Is the Second Phase of a Biphasic Defibrillation

Waveform the Defihrillating Phase?

RUSSELL E. HILLSLEY, ROBERT G. WALKER. DAVID K. SWANSON,
DENNIS L. ROLLINS. PATRICK D. WOLF, WILLIAM M. SMITH,
and RAYMOND E. IDEKER
From the Departments of Medicine and Pathology. Duke University Medical Center, and the
Engineering Research Center for Emerging Cardiovascular Technologies of the School of
Engineering. Durham, North Carolina

HILLSLEY, R.E., ET AL.: IS the Second Phase of a Biphasic Defihrillation Waveform the DePihrillating
Phase? Why some biphasic waveforms defibrillate with lower energies Ihan monophasic waveforms of
similar duration is unknown. One hypothesis is that the first phase of a hiphasic waveform acts as a
conditioning, hyperpolarizing prepulse to prepare for defihri/Iafion by a second depolarii^ing phase. To
test whether the second phase of a biphasic waveform is the de/ibriiiating phase, three monophasic
wave/arms, an ascending ramp (AJ, a square wove (SJ, and a descending ramp (D), were compared to
three biphasic waveforms with A, S, or D in the first phase fbiphasic first phasej and three hiphasic
waveforms with A, S, or D in the second phase (biphasic second phasej. Two defibrilicition thresholds
for each ivaveform were performed in IS open chest pigs and mean defibril/ation threshoJds were com-
pared. In nine pigs 16-msec monophasic and 16/16-msec biphasic waveforms were ranked hy mean
current and energy at defibrilJation threshold. The ranks were the same for monophasic and hiphasic
secondphase waveforms: for mean current A < S = D and for energy A < S < D. The ranks were different
for the biphasic first phase ivaveforms: far mean current S < A = D and for energy S < A = D. Aithough
ranks for the ]G-msec monophasic ivaveforms matched those for the 16/16-msec hiphasic second phase
waveforms, the biphasic ivaveforms had higher mean currents and energies at defihriilation threshoid.
in nine pigs defihrilJation thresholds for 6-msec monophasic and 6/6-msec biphasic ivaveforms were
ranked. For mean current the ranks were monophasic: A < S ^ D: biphasic first phase: A = S = D;
and biphasic second phase: S ^ D < A. For energy the ranks were monophasic: A = S < D; hiphasic
first phase: A = S = D: and hiphasic second phase; S = D < A. Thus, ranks for the 6-nisec monophasic
waveforms di/feredfrom those for the 6/6-msec biphasic second phase waveforms. For 16/16-msec bipha-
sic waveforms, Jess effective for defihriJJation than corresponding 16-msec monophasic waveforms, these
results support the hypothesis that the second phase of a biphasic waveform defihriJJates since the
defihriilation efficacy of a 16/16-msec biphasic waveform is reiated to the defibriiiation efficacy of its
second phase waveshape. However, for cJinicaiJy usefuJ 6/6-msec biphasic waveforms, more effective
for defibriJIation than 6-msec monophasic waveforms, (he hypothesis is not supported because the ability
of a 6/6-msec biphasic waveform to defibriJJate is unreJated to the defibrilJation efficacy of its second
phase waveshape. (PACE, Vol. 16, July 1993, Part IJ

ventricuJarfibriJJation, defibriJJation, biphosic shocks, sudden cardiac death

Supported in part by the National Institutes of Health research

grants HL-42760, HL-44066. HL-28429, and HL-33637, The Na-
tional Science Foundation Engineering Research Center Grant
CDR-8622201, and by Cardiac Pacemakers, Inc. and Physio-
Control Corporation.
Address for reprints: Russell E. Hillsley, M.D., Box 31046, Duke
University Medical Ctr., Durham, NC 27710. Fax: (919) 660-
5405.
Received September 24, 1992; revision January 12. 1993; ac-
cepted February 5, 1993.
Introduction
Implantable cardioverter defibrillators may
use either monophasic waveforms or biphasic
waveforms with a second phase of opposite polar-
ity to the first. Many biphasic waveforms have
been observed to defibriliate with lower current
and energy than monophasic waveforms of similar

