Effects of an active pectoral-pulse generator shell on defibrillation efficacy with a transvenous lead system

Transvenous lead systems have become routine for defibrillator implantation. A reduction of pulse generator size has made pectoral placement possible and enabled the pulse generator shell to become an active part of the defibrillation pathway. To directly assess the effect of the addition of an active generator on defibrillation thresholds to a transvenous lead system, we prospectively measured paired, randomized defibrillation thresholds (DFTs) in 21 patients undergoing defibrillator implantation. A dual coil lead (Endotak C, Cardiac Pacemakers, Inc., Guidant Corp., St. Paul, Minnesota) was used with the distal coil as the cathode for all shocks. The DFT was 8.4 +/- 3.2 J with the active shell, compared with 13.1 +/- 6.9 J with the lead alone (p <0.01). This reduction was greatest in those patients with higher thresholds with the lead-alone configuration and resulted in DFT less than or equal to 15 J with the active shell configuration in all patients. Shock impedance was reduced from 49 +/- 5 to 42 +/- 4 ohms (p <.001), but peak current at defibrillation threshold was unaffected by the addition of the active pectoral shell. We conclude that the addition of an active pectoral shell to a 2-coil transvenous lead system resulted in a marked reduction of defibrillation energy requirements, The uniformly low DFT (less than or equal to 15 J) observed suggests that an active poise generator with a 25 J maximum output could be implanted in most patients while maintaining an adequate defibrillation safety margin.