Multiple monophasic shocks improve electrotherapy of ventricular tachycardia in a rabbit model of chronic infarction

Background: We previously showed that the cardioversion threshold (CVT) for ventricular tachycardia (VT) is phase dependent when a single monophasic shock (1MP) is used. Objective: The purpose of this study was to extend these findings to a biphasic shock (1BP) and to compare the efficacy of phase-independent multiple monophasic (5MP) and biphasic shocks (5BP). Methods: Panoramic optical mapping with blebbistatin (5 μM) was performed in postmyocardial infarction rabbit hearts (n = 8). Flecainide (1.64 ± 0.68 μM) was administered to promote sustained arrhythmias. 5MP and 5BP were applied within one VT cycle length (CL). Results were compared to 1BP and antitachycardia pacing. Results: We observed monomorphic VT with CL = 149.6 ± 18.0 ms. Similar to 1MP, CVTs of 1BP were found to be phase dependent, and the maximum versus minimum CVT was 8.6 ± 1.7 V/cm versus 3.7 ± 1.9 V/cm, respectively (P = .0013). Efficacy of 5MP was higher than that of 1BP and 5BP. CVT was 3.2 ± 1.4 V/cm for 5MP versus 5.3 ± 1.9 V/cm for 5BP (P = .00027). 5MP versus averaged 1BP CVT was 3.6 ± 2.1 V/cm versus. 6.8 ± 1.5 V/cm, respectively (P = .00024). Antitachycardia pacing was found to be completely ineffective in this model. Conclusion: Maintenance of shock-induced virtual electrode polarization by multiple monophasic shocks over a VT cycle is responsible for unpinning of reentry leading to self-termination. Elimination of virtual electrode polarization by shock polarity reversal during multiple biphasic shocks proved ineffective. A significant reduction in CVT can be achieved by applying multiple monophasic shocks within one VT CL or one single shock at the proper coupling interval.