PACE. Vol. 16 July 1993, Part I 1401

 HILLSLEY. ET AL.
duration altbough the mechanism is not
known.'"" Jones et al.'^"'"* hypothesize that tbe
first phase of a bipbasic shock acts as a condition-
ing prepulse to reduce tbe threshold for excitation
or prolongation of refractoriness by the second de-
fibrillating phase.
An implication of this hypothesis is that the
second pbase of the biphasic waveform is acting
similarly to a monophasic waveform. To test this
implication, three monopbasic waveforms of dif-
fering defihrillation efficacy were chosen and used
as the first or second pbase of biphasic waveforms
with each phase equal in duration to tbat of the
monophasic waveforms. The goal was to see if
varying the waveshape of the second phase of a
hiphasic waveform caused changes in defihrilla-
tion efficacy similar to those produced hy varying
the waveshape of a monophasic waveform.
Scbuder et al,'^ found that ascending ramps
of long duration defihrillated more effectively than
descending ramps. Thus, the initial monopbasic
waveforms used were an ascending ramp, a de-
scending ramp, and a square wave, each 16 msec
in duration: and 16/16-msGc biphasic shocks with
tbe waveforms above in the second phase and a
square wave of the same mean current but oppo-
site polarity in the first phase. Bipbasic shocks
with the above monophasic waveforms in tbe first
phase and a square wave in the second phase were
also tested to see if varying the first phase of the
hiphasic had a different effect. Since the duration
of biphasic waveforms commonly used in avail-
able defibrillators is usually much shorter tban 32
msec and since the observations made at these
shock durations may not also apply to shorter
shocks, the second part of tbe study examined de-
fibrillation with the same waveshapes but a
shorter duration: 6-msec monophasic and 6/6-
msec bipbasic waveforms.
Methods
This study consisted of two similar hut dis-
tinct protocols, descrihed as part I and part II
helow. Part 1 measured defibrillation thresholds
for long (16/16 msec) hiphasic waveforms wbile
part II determined defihrillation thresholds for
shorter (6/6 msec) biphasic waveforms. The com-
mon portions of the protocol are descrihed first.
All pigs were treated and cared for in accordance
1402 July 1993, Part 1
with tbe National Institutes of Health Guide for
the Care and Use of Laboratory Animals."'
Animal Preparation
Twenty pigs (25-40 body mass] were preanes-
thetized witb ketamine (25 mg/kg) and acepromaz-
ine (0.5 mg/kg), intramuscularly. Subsequently,
anesthesia was maintained with pentoharbital (8
mg/kg initial intravenous dose followed by a con-
tinuous intravenous infusion of 0.05 mg/kg per
min). Succinylcholine (1.5 mg/kg initial intrave-
nous dose then 0.5 mg/kg intravenously every 20
min) was used to provide adequate muscle relaxa-
tion. The pigs were intubated with a cuffed endo-
tracheal tube and ventilated with room air and ox-
ygen through a respirator [Harvard Apparatus,
Inc., South Natick, MA. USA). A femoral arterial
line was inserted and systemic pressure was con-
tinuously displayed. Rectal temperature was mon-
itored continuously and maintained within nor-
mal limits. Arterial blood samples were drawn
every 60 minutes for determination of pH, partial
pressure of oxygen (pO:;). and serum electrolytes.
Normal saline with dextrose was continuously in-
fused and supplemented as needed to maintain pH
and electrolytes within normal ranges. Electrocar-
diographic leads were applied for continuous
monitoring.
The chest was opened by median sternotomy
and the pericardial sac opened to expose the heart.
Large, contoured, stainless steel electrodes were
then sutured to the heart for delivering defibrilla-
tion shocks. The right ventricular epicardial elec-
trode was the cathode for monophasic shocks and
fur the phase with variable waveshape in the bi-
phasic shocks: the left ventricular epicardial elec-
trode was of tbe opposite polarity.
Defibrillation Protocol
Ventricular fibrillation was induced by 60-Hz
alternating current delivered lor approximately 1
second through two wires sutured to the epicar-
dium. Defihrillation waveforms were created by a
custom-built, constant-current waveform genera-
tor (Cardiac Pacemakers. Inc.. St. Paul. MN, USA).
Fihrillation was sustained for 15 seconds before
defibrillation was attempted. A failed defibrilla-
tion was followed hy a rescue shock of higher en-
ergy than the failed shock and delivered hy a 150-
PACE, Vol. 16
 EFFECT OF WAVESHAPE ON DEFIBRILLATION
[JLF defibrillator (HVS-02, Ventritex. Inc., Sun-
nyvale, CA, USA). During each attempted defibril-
lation the applied current and voltage across the
heart were sampled at 20 kHz by a Data Precision
6100 waveform analyzer [Data Precision, Inc.,
Danvers, MA, USA). Signal analysis software
within the analyzer was used to obtain the imped-
ance and energy measurements. The output of the
waveform analyzer was sent to a computerized da-
tafile [Sun Microsystems, Inc., Mountain View,
CA, USA) and stored. At least 4 minutes were al-
lowed for the animal to recover after each fibrilla-
tion-defibrillation episode.
Part I
Nine different defibrillation waveforms were
tested (Fig. 1) in 11 pigs. The three monophasic
Ascending Ramp Square Descending Ramp
(A) (S) (D)
Monophasic
Biphasic - First Phase
t 0.4 A, and a repeat attempt at defibrillation was
2a
f tion attempt.
Biphasic - Second Phase
t were performed for each animal. The defibrillation
2a
1 f f
Figure 1. Ninf! r;urrenf waveforms used in parf 1. The
three monophasic waveforms are each 16 msec in dura-
tion. The six hiphasic waveforms are 32-msec total du-
ration and 16 msec in each phase. For the biphasic-/irst
phase waveforms (he monophasic waveform was used
as the first phase wilh the second phase a square wave
wilh opposile polarity. For the biphasic-second phase
waveforms the monophasic waveform was used as the
second phase wilh a square wave of opposite polarity
preceding il. In all the hiphasic waveforms the mean
current of the first phase equah the mean current of tbe
second phase. The peak current in each phase of the
