j.jacc.2013.07.098. Epub 2013 Sep 26.


Objectives: The goal of this study was to develop a low-energy, implantable device-based multistage electrotherapy (MSE) to terminate atrial fibrillation (AF).

Background: Previous attempts to perform cardioversion of AF by using an implantable device were limited by the pain caused by use of a high-energy single biphasic shock (BPS).

Methods: Transvenous leads were implanted into the right atrium (RA), coronary sinus, and left pulmonary artery of 14 dogs. Self-sustaining AF was induced by 6 ± 2 weeks of high-rate RA pacing. Atrial defibrillation thresholds of standard versus experimental electrotherapies were measured in vivo and studied by using optical imaging in vitro.

Results: The mean AF cycle length (CL) in vivo was 112 ± 21 ms (534 beats/min). The impedances of the RA-left pulmonary artery and RA-coronary sinus shock vectors were similar (121 ± 11 Ω vs. 126 ± 9 Ω; p = 0.27). BPS required 1.48 ± 0.91 J (165 ± 34 V) to terminate AF. In contrast, MSE terminated AF with significantly less energy (0.16 ± 0.16 J; p < 0.001) and significantly lower peak voltage (31.1 ± 19.3 V; p < 0.001). In vitro optical imaging studies found that AF was maintained by localized foci originating from pulmonary vein-left atrium interfaces. MSE Stage 1 shocks temporarily disrupted localized foci; MSE Stage 2 entrainment shocks continued to silence the localized foci driving AF; and MSE Stage 3 pacing stimuli enabled consistent RA-left atrium activation until sinus rhythm was restored.

Conclusions: Low-energy MSE significantly reduced the atrial defibrillation thresholds compared with BPS in a canine model of AF. MSE may enable painless, device-based AF therapy.

Keywords: ASET; BPS; CS; DFT; HRP; LA; LPA; MSE; OAP; PV; RA; RAA; VSET; atrial fibrillation; atrial shock excitation threshold; cardioversion; coronary sinus; defibrillation; defibrillation threshold; high-rate pacing; left atrium; left pulmonary artery; low energy; multistage electrotherapy; optical action potential; pulmonary vein; right atrial appendage; right atrium; single biphasic shock; ventricular shock excitation threshold.

Publication types

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

MeSH terms

  • Animals
  • Atrial Fibrillation / physiopathology
  • Atrial Fibrillation / therapy*
  • Cardiac Catheterization
  • Disease Models, Animal
  • Dogs
  • Electric Countershock / methods*
  • Electric Stimulation Therapy / instrumentation*
  • Electrocardiography
  • Electrodes, Implanted*
  • Heart Atria / physiopathology*