New concepts in transthoracic defibrillation.

The transition of biphasic waveforms from ICDs to external defibrillators constitutes a significant technological advances for transthoracic defibrillation. Impedance compensation has enabled the delivery of defibrillating current adapted to each patient and each shock in the same patient. Optimally designed biphasic waveforms have been shown clinically to have greater efficacy in the termination of VF when compared with monophasic waveforms, and because peak current delivery is less, these waveforms are likely to be less injurious to myocardial function. Advances in the understanding of the mechanisms of fibrillation and defibrillation have identified the electrophysiologic events that initiate and sustain VF and the effects of defibrillation shocks on those events. Definition of the role of VEP and postshock excitation has clarified the mechanisms by which shocks can either fail or succeed. The ability of the second phase of optimal biphasic waveform shocks to exploit recruited sodium channels in negatively polarized areas and thus induce rapid propagation of postshock excitation assures uniform depolarization and prevention of re-entry. This appears to be the major mechanism of greater efficacy of biphasic waveforms. It seems certain that continuing investigation of virtual electrodes will enhance our understanding of defibrillation and optimal waveforms. At the same time, much more needs to be known regarding translation of these experimental observations to mechanisms of defibrillation in human hearts with long-standing underlying structural heart disease, which often arises of multiple factors. This represents a major challenge in defibrillation research.