biphasic waveforms is represented as multiples of the
symbol a.
PACE, Vol. 16
waveforms, an ascending ramp, a square wave,
and a descending ramp, were each 16 msec in du-
ration. The biphasic waveforms were all 32 msec
in duration, 16 msec in each phase. The mean cur-
rent of the first phase of the biphasic was set equal
to the mean current of the second phase. Three
of the biphasic waveforms were composed of the
monophasic waveforms above in phase one with
a square wave of opposite polarity in phase two
[biphasic first phase). The other three biphasic
waveforms contained the monophasic waveforms
in phase two with a square wave of opposite polar-
ity in phase one (biphasic second phase).
The defibriliation threshold was defined as
the lowest current and energy that achieved defi-
brillation. The initial current was the mean cur-
rent at defibrillation threshold for that waveform
in the previous animals. If a defibrillation shock
was successful, the mean current of the monopha-
sic or both phases of the biphasic shock was de-
creased by 0.4 A, and a repeat attempt at defibrilla-
tion was made. This procedure was repeated until
an unsuccessful shock occurred; then, the mean
current was increased by 0.2 A, and a final defibril-
lation attempt was made. If the initial defibrilla-
tion shock failed, the mean current was increased
made. This procedure was repeated until a suc-
cessful defibrillation occurred; then, the mean cur-
rent was decreased by 0.2 A for the final defibrilla-
Two sets of nine defibrillation thresholds
threshold for each waveform was determined in
random order in each set. Two animals died dur-
ing the second set of defibrillation thresholds;
only the first complete set of defibrillation thresh-
olds was included for those animals. Two animals
were excluded from analysis: one died before com-
pleting a single set of defibrillation thresholds; in
the other animal the electrodes were inadvertently
used in reverse polarity throughout the exper-
iment.
Part II
Nine different defibrillation waveforms were
tested (Fig. 2) in nine pigs. The three monophasic
waveforms, an ascending ramp, a square wave,
and a descending ramp, were each 6 msec in dura-
July 1993, Part I 1403
 HILLSLEY, ET AL.
Ascending Ramp Square Descending Ramp
(A) (S) (D)
Monophasic
l\ 2a Biphasic - First Phase
t olds: only the first complete set of defibriiiation
Biphasic - Second Phase
Figure 2. Nine currenf waveforms used in porl /I. The
Ihref! monophnsic uav'f;/nrm,s QTP. each 6 msec in dum-
Hon. The six biphasir wtn'ejnrms are I2-msec total du-
ration and 6 msec in each phase. For Ihe bi phasic-firs I
phase waveforms the monophasic ivavofonn was used
as phase one ivifh tb(; .second phase a square wuve with
opposite pokirily. For fhe biphasic-second phase wove-
forms the monophasic waveform was used as the sec-
ond phase wilh a square wave of opposite polarity pre-
ceding i(. In all (he hiphasic waveforms (he mean
current oi (he firsl phase was twice the mean curi-enl of
the second phase. The peak current in each phase of
the biphasic waveforms is represented by mu/tiples of
the symbol a.
tion. The biphasic waveforms were all 12 msec,
6 msec per phase, To simuiato the most effective
biphasic waveforms studied and currently in use
in available defibriliators, the mean current of the
first jjhase of the biphasic was set to twice the
mean current ofthe second phase.^ •*•"'" As in part
I, three biphasics were composed of the monopha-
sics above in phase one and a square wave of oppo-
site polarity in phase two (biphasic first phase).
The other three biphasics contained the monopha-
sics above in phase two and a square wave with
opposite polarity in phase one (biphasic second
phase).
The defibrillation threshold was defined simi-
larly and an identical protocol to that in part I was
followed for the monophasic waveforms. Since the
mean current of the first phase of the biphasic
waveforms was twice the mean current of the sec-
ond phase, initially during defibrillation testing
the mean current of the first phase was changed
1404 luly 1993. Part I
by 0.4 A, and the mean current of the second phase
was changed by 0.2 A. After a transition from suc-
cess to failure or failure to success, the final change
in mean current was 0.2 A for the first phase hut
0.1 A for the second phase.
Two sets of nine defibrillation thresholds
were determined in each pig. As in part 1. the defi-
brillation threshold for each waveform was deter-
mined in random order in each set. One animal
died during tho second set of defibrillation thresh-
thresholds was included for this animal.
Upon completion of a protocol, the pig was
euthanized by electrically induced fibrillation.
The electrodes were removed and the heart was
excised and weighed.
Statistical Analysis
In part I. 16 complete sets of defibrillation
thresholds were available: two sets from each of
seven animals and one set from each of two ani-
mals. In part II, 17 complete sets of defibrillation
thresholds were available: two sets from each of
eight animals and one set from one animal. For
each part of the experiment data from ail com-
pleted sets of nine defibrillation thresholds, 16
sets in part I and 17 sets in part II. were combined
to determine a mean and standard deviation for
each waveform. Repeated measures analysis of
variance with the Student-Newnian-Keul's test
(SAS Institute. Inc.. Cary, NC. USA) was used to
compare the three monophasics and produce a
rank order hy mean current and energy. The same
procedure was followed to produce rank orders for
the three biphasic first phase waveforms and rank
orders for the three biphasic second phase wave-
forms. The null hypothesis was rejected for P <
0.05 and P < 0.05 was required for each compari-
son to be statistically significant.
Results
Parti
The mean heart weight was 178 ± 19.2 g for
the nine pigs. Figure 3 depicts the mean energy at
defihrillation threshold for each waveform in each
of the nine pigs. After combining the data from all
16 sets of defibrillation thresholds in nine pigs,
the mean current and energy at defibrillation
PACE. Vol. 16
 EFFECT OF WAVESHAPE ON DEFiBRItXATION

