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EP Summit 2014: The History of Cardioversion: A Tale Little Known

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Albert Waldo, MD

Albert Waldo, MD

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  • 1. The History of ! Cardioversion/ Defibrillation Albert L. Waldo, MD The Walter H. Pritchard Professor of Cardiology, Professor of Medicine and Biomedical Engineering Case Western Reserve University
  • 2. An Invitation From
  • 3. The Early Work (Leiden) jar 1745 aard 1775 - Earliest recorded scientific approach with t electric shocks i 1781 - link to electricity in biological systems! 88 Possibly the first description of a successful resusc th the use of electricity and Hoffa 1849 – 1st Description of Fibrillation n 1874 - Coined the term “fibrillation;” 1st to suggest th art was responsible for originating and sustaining this ythm cWilliam 1857 – 1937 - 1st to suggest that VF, and not card andstill, was the mechanism of sudden death in humans t and Battelli 1899 - Showed that a small amount of ele livered across the chest can induce VF - Footnote: larg
  • 4. Frederic Battelli, M.D.! " 9 - First Defibrillation , University of Gen firmed the observations of Vulpian, Ludwig, McWilliam by showing that a small amount o ctricity delivered across the chest can induce
  • 5. Work in the 1st Half o he 20th Century in th West
  • 6. am Kouwenhoven,PhD; Orthello Langwo nd Donald Hooker, MD – Johns Hopkins Univ 33 k and Countershock They studied both AC and DC shocks, and oncluded that AC shock was more effectiv erminating VF. In 1933, the Johns Hopk roup succeeded in terminating VF in a d when they accidently applied a second sh hence the term countershock.
  • 7. University - Cleveland  Carl Wiggers M.D.   1883 - 1963 J. Am. Heart Journal. 1940;20:399-412. J WR. Am J Physiol. 1940;128:500-5. ked on mechanisms of fibrillation and rillation. Described the induction of VF thro oncept
  • 8. ude S. Beck M.D.! 1894-1971 ! rsity Hospitals of Cleveland! 1949 - 1st Known Defibrillation of VF in Humans s operating on a 14 year-old boy. During closure of d, the pulse stopped, upon which the wound was re c massage was performed for the next 45 minutes med VF, and seeing no other option, Beck delivered but it failed to defibrillate the VF. After intracard
  • 9. Work in the Soviet Union
  • 10. enhoven, Langworthy, and Hooker 1932 – 33 Shock and ountershock rs 1883 – 1963 the concept of the vulnerable period 947 - First Known Defibrillation of VF in Humans k in the Soviet Union tern 1878 – 1968 - Director of The Institute of Physio the 2nd Medical University in Moscow, Professor Stern ormer trainee and then associate of Prévost and Batte d studied VF and defibrillation. She assigned the study rhythmogenesis and defibrillation as a PhD project to N urvich, a young physician member of her laboratory.
  • 11. Lina Stern M.D.! 1878 - 1968! or of The Institute of Physiology at the 2nd Medic rsity in Moscow, Professor Stern, was a former tra en associate of Prévost and Battelli, and had stud efibrillation. She assigned the study of
  • 12. 1905 – 1981! Institute of Physiology, ! 2nd Medical Univ, Moscow ! h became a key figure, and made mental discoveries in the fields of tion and defibrillation. In 1939, in assical work, Gurvich and Yuniev ed using a single discharge from a or to defibrillate VF, thus effectively cing DC shock for defibrillation Courtesy of M. Bogushe es. Until then, an AC shock was , and the being ped as was most effective way to defibrillate VF. Parenthet West, AC shock continued to be used exclusively until the . During his doctoral research (1933 - 9), Gurvich found ck at a frequency of 50 - 500 Hz could not be tolerated, an ads to VF. But he also showed that a single discharge from or with a DC shock terminated VF. Another advantage of
  • 13. lation that was based on using biphasic defibrillation wavefor reported using rounded biphasic waveforms, produced by a or and inductor, for defibrillation as early as 1939, although a was unaware of the superiority of this waveform over the hasic waveform. What is more important, these advances allo h to propose his “excitatory” theory of defibrillation, which su rect excitation of the myocardium is what prevents further ation of fibrillatory waves without preventing resumption of n hythm. He also introduced the mother reentrant circuit conce tion for the development and sustainability of ventricular tion. 2, Gurvich designed the first commercially available transthor lator in the world. The application of this device was describe etail in the Soviet Ministry of Health resuscitation guidelines ed first in 1952. The guidelines required every operating room hospital to have a defibrillator. This first DC defibrillator, ID-1 monophasic waveform which, 10 years later, became known a waveform.
