Basic Mechanisms of Ventricular Fibrillation and Defibrillation

Abstract

Recordings made simultaneously from many electrodes placed on and in the hearts of animals have provided much new information about the basic principles of ventricular fibrillation and defibrillation. The findings are listed below. Fibrillation is maintained predominantly by wandering wavelet reentry and secondarily by repeating spiral rotor reentry. Activation sequences become more organized after 1 min of fibrillation than during the first few seconds of fibrillation and become less organized again after 5 min of fibrillation. Earliest activation following a shock slightly lower in strength than needed to defibrillate (a subthreshold defibrillation shock) occur in those cardiac regions in which the potential gradients generated by the shock are weakest. Activation fronts after subthreshold shocks are not continuations of activation fronts present just before the shock. An upper limit exists to the stength of shocks that induce fibrillation when given during the “vulnerable period” of regular rhythm. This upper limit of vulnerability correlates with and is similar in strength to the defibrillation threshold. To defibrillate, a shock must halt the activation fronts of fibrillation without giving rise to new activation fronts that reinduce fibrillation.The response to shocks during regular rhythm just below the upper limit of vulnerability is similar to the response to subthreshold defibrillation shocks. Shocks during regular rhythm initiate rotors of reentrant activation leading to fibrillation when a critical point is formed at which a certain critical value of shock potential gradient field strength intersects a certain critical degree of myocardial refractoriness. This critical point may explain the existence of the upper limit of vulnerability. The critical point may also partially explain the finding that the relationship between shock strength and the success of the shock in halting fibrillation is better represented by a probability function rather than by a discrete threshold value. Very high potential gradients, approximately an order of magnitude greater than needed for defibrillation, have detrimental effects on the heart, including conduction block, induction of arrhythmias, decreased wall motion, and tissue necrosis. Biphasic waveforms are superior to monophasic waveforms for defibrillation because they require a lower potential gradient to halt fibrillation activation fronts and require a higher potential gradient to cause detrimental effects. These results suggest that, for defibrillation, the best shock waveform is biphasic and the best electrode configuration is the one that creates a certain minimum potential gradient throughout the ventricles with the smallest strength shock.