80 Monophasic
Q.—o Ascending Ramp
a — • Square
O—O Descending Ramp

Biphasic - First Phase

G- -O Ascending Ramp
60 Q-- D Square / \
O - O Descending Ramp / \

Biphasic - Second Phase 1 «> ^ o. if

•' ••• /I
O- -G Ascending Hamp tl
,'O ••, //
Q—E] Square / ,'H\ \ ,,
;'•
•,
'••,
••,'/
f.

<>—0 Descending Ramp ,-'•' P-\ \ .f •/ ••

-••'•' / Nft
40 ••'/ \ \ \ V
x
c / /•
)• ,•• / /
LU ^ . '•••.
y /
\\^' / /

'•\\ l\i '^ \^\ ! ^1

20
^^ / .0' 3
''•'.''<> i ,'•:
W / •
/ \
& \\ VS
'• It
y ^ y\;'' /•''-' ,0 -^

^ ^ ^ ^ ^ ^
G— e^
n
G- e- —©"^
J L . 1 1
>—^1^^
5
Animal

Figure 3. De/ibrilJalion threshold energy/or Ihe nine lG-msec monophasic OT 16/16-msec bipha-
sic mi ve/onns te.fited in parf f ploflod/or ecich animcil. For seven animnis (he energies represent
the mean of two de/ibri/I(j(ion threshulds; in two animah only onv. de/ibrilJulion threshold is
represenled.

threshold were determined and are given in Tables
I and I! for the nine long waveforms. The ranks for
tho monophasic, the biphasic first phase, and the
biphasic second phase waveforms are given in
Table III (duration 16 msec). The ranks were hased
on the first phase energy for the bipiiasic first
phase waveforms and the second phase energy for
the biphasic second phase waveforms. For the bi-
phasic waveforms the mean current and energy at
defihrillation threshold were higher than those for
the corresponding monophasic waveforms (P <
0.05).
For the monophasic waveforms the ascending
ramp had the lowest mean current and energy at
defibrillation threshold. By contrast the descend-
ing ramp had the highest mean current and energy
at defibrillation threshold. The square wave was
not different from the descending ramp by mean
current but was intermediate between the ascend-
ing ramp and descending ramp by energy.

Table 1.
Mean Current ± Standard Deviation (Amps) at Defibrillation Threshoid for 16 msec Monophasics
and 16/16 msec Biphasics

Waveform Ascending Ramp Square Descending Ramp

Monophasic 2.37 ± 0,88 3,43 ± 0,53 3,46 ± 0,82

Biphasic-first phase 4.54 ± 1,15 3.60 ± 1.33 4.79 ± 1.33
Biphasic-second phase 2,65 ± 0.86 4.14 ± 1.52 4.41 ± 1.52

PACE, Vol. 16 July 1993. Part ! 1405

 HtLLSLEY, ET AL.

Table 11.
Energy ± Standard Deviation (Jouies) at Defibriliation Threstioid for 16 msec Monophasics
and 16/16 msec Biphasics

Ascending Ramp Square Descending Ramp

Monopbasic 5.48 :t 3.78 8.41 ± 2.09 10.4 + 4.18

Biphasic-first phase
First phiase energy 18.0 -t 7.88. 9.75 ± 6.26 19.6 ± 9.83
Totai energy 31.3 ^t 13.7 18.7 ± 12.3 34.1 + 17.5
Bipliasic-second phase
Second phase energy 6.19 1- 3.88 12.1 ± 8.40 16.4 ± 11.4
Totai energy 11.6 ir 7.03 25.2 + 16.8 30.4 ± 20.0