  • 14. ID-1-VEI, 1952 st DC llator for al transthoracic ernal use, n the USSR in Paddles and re stored in the te metal box is leaning on vice. The llator in this was given to bert Hosler, an ate of Dr. Claude by Dr. Vladimir sky during Dr. Courtesy of Dittrick Medical History C
  • 15. Bohumil Peleška, M.D. Prague, Czechoslovakia 57, he reported on both direct and thoracic use of DC shock for defibrillatio oses. He constructed his own DC defibrill fying Gurvich’s design by including an in the inductor, and is credited with oving the procedure of cardioversion by g lower voltage and describing the effect hock. m, the work on DC current cardioversion rillation and biphasic defibrillation
  • 16. during open heart surgery Vishnevskii and Tsukerman patient had AF for 3 years, and the restoration of nor sinus rhythm took place during mitral valve surgery. 60 First reported transthoracic DC cardiove of atrial arrhythmias (20 patients) Vishnevskii and Tsukerman
  • 17. Work in the Western World After 1950
  • 18. Paul Zoll, M.D. 1911 - 1999 h Israel Hospital and rvard Medical School, Boston 1956 First ransthoracic fibrillation in mans using AC current
  • 19. isiere al, Paris Bloc animateur 1953 first automatic external acemaker efibrillator Courtesy of Fred Zacouto, ble to sense a slow pulse from an infrared device attached to an ear nd provide transcutaneous pacing until spontaneous return of hear At the same time, it could detect VF from an ECG, and deliver an A
  • 20. M,D. 9 - Transthoracic AC ardioversion of VT the remotest idea how to use one. A host o questions needed prompt answers: Was the painful? Was the anesthesia required? W an appropriate voltage setting to reverse ventricular tachycardia? If the shock faile many additional ones could be delivered? D electric discharge traumatize the heart or i the nervous system? Could it burn the skin there any hazards for bystanders? Was it explosive for the patients receiving oxygen head was migrainous from the avalanche o
  • 21. Barouh V. Berkovits 1926 - 2012 Courtesy of Heart Rhythm Foundation n Prague, Czechoslovakia; educated at Charles University ated to Israel in 1949, and then in 1956 to the United Sta he became Senior Engineer at the Brooklyn Polytechnic ute. In 1959, he joined the American Optical Corporation a or of Cardiovascular Research, a post which he held until
  • 22. M.D. rouh Berkovitz (2/6/61) M.D. to Barouh Berkovit (4/10/61)
  • 23. arvard School of Public alth Peter Bent Brigham Hospital! Boston the previous work with DC lation in humans by Gurvich in the Union and Peleška in Czechoslovakia, as the adverse effects of AC shock, in own et al. reported their success in ating VT with a single DC monophasic n nine patients. He subsequently n to expand DC cardioversion to fully convert both atrial and ular arrhythmias using the hasic DC shock. Courtesy’ Low Cardiovascula Research Founda
  • 24. arvard School of Public alth Peter Bent Brigham Hospital! Boston s credited In the Western world nitiating the modern era of version. He was the first in the o combine defibrillation and version with portability and safety. also is credited with coining the cardioversion” for delivery of a onized shock during an hmia other than VF. Courtesy’ Low Cardiovascula Research Founda
  • 25. Bernard Lown Barouh Berkovits Naum Gurvich Lina Stern Jean-Louis Prévost Edmé Félix Vulpian
