a shocking past: a walk through generations of defibrillation development

1466 IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. 61, NO. 5, MAY 2014

A Shocking Past: A Walk Through Generations ofDefibrillation Development

Sarah R. Gutbrod and Igor R. Efimov∗, Member, IEEE

Abstract—Defibrillation is one of the most successful and widelyrecognized applications of electrotherapy. Yet the historical roadto its first successful application in a patient and the innovativeadaptation to an implantable device is marred with unexpectedturns, political and personal setbacks, and public and scientificcondemnation at each new idea. Driven by dedicated scientistsand ever-advancing creative applications of new technologies, fromelectrocardiography to high density mapping and computationalsimulations, the field of defibrillation persevered and continued toevolve to the life-saving tool it is today. In addition to critical tech-nological advances, the history of defibrillation is also marked bythe plasticity of the theory of defibrillation. The advancing theoriesof success have propelled the campaign for reducing the defibril-lation energy requirement, instilling hope in the development of apainless and harmless electrical defibrillation strategy.

Index Terms—Defibrillation, electrical stimulation, history ofmedicine.

I. INTRODUCTION

THE history and future of defibrillation offers a uniqueperspective on the evolution of a critical medical ther-

apy and illustrates the far-reaching influences that continue toshape its development. The evolution of defibrillation has beencircuitous, often stalled and at other times experienced greatleaps of advancement. Over several centuries it has traversedlong geographical distances, circumvented political and culturalroadblocks, and faced bold scientific and public opposition. De-spite the many external setbacks, new advances in technologyhave persistently driven defibrillation from the naıve applica-tion of newfound electricity by amateurs in the 18th centuryto the powerful, life-saving, clinical tool it is now in the 21stcentury. This path navigates many seemingly unrelated fieldsof science and technology, including zoology, physics, powerand circuitry engineering, physiology, cardiology, and com-puter modeling. Dogged key individuals, who dedicated theircareers to reversing sudden cardiac death and understanding thebiophysical interaction between the heart and applied electricfields, propelled the study of defibrillation across generations

Manuscript received October 1, 2013; revised January 7, 2014; acceptedJanuary 13, 2014. Date of publication January 16, 2014; date of current versionApril 17, 2014. Asterisk indicates corresponding author.

S. R. Gutbrod is with the Department of Biomedical Engineering, Wash-ington University in St. Louis, St. Louis, MO 63108 USA (e-mail: [email protected]).

∗I. R. Efimov is with the Department of Biomedical Engineering, WashingtonUniversity in St. Louis, St. Louis, MO 63108 USA (e-mail: [email protected]).

Color versions of one or more of the figures in this paper are available onlineat http://ieeexplore.ieee.org.

Digital Object Identifier 10.1109/TBME.2014.2301035

and continents. Many reviews detail the history of fibrilla-tion and defibrillation [1]–[6]; this review, however, will focusspecifically on the critical role biomedical engineering technol-ogy has played in shaping the optimization of delivery, reductionin shock strength, and the ever-evolving, working hypothesis ofthe mechanism of success and failure of defibrillation.

II. PATH TO RESTORING LIFE BEGINS

A. Early Naıve Applications of Electrotherapy

The powerful therapeutic potential of electricity applied tothe human body was recognized long before the language ofphysics and physiology were formed to explain the observedphenomena. In ancient times, electric fish were used in bothSouth American and Greek societies for remedial purposes [7].The therapeutic use of the fish’s natural abilities is shrouded inmyth; the efficacy of shocks delivered in such an uncontrolledmanner is no longer known. The first significant technologyto impact the development of defibrillation was the invention ofinstrumentation that could produce and store electricity and thenprovide controlled electrical discharges, known as a capacitor.These initial devices included Otto Guericke’s sphere and theLeyden jar shown in Fig. 1(a) and (b) [8]–[11]. As these deviceswere relatively mobile and available to the fascinated public, itdid not take long for them to be used to deliver electrotherapyin the hospitals and in the field. By the late 18th century, thereare multiple reports detailing the application of external shocksas a form of resuscitation; the first of which was a 1788 humanresuscitation case reported by Kite [12] (see Fig. 2).

Unfortunately, theoretical support for the use of electricalstimulation lagged behind anecdotal evidence of success andthere was widespread unregulated use of electrotherapy withouta mechanistic foundation by both amateurs and hospitals alike.The first reports of electrical stimulators in hospital settings dateback to 1767 and 1777 at London St. Bartholomew and King’shospitals, respectively [13]. Electric shocks of up to ∼50 000 Vwere naively applied with a wide range of electrode placementsand materials. Purely empirical animal experiments conductedduring this time period did not add much enlightenment to whenand why electrical stimulation worked [14]. The combined lackof an understanding of electrical conduction within the car-diac tissue and the lack of an existing method for monitoringthe electrical activity of the heart significantly limited theseexperiments. Important mechanistic strides were made in therelated field of animal electricity and muscle contraction, ledby Galvani [15], but anecdotal success appeared sufficient forelectrotherapy in humans. In 1792, the first clinical recommen-dations for resuscitation were published [10], which were based

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GUTBROD AND EFIMOV: SHOCKING PAST: A WALK THROUGH GENERATIONS OF DEFIBRILLATION DEVELOPMENT 1467

Fig. 1. Milestone historical advances in electricity. (a) Otto von Guericke’s sphere to create charge [8], (b) the Leyden jar used to store charge [9], and(c) Alessandro Volta’s depiction of a voltaic pile, which would lead to modern batteries in implantable devices [11].

Fig. 2. Early devices for electric resuscitation of the “apparently dead.”(a) Charles Kite’s 1788 implementation of a defibrillation system with theLeyden jar and two electrodes [12]. (b) Mr. Fell’s portable defibrillation device,based on a Leyden Jar, and the accompanying guidelines of how to resuscitatepersons apparently dead [10].

on the experience of the Lancashire Society for Recovery ofApparently Dead. These