The biphasic first phase waveforms ranked
differently from the monophasic waveforms. The
most effective waveform by mean current and en-
ergy was the square wave. The ascending and de-
scending ramps were not different from each other
by either criterion.
With the biphasic second phase waveforms,
the ascending ramp again had the lowest mean
current and energy at defibrillation threshold, As
for the monophasic waveforms, the descending
ramp was the worst by mean current and energy
while the square wave matched the descending
ramp by mean current but was intermediate be-
tween the ascending and descending ramps by en-
ergy. Thus, the ranks for the monophasic wave-
forms and the biphasic second phase waveforms
were identical and the ranks for the biphasic first
phase waveforms were different.
Part II
The mean heart weight was 170 ± 19.2 g for
the nine pigs. The mean energy at defihrillation
threshold for each of the nine short waveforms in
each of nine pigs is shown in Figure 4. For the
combined 17 sets of defibrillation thresholds
available from nine pigs, the mean current and en-
ergy at defibrillation threshold for the nine short
waveforms were determined and are given in Ta-
hles IV and V. The ranks for the monophasic, the
biphasic first phase, and the biphasic second
phase waveforms are given in Table III (duration
6 msec). The ranks for the hiphasic first phase
waveforms were derived from the mean current
and energy contained in the first phase, and the
ranks for the biphasic second phase waveforms
were derived from the mean current and energy
in the second phase. Unlike in part L the mean
current and total energy at the defibrillation
threshold for the biphasic waveforms were lower
than for the corresponding monophasics (P <
0.05].
For the monophasic waveforms the ascending
ramp was the most effective by mean current,
but by energy the square wave and ascending
ramp were equally effective. By mean current

Table IIL
Rank Orders By Mean Current and Energy

16 msec 6 msec
Duration Mean Current Energy Mean Current Energy

Monophasic A < S - D A< S< D A< S = D A - S < D

Biphasic-first phase S < A - D S < A - D A - S = D A - S - D
Biphasic-second phase A< S - D A < S< D S - D < A S = D < A

1406 July 1993. Part I PACE, Vol.

 EFFECT OF WAVESHAPE ON DEFIBRILLATION

Monophatic
G—o Ascending Ramp
15 B—o Square
O—O Descending Ramp

Biphasic - First PhaM

O- o Ascending Ramp
D • Square
O—O Descending Ramp

Biphasic - Second Phase

O- - o Ascending Ramp
10 Q — • Square
0—o Descending Ramp

CD
LU

1 2 3 4 5 6 7 8 9
Animal

Figure 4. Defibrillation threshold energy for tbe nine 6-msec monophasic or 6/6-msec biphasic
waveforms tested in part JI plofled for each animal. For eight nnimaJs Ihe energies represent
the mean af two de/ibrillalion thresholds; in one animal only one defibrilJalion threshold for
each waveform is represented.

and energy the descending ramp was the worst
waveform.
The biphasic first phase waveforms wero not
different for either mean current or energy. (P ^
0.34 for rejecting the null hypothesis for mean cur-
rent and P - 0.40 for rejecting the null hypothesis
for energy.)
The biphasic second phase waveforms were
different and the ascending ramp was the least ef-
fective for defibrillation. The square wave and de-
scending ramp were equally effective, and both
defibrillated better than the ascending ramp. Nota-
bly, although the 6-msec monophasic ascending
ramp was the most efficient at defibrillation, the

Table IV,
Mean Current Standard Deviation (Amps) at Defibrillation Threshold for 6 msec Monophasics
and 6/6 msec Biphasics

Ascending Ramp Square Descending Ramp

Monophasic 3.92 ± 1,07 4.61 ± 1.15 4.66 ± 1.00

Biphasic-first phase
First phase mean current 2.65 ± 0.85 2.86 ± 0.67 2.82 ± 0.77
Both phases mean current 1.90 ± 0.63 2.11 ± 0.51 2.05 ± 0.58
Biphasic-second phase
Second phase mean current 1.63 ± 0.48 1.26 ± 0.33 1.23 ± 0.29
Both phases mean current 2.33 ± 0.69 1.95 ± 0.50 1.78 ± 0.44