  • 26. All defibrillators with Biphasic waveform 1st DC cardioversion " of supraventricular arrhythmias 1st commercial " DC defibrillatior DC defibrillation in clinical practice llation uced 9 1st Bip Defibri 1st experiments with DC defibrillation 1952 1959 1962 1970 199
  • 27. Royal Victoria Hospital, Belfast, UK ity to “reverse death” with a simple arkedly improved inhospital cardiac utcomes. Yet, the highest mortality was lace mainly outside the hospital. Mobile Coronary Care Unit an operation on January 1, 1966 Battery Operated Portable Defibrillator ial assembly of the defibrillator for this mobile unit, consisting of t s, a static inverter, and an American Optical defibrillator, weighed pticism that out of hospital defibrillation would not be feasible, an
  • 28. London 1970–1980 of the work of Peleška , r improvements in the of the defibrillator were A key stage in the pment of the mobile ive care unit came with sign of a small, portable llator. Using the ure capacitor developed U.S. National autics and Space nistration, Pantridge, er with John Anderson, a dical engineer, developed Defibrillator, battery oper type 180c, with type 182
  • 29. Defibrillator great passion, Pantridge advocated his appro king early defibrillation readily available where. His ideas first became widely accepte S. Subsequently, Anderson together with Jen y, another physician from the Belfast group, w g the first to develop the semi-automatic and matic portable external defibrillator in the lat and early 80‘s. With continued development, ble defibrillator was gradually taken from th sive use by doctors, and given to paramedics, en and finally to the members of the public. T ts of this approach are more than obvious tod
  • 30. The Implantable rdioverter-Defibrillat
  • 31. Michel irowski, M.D. (Mordechai Frydman) 1925 - 1990 Sinai Hospital of Baltimore
  • 32. Warsaw L’vov Kiev Rostov Krasnodar 1939 – Warsaw 1941 – Kiev 1939 – L’vov 1941 – Rostov Andi 1942 – Andijan
  • 33. Morton Mower (left) ! ors wski and er with first otype of an matic rillator. 1970 - !
  • 34. ctrical Engineer and Associate Professo omedical Engineering at the University ouri in Columbia was the first to implant cessfully use a cardiac defibrillator in a d y simultaneously and independently, John Schuder also beg n an implantable defibrillator. While contemplating future pr an AHA meeting in 1969, and having been steeped in “… oracic defibrillation, knowledge about waveform efficacy, and ation of circuit design and component problems, it was almo ately apparent that the automatic implantable defibrillator w project. I decided to go home and do it.” r abandoned work on the implantable defibrillator, instead rating on optimization of shocking waveforms. Schuder’s ed contributions laid the foundation for the miniature, low e
  • 35. pp 637-9
  • 36. Arthur Moss’ er to the editor : Dr. Lown’s editorial
  • 37. Mirowski’s Response Dr. Lown’s editorial
  • 38. r. Lown’s response to the lette
  • 39. THANKS TO: Ivan Cakulev; Igor Efimov .A. Jennifer Adgey; Sidney Alexander; Raghava rasingham; Barouh Berkovits; Amy Beeman; B nsky; Ian Clement; Leonard Dreifus; Edwin Duf n Fisher; Gregory Flaker; Bruce Fye; John Ged ris Gorbunov; Robert J. Hall; M. Stephen Heilm ymond Ideker; James Jude; Alan Kadish; Claud ey; Richard Kerber; G. Guy Knickerbocker; Ber osowsky; Peter Kowey; Mark Kroll; Samuel Lev rnard Lown; Frank Marcus; Morton Mower; Jo ler; Michael Orlov; Phillip Podrid; Christine Rie emy Ruskin; Ariella Rosengard; Vikas Saini; Jo uder; Richard Verrier; Hein Wellens; Roger Win