Lung procurement from a donor with a long-term left ventricular assist device.

(DFT) testing the patient’s ICD was unsuccessful in multiple configurations and an azygous coil was placed. His DFT was at the maximum output of his device (41 J), which was achieved after 7 inductions of VF. Six months later, he received 5 ICD shocks before presenting to an outside hospital. Interrogation of his ICD showed sustained VF, which was untreated because the device had exhausted therapy (Figure 1). He was transferred 200 miles to our center. He failed to convert despite 5 additional attempts with various ICD coil and polarity configurations. A biphasic 200-J external shock also failed (Zoll Defibrillator, Chelmsford, MA). Two sets of pads were placed, attached to 2 external defibrillators. One set of pads was placed in an anterior–posterior arrangement, and the other to the right of the sternum and over the apex. The buttons were pushed simultaneously by one person, delivering a total energy of 400 J. He successfully converted to a ventricular paced rhythm. Over the ensuing months, he presented twice with VF unresponsive to ICD shocks. The first time he was defibrillated with a 200-J external shock. The second time he again required simultaneous defibrillation with 2 sets of pads. He subsequently underwent ablation of triggering premature ventricular complexes, and has been free of VF since that time. Treatment of VF in LVAD patients presents unique opportunities in light of the hemodynamic support provided by the LVAD. Dual defibrillation is a safe, effective treatment for refractory atrial fibrillation. However, stacked shocks have not been examined in ventricular rhythms. To achieve a 400-J external shock, 2 defibrillators and 2 sets of pads must be used simultaneously. Perhaps for this reason, dual defibrillation has not been examined in unstable patients with ventricular arrhythmias who fail 200-J defibrillation. It is possible that nearly simultaneous, rather than truly simultaneous, shocks were delivered. However, if this had occurred, the length of the shock waveform would have resulted in overlapping waves and caused an additive effect similar to our goal. Although the small number of patients with LVADs limits the ability to rigorously study the double defibrillation approach to refractory VF, it should certainly be attempted if other means fail.