Changes in cerebral oxygen uptake and cerebral electrical activity during defibrillation threshold testing

Abstract

During cardioverter-defibrillator implantation, repeated episodes of ventricular fibrillation (VF) are induced. Insufficient recovery of oxygen metabolism may cause neurological sequelae. In this prospective clinical study, we monitored the electroencephalogram (EEG), middle cerebral artery blood flow velocity (Vmca), and jugular bulb oxygen saturation and estimated cerebral oxygen uptake. Results were analyzed for tests requiring a single shock (Group 1) and tests requiring multiple shocks for defibrillation (Group 2). Immediately after the induction of VF, the mean arterial blood pressure (MAP) decreased to < 30 mm Hg, and the Vmca decreased to 0 cm/s. The EEG showed ischemic changes consisting of a decrease of fast, and an increase of slow, activity, progressively declining to isoelectricity within 11 +/- 2 s. After defibrillation, the MAP recovered rapidly regardless of the arrest duration (3 +/- 2 s). The EEG recovered within 17 +/- 9 and 22 +/- 12 s, respectively, for Groups 1 and 2 (P < 0.05) and did not reveal ischemic changes until induction of a subsequent arrest. In Group 1, the cerebral oxygen uptake increased to 191% +/- 31% of baseline values and returned to baseline in 16 +/- 7 s, whereas in Group 2, it increased to 229% +/- 38% (P < 0.05), followed by a significant decrease to less than baseline (85% +/- 18%; P < 0.005), and returned to baseline simultaneously with the Vmca. We conclude that, although restoration to normal of the EEG and cerebral oxygen uptake coincide in short arrests, EEG recovery underestimates metabolic recovery after tests requiring multiple shocks.

Implications: Short test intervals have been mentioned as a cause of neurological sequelae after cardioverter-defibrillator implantation. This study demonstrates that although all systemic hemodynamic variables and the electrocardiogram may have returned to normal, cerebral oxygen uptake may still be depressed for a considerable time, especially after tests requiring two or more shocks.