High defibrillation threshold at cardioverter defibrillator implantation under amiodarone treatment: Favorable effects of D,L-sotalol

A 57-year-old man with primary dilated cardiomyopathy and obesity received an implantable cardioverter defibrillator because of recurrent, poorly tolerated ventricular tachycardia despite continuous treatment with amiodarone. When the device was implanted, assessment of the ability to defibrillate induced ventricular fibrillation showed high energy requirements, with a lack of conventional safety margin between energies effective at defibrillation testing and maximal device output. Treatment with oral amiodarone was withdrawn and substituted with oral sotalol. A repeat defibrillation test, performed 54 days after amiodarone withdrawal and during D,L-sotalol treatment, showed a reduction in defibrillation energy requirements. In view of this experience, replacement of amiodarone treatment with an alternate class Ill agent (D,L-sotalol or other agents, if available) can be considered as a possible option in case of high defibrillation threshold at the time of the implantation in a patient receiving continuous amiodarone treatment.