PACE. Vol. 16 July 1993. Part I 1407

 HILLSLEY, ET AL,
Table V.
Energy ± Standard Deviation (Joules) at Defibriilation Threshold for 6 msec Monophasics
and 6/6 msec Biphasics
Waveform Ascending Ramp
Monophasic 5.16 ± 3.07
Biphasic-first phase
First phase energy 2.43 ± 1.45
Totai energy 2,75 ± 1.67
Biphasic-second phase
Second phase energy 0,73 ± 0.47
Total energy 3.31 ± 1.98
6/6-mset: biphasic with an ascending ramp in the
second phase was the least efficient. This resuit
contrasts with that from part I for which the 16-
msec monophasic ascending ramp and the 16/16-
msec biphasic with the ascending ramp in the sec-
ond phase were the most efficient monophasic and
hiphasic waveforms, respectively. Thus, the ranks
for the 6-msec monophasic waveforms and the 6/
6-msec hiphasic second phase waveforms were
different.
Discussion
This study investigated the mechanism of de-
fibrillation witb biphasic waveforms by defibril-
lating with shocks of different waveshapes and de-
termining whether the defibrillation efficacy of tbe
first or second phase of tbe biphasic waveform cor-
responded to tbat of a monopbasic waveform. For
monopbasic waveforms defibriilation efficacy
witb ramps and square waves was found to corre-
spond to the stimulation efficacy of these wave-
forms in previous studies.^^^'* Short duration (6
msec) monopbasic ascending ramps defibrillated
better tban square waves or descending ramps. For
16/16-msec bipbasic waveforms, varying tbe
shape of the second pbase produced similar
cbanges in defibrillation efficacy to tbose pro-
duced by varying tbe sbape of a 16-msec mono-
phasic waveform; this was not true for 6/6-msec
bipbasic waveforms.
Monophasic Waveforms
Scbuder and co-workers^^ first used ascend-
ing and descending ramp waveforms for defibrilla-
1408 July 1993, Part I
Square Descending Ramp
5.62 ± 2,70 6.74 + 2.72
2.33 ± 1.04 2.67 ± 1,44
2.74 ± 1.26 3.05 + 1,68
0.36 ± 0,21 0.38 ± 0.21
2.33 ± 1,17 1.94 ± 1.07
tion. In earlier studies of cardiac stimulation, as-
cending ramp waveforms stimulated myocardium
more effectively, with iess energy and charge, tban
did a square wave or a descending ramp.'^'"
Tbese results for stimuiation are consistent witb
tbe resuits for defibrillation with monopbasic
shocks of 6-msec and 16-msec duration. In both
cases tbe descending ramp required the greatest
energy for defibrillation. in addition, tbe ascend-
ing ramp defibrillated witb lower mean current
tban did tbo square wave or tbe descending ramp
at hoth durations.
Schuder et al.^^ demonstrated a greater proba-
bility of successful defibrillation for transthoracic
defibrillation witb ascending ramps than descend-
ing ramps when shock duration was longer than
16 msec. Unlike in the present study, at shorter
durations tbe two ramp waveforms appeared simi-
lar in efficacy. However, defibrillating with epicar-
dial electrodes in open cbest pigs may not give tbe
same results as with transthoracic electrodes in
calves. In addition, tbe waveforms were not tested
in random sequence in tbe calves. Matbematical
models and experiments witb trapezoidal wave-
forms, wbicb approximate ascending and de-
scending ramps, have shown improved defibrilla-
tion efficacy with ascending ramp waveforms. ^^'^^
The similar results for myocardial stimulation
and defihrillation with tbese monopbasic
wavesbapes are consistent witb the hypothesis
tbat monopbasic waveforms defibriliate by excita-
tion or by prolongation of refractoriness. Tbese
results differ from those witb sbort duration bi-
phasic sbocks.^'-^^ Sbort biphasic shocks that
defibrillated more efficiently tban monopbasic
PACE, Vol, 16
 EFFECT OF WAVESHAPE ON DEFIBRILLATION
waveforms did not excite myocardium or prolong
refractoriness as nffoctively.
Biphasic Waveforms
The results for the 16/16-msec and 6/6-msec
biphasic waveforms were different. For the 16/16-
msec biphasic shocks defibrillation efficacy was
related to the ability of the second phase
waveshape to defibrillate. An ascending ramp was
the most effective 16-msec monophasic waveform
and the most effective second phase for the 16/16-
msec biphasic waveform; conversely, the descend-
ing ramp was the least effective for both. This is
consistent with the hypothesis by Jones et al. '^ '•*
that the first phase of the biphasic waveform pre-
pares the heart for defibrillation by the second
phase.
However, the defibrillation thresholds for the
16/16-msec biphasic waveforms were greater than
those for the 16-msec monophasic waveforms. For
example, the 16-msec monophasic ascending
ramp had a lower mean current and energy at defi-
brillation threshold than the 16/16-msec biphasic
waveform with an ascending ramp in the second
phase. Since the biphasic waveform is less effec-
tive at defibrillation than the monophasic wave-
form, it is unlikely that the first phase is condition-
ing the myocardium for defibrillation by the sec-
ond phase. The higher defibrillation thresholds
with the 16/16-msec biphasic waveforms com-
pared with the 16-msec monophasic waveforms
contrasts with the excitation experiments of Jones
