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LETTER TO THE EDITOR

Cardioversion During Closed Chest Robotic Surgery: Relevance of Pad Position

Nottingham University Hospital NHS Trust; City Hospital Campus; Hucknall Road NG5 1PB; Nottinghamshire, United Kingdom; ptewari123{at}yahoo.co.in

To the Editor:

A recent case report (1) described difficult defibrillation in a patient undergoing robotic-assisted coronary artery surgery. Success of cardioversion depends on the correct amount of current delivered through the critical mass of heart, which in turn depends on proper energy selection and reducing Transthoracic Impedence (TTI). The authors mentioned various means of reducing TTI, including elimination of the air or carbon dioxide induced pneumothorax. One additional point not mentioned is the need to reduce the distance between the electrodes.

We recommend applying the electrode pads as shown in Figure 1. This position, anterioposterior application, provides the shortest distance between the pads, does not interfere with the surgical field, and directs the current through the critical mass of left ventricle (2). Also, with the electrodes in this position, the amount of air or carbon dioxide pneumothorax between the pads is decreased.

View larger version (9K): [in this window] [in a new window]   Figure 1. Graphic depiction of pad application. The anterior pads can be applied on either of the positions A or B on the side of sternum. Posterior pad is applied between medial border of scapula and the spine on the right side at position C. Shaded area shows carbon dioxide pneuomothorax.

REFERENCES

1. Hatton KW, Kilinski LC, Chandrashekar R, Schell RM. Multiple failed external defibrillation attempts during robot-assisted internal mammary harvest for myocardial revascularization. Anesth Analg 2006;103:1113–14[Abstract/Free Full Text]
2. Botto GL, Politi A, Bonini W, Broffoni T, Bonatti R. External cardioversion of atrial fibrillation: role of paddle position on technical efficacy and energy requirements. Heart 1999;82:726–30[Abstract/Free Full Text]

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