Is defibrillation testing required for defibrillator implantation?

The assessment of defibrillation (DFT) efficacy has long been the standard of care during defibrillator implantation. To ensure an acceptable DFT safety margin, early defibrillator systems frequently required that the shock polarity and the location, type, or number of electrodes had to be altered. Advances in defibrillator and lead technology have resulted in lower and more consistent DFT thresholds in the range of 10 J, with an infrequent requirement to modify the DFT system. Yet, one can make an argument for and against continuation of DFT testing at the time of defibrillator implantation. The goal of this paper is to address both the data that do support and the data that do not support continuation of DFT testing at the time of device implantation. Scientifically, DFT testing should be abandoned only when prospective evidence demonstrates that defibrillator implantation without testing is as safe and has the same mortality benefits as implantation with testing. The most attractive aspect of eliminating DFT efficacy testing is that more patients may have the opportunity to be treated with this life-saving therapy. Perhaps there are alternative strategies to improve accessibility to defibrillator therapy without possibly eroding its effectiveness. In the end, will lives be saved or lost if we discontinue DFT efficacy testing and lower the barriers to implantable defibrillator therapy?