et al.'^ in which symmetric biphasic stimuli of up
to 40 msec/phase in duration excited chick myo-
cardial cells better than monophasic stimuli equal
in duration to the second phase of the biphasic
stimuli. In the present study, the addition of the
first phase made this long waveform less able to
defibrillate.
For the 6/6-msec biphasic shocks, varying the
waveshape of the second phase did not produce
the same changes in defibrillation efficacy as
when varying the monophasic waveshapes. The
ascending ramp, which was efficacious for the 6-
msec monophasic waveform, was not as effective
as either a square wave or a descending ramp when
inserted into the second phase of the 6/6-msec bi-
phasic waveform. Unlike the 16/16-msec biphasic
waveforms, these shorter biphasic waveforms de-
fibrillated with lower current and energy than the
PACE, Vol. 16
corresponding monophasic waveforms. Thus,
while there is a beneficial interaction between the
two phases of these biphasic waveforms, it does
not appear to be explained by the ability of the
second phase to defibrillate in tho same manner
as the monophasic waveform.
This finding seems reasonable since for the
shorter 6/6-msec biphasic waveforms the energy
content of the second phase was significantly less
than the energy content of the first phase. Typi-
cally, the first phase contained three to four times
the energy of the second phase. This is also true
of clinically useful biphasic waveforms.'*'" It is
difficult to view the first phase of these biphasic
waveforms as merely a conditioning phase since
it contains such a large proportion of the energy.
However, varying the waveshape of the first phase
of the 6/6-msec biphasic waveforms did not pro-
duce a significant change in defibrillation efficacy.
Consequently, the increased efficacy of biphasic
waveforms does not appear to result solely from
the ability of the first phase to defibrillate in the
same manner as the monophasic waveform either.
Schuder et al.''^ proposed that descending
ramps were ineffective for defibrillation because
they tended to produce refibrillation. This hypoth-
esis appears consistent with the results for the
longer waveforms; the descending ramp may have
been the worst waveform for the second phase be-
cause it reinduced fibrillation. However, for the
shorter waveforms a descending ramp in the sec-
ond phase was much more efficient for defibrilla-
tion than was an ascending ramp.
This study suggests that it is incorrect to refer
to the second phase of all biphasic waveforms as
the defibrillating pulse''' since the interaction be-
tween the two phases appears complex. Although
for a long (16/16 msec) biphasic waveform, the de-
fibrillation efficacy varied with the shape of the
second phase; this was not the case for a shorter
(6/6 msec) biphasic waveform. This difference in
defibrillation behavior suggests that different
mechanisms may apply to long and short biphasic
waveforms, and that for the shorter 6/6-msec bi-
phasic waveforms the second phase is not the sole
defibriliating phase.
Optimizing Defibrillation Waveforms
Selection of the optimal waveshape is impor-
tant to the production of an effective implantable
|uly 1993. Part I 1409
 HILLSLEY, ET AL.
defibrillator. As suggested by prior studies,^' tbe
best dofibrillation wavesbape is not reliably pre-
dicted by tbe wavesbape tbat stimulates myocar-
dium most effectively. Ascending ramps bave
been sbown to stimulate myocardium effectively,
and in tbis study monopbasie ascending ramps
and long (16/16 msec) bipbasic waveforms witb
an ascending ramp in tbe second pbase defibrillate
well; however, sbort [6/6 msec) bipbasic wave-
forms witb an ascending ramp in tbe second pbase
defibrillate poorly. Tbus, tbe cboice of specific
monopbasie and bipbasic wavesbapes for defibril-
lation should not be based solely on tbe ability of
tbe waveform to stimulate but sbould be tested for
defibrillation before being used in a device.
Ascending ramps were tbe best 6-msec and
16-msec monophasic defibrillation waveforms in
this study. By constrast, descending ramps were
the least effective while square waves were inter-
mediate in efficacy. Tbus, if a descending ramp is
considered an approximation of a bigb tilt expo-
nential waveform and a square wave is considered
the waveform of lowest tilt, then a low tilt expo-
nential monophasic waveform sbould be better
tban one with high tilt. The benefit of low tilt
waveforms bas been noted previously,"'' One prac-
tical disadvantage of low tilt waveforms is tbat
they require a larger capacitor for generation.
References
1. Dixon EG. Tang ASL, Wolf PD. et al. Improved de-
fibrillation thresholds with large contoured epiuar-
dial electrodes and biphasic waveforms. Circula-
tion 1987: 76:1176-1184,
2, Tang ASL. Yabe S. Wharton JM, et al. Ventricular
defibrillation using biphasic waveforms: The im-
portance of phasic duration, | Am Goll C'ardiol
1989: 13:207-214.
3, Feeser SA. Tang ASL, Kavanagh KM. et al.
Strength-duration and probability of success
curves for defihrillation with hiphasic waveforms.
