Delayed success in termination of three-dimensional reentry: role of surface polarization.

Abstract

Defibrillation shocks slightly stronger than cardioversion threshold may defibrillate not immediately but after a transient period of postshock activity (delayed success). The effect of a defibrillation shock is that it polarizes the tissue, primarily at the surfaces; therefore, surface polarization may play an important role at near-threshold shock intensities. We numerically investigate the effect of a monophasic transmural electrical shock on a three-dimensional (3D) reentrant wave (scroll wave). For simplicity, we assume uniform polarization of the epicardial and endocardial surfaces. We demonstrate that the effect of surface polarization alone is sufficient to induce delayed termination of self-sustained activity (3-4 beats after the shock). In agreement with experimental observations, both successful and failed shocks cause prolongation of the action potentials on the depolarized side and shortening on the hyperpolarized side, while at the same time inducing a shift from a reentrant to a focal activation pattern. Our simulations suggest that the outcome of the shock is determined by its effect on the shape of the scroll wave's center of rotation (filament). We propose a simple rule to predict the postshock filament shape that allows us to make accurate predictions of success and failure of a termination attempt. Surface polarization due to an electrical shock can terminate a reentrant scroll wave. This mechanism may explain the phenomenon of delayed success in defibrillation.