Orthostatic increase in defibrillation threshold leading to defibrillation failure and prolonged cardiac arrest in a sitting position: Lessons from a.

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Presentation transcript:

Orthostatic increase in defibrillation threshold leading to defibrillation failure and prolonged cardiac arrest in a sitting position: Lessons from a patient’s near-fatal experience Xiaoke Liu, MD, PhD, Samuel Asirvatham, MD, FHRS, G. Glenn Kabell, MD, PhD, FHRS HeartRhythm Case Reports Volume 2, Issue 4, Pages 313-317 (July 2016) DOI: 10.1016/j.hrcr.2016.03.005 Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 1 Detection and treatment of ventricular fibrillation (VF) in both the upright and supine positions. A: Initial detection of VF when patient was sitting up in a chair. B, C: Six consecutive shocks from the implantable cardioverter-defibrillator (ICD) failed to defibrillate. Only shocks 1 (B) and 6 (C) are shown. D: Successful defibrillation by an automated external defibrillator (AED) after patient was placed in a supine position. E, F: Patient developed 3 additional VF episodes in the field after being placed in the supine position. All these were successfully treated by the ICD. Only episodes 1 (E) and 3 (F) are shown. Arrows indicate the time when shock was delivered by the ICD. HeartRhythm Case Reports 2016 2, 313-317DOI: (10.1016/j.hrcr.2016.03.005) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 2 Posterior-anterior (PA) and lateral views of the implantable cardioverter-defibrillator (ICD) system in both supine and upright positions. A, B: Chest x-ray in the supine position. C, D: Patient’s ICD can was seen to be inferiorly (C) and anteriorly displaced (D) in the upright position compared to the supine one (A, B). In the upright position, the shock vector between the right ventricular coil and can (their midpoints connected with dashed lines) appears to encompass less of the cardiac mass, especially the left ventricle (D). E, F: PA (E) and lateral (F) views in the upright position after addition of an azygos vein coil (arrow). The shock vector between the coils and can now encompasses more of the left ventricle in the upright position (F). HeartRhythm Case Reports 2016 2, 313-317DOI: (10.1016/j.hrcr.2016.03.005) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 3 Defibrillation threshold testing when patient was in a sitting position with and without the azygos coil in the shock circuit. A: Using the initial right ventricular (RV) coil–to–ICD can configuration, a 25 J shock failed to defibrillate the patient. B: Immediately following the failure using the old configuration, a 15 J manual shock using the new RV coil–to–azygos vein/ICD can configuration successfully converted the patient to a paced rhythm. HeartRhythm Case Reports 2016 2, 313-317DOI: (10.1016/j.hrcr.2016.03.005) Copyright © 2016 Heart Rhythm Society Terms and Conditions