Circulation 1990: 82:2128-2141.
4. Kavanagh KM, Tang ASL, Rollins DL, et al. Com-
parison of the internal defihrillation thresholds for
monophasic and double and single capacitor hi-
phasic waveforms, ) Am Goll Gardiol 1989: 14:
1343-1349.
5. P'ain ES, Sweeney MB, Franz MR, Improved inter-
nal defihrillation efficacy with a biphasic wave-
form. Am Heart 1 1989: 117:358-364.
6, Winkle RA, Mead RH, Ruder MA, et al. Improved
low energy defibrillation efficacy in man with the
1410 July 1993. Part I
whicb may increase tbe size of tbe implanted defi-
brillator.
In earlier studies,^-^ biphasic waveforms with
a second phase shorter than the first phase were
more effective tban tbose with a second pbase
longer than or equal in duration to the first. How-
ever, the relative duration of the two phases is not
tbe only determinant of biphasic efficacy since all
the biphasic sbocks compared in this study had
pbases of equal duration. The long (16/16 msec)
biphasic waveforms were not as effective for defi-
brillation as tbe 16-msec monopbasie waveforms
and, as a result, are not as useful clinically. For tbe
6/6-msec bipbasic waveform an ascending ramp in
tbe second pbase is not as effective as a square
wave or a descending ramp for defibrillation.
Since tbe second phase descending ramp and
square waves were equally effective, it may be ac-
ceptable to substitute a bigb tilt exponential wave-
form into the second phase. Such a waveform bas
been described.^^' Varying the shape of the first
phase of tbe 6/6-msec bipbasic waveform had no
significant effect in this study.
Acknoiv/edgmeitts; We thatik Sharon Meltiick. |enny
Hagler, and EHen Dixon-Tullocn for their technical asshslance.
use of a hiphasic truncated exponential waveform.
Am Heart J 1989: 117:122-127.
7. Schuder JG, Cold JH, Stoeckle H, et al, Transtho-
racic ventricular defihrillation in the 100 kg calf
with symmetrical one-cycle bidirectional rectan-
gular wave stimuli. IEEE Trans Binmed Eng 1983:
BME-30:415-422,
8. Jones IL, Swartz JF, Jones RE. et al. Increasing fi-
hrillation duration enhances relative asymmetrical
hiphasic versus monophasic defihrillator wave-
form efficacy, Circ Res 1990: 67:376-384.
9. Elaker GC. Schuder JC, McDaniel WC, et al. Superi-
ority of hiphasic shocks in the defihrillation of
dogs by epicardial patches and catheter electrodes.
Am Heart J 1989: 118:288-291,
10, Bardy GH, Ivey TD. Allen MD. et al, A prospective
randomized evaluation of hiphasic versus mono-
phasic waveform pulses on defibrillation efficacy
in humans. J Am Goll Cardiol 1989: 14:728-733.
11. Chapman PD, Vetter JW, Souza JJ. et al. Gompara-
tive efficacy of monophasic and biphasic truncated
exponential shocks for nonthoracotomy internal
PAGE, Vol. 16
 EFFECT OF WAVESHAPE ON DEFIBRILLATION
defibrillation in dogs. J Am Coll Cardiol 1988; 12:
739-745.
12. Jones )L, [ones RE. Balasky G. Improved cardiac
cell excitation with symmetrical biphasic defibril-
lator waveforms. Am J Physiol 1987; 253:H1418-
H1424.
13. Jone.s ]L. Jones RE. Improved safety factors for tri-
phasic defibrillator waveforms. Circ Res 1989; 64:
1172-1177.
14. Swartz JF. Jones JL, Jones RE, et al. Conditioning
prepulse of biphasic defibrillator waveforms en-
hances refractoriness to fibrillation wavefronts.
Circ Res 1991; 68:438-449.
15. Schuder JC, Rahmoeller GA. Stoeckle H. Transtho-
racic ventricular defibrillation with triangular and
trapezoidal waveforms. Circ Res 1966; 19:
689-694.
16. National Research Council. Committee on the Care
and Use of Laboratory Animals: United
States—Revised 1985. Washington. DC, US Gov-
ernment Printing Office, 1985.
17. Angelakos ET, Torres JC. The efficiency of electri-
cal pulses for cardiac stimulation. Cardiologia
1964; 44:355-365.
18. Roy OZ, Wehnert RW. A more efficient waveform
for cardiac stimulation. Med Biol Eng 1971; 9;
495-501.
PACE, Vol. 16
19. Koning G. Some physical aspects of ventricular de-
fibrillation: A system analytic approach. Amster-
dam, The Netherlands, Free University of Amster-
dam, 1972.
20. Rauglas E, Blazek Z, Vrana M. Efficacy of mono-
phasitj eiectricai impulses with steep leading and
trailing edges in cardiac defibrillation. Cor Vasa
1977: 19;37B-384.
21. Daubert ]P, Frazier DW, Wolf PD. et al. Response
of relatively refractory canine myocardium to mo-
nophasic and biphasic shocks. Girculation 1991;
84:2522-2538.
22. Wbarton JM, Richard V), Murry CE Jr, et al. Electro-
physiologic effects in vivo of monophasic and bi-
phasic stimuli in normal and infarcted dogs. PACE
1990; 13:1158-1172.
23. Zhou X, Knisley SB, Wolf PD, et al. Prolongation
of repoiarization time by electric field stimulation
with monophasic and biphasic shocks in open
chest dogs. Circ Res 1991; 68:1761-1767.
24. Wessale JL. Bipolar Catheter Defibrillation in Dogs
Using Trapezoidal Waveforms of Various Tilts. W.
Lafayette, IN, Purdue University. 1978.
25. Tchou P, Krum D, Akhtar M, et al. Reduction of
defibrillatiou energy requirements with a new bi-
phasic waveform, (abstract) PACE 1990; 13:506.
July 1993, Part I 1411