No abstract

To examine the relationship between the defibrillation threshold and the strength of shocks that induce ventricular fibrillation during the vulnerable period, we determined the defibrillation threshold in 22 open-chest dogs using epicardial defibrillation electrodes with the cathode at the ventricular apex and the anode at the right atrium. We also determined whether there was an upper limit of shock strength that induces fibrillation in the vulnerable period by giving shocks of various energy through these same electrodes during the repolarization phase of paced rhythm. The above determinations were also made with the anode at the ventricular apex and the cathode at the right atrium in eight of the dogs and with the cathode at the ventricular apex and the anode at the left atrium in another eight of the dogs. In all dogs for all electrode configurations, there was an upper limit to the shock strength that induced ventricular fibrillation during the vulnerable period. Depending on the electrode combination, this upper limit of ventricular vulnerability either was not significantly different from or was slightly lower than the defibrillation threshold. The correlation coefficient between the two was highly significant for all three electrode configurations. These results support the hypothesis that successful defibrillation with epicardial electrodes requires a shock strength that reaches or exceeds the upper limit of ventricular vulnerability and that shocks slightly lower than the defibrillation threshold fail because they reinitiate ventricular fibrillation by stimulating portions of the myocardium during their vulnerable period. Circulation 73, No. 5, 1022-1028, 1986 UNTIL RECENTLY, the accepted hypothesis for the mechanism of ventricular defibrillation was based on studies indicating that a critical mass of myocardium is necessary for the maintenance of fibrillation. ' brillation stimulus will always occur when some portion of the myocardium is repolarizing. A stimulus can induce fibrillation if given during the vulnerable period of repolarization.5 These findings suggest the hypothesis that unsuccessful epicardial shocks of at least 1 J halt fibrillation and then reinitiate it by stimulating myocardium that is in the vulnerable period of repolarization. The hypothesis implies that there is an upper limit of strength above which a shock will not induce fibrillation during the vulnerable peridd and that this upper limit of ventricular vulnerability should correlate with the defibrillation threshold. The purpose of this study is to test these implications. MethodsTwenty-two mongrel dogs (mean weight + SD, 18.9 + 3.4 kg) were anesthetized with pentobarbital (30 to 35 mg/kg)6' 7 and succinylcholine (1 mg/kg). Each was intubated with a cuffed endotracheal tube and ventilated with 30% to 60% oxygen through a Harvard respirator. Ringer's lactate was continuously infused and supplemented with potassium chloride, sodium bicarbonate, and calcium chloride when indicated. Via a separate intravenous line, pent...

In selected patients, resection of the head of the pancreas achieves long-term pain improvement in over 90% of cases. The early development of diabetes mellitus is infrequent, but over longer follow-up periods it reaches prevalence rates similar to those described in patients who have not undergone resection. Weight gain in this group was superior to that previously reported for our patients who underwent "standard Whipple" operation for chronic pancreatitis.

The introduction of laparoscopic techniques for the management of biliary stone disease has expanded the therapeutic choices for surgeons confronted with choledocholithiasis. As new strategies emerge, the treatment of cholelithiasis and choledocholithiasis remains controversial. This paper discusses the options available for the treatment of common bile duct stones. Diagnostic and therapeutic algorithms are proposed. The treatment of these patients must be individualized, taking into consideration the condition of the patient, associated diseases, secondary complications of the gallstones, and the surgical expertise and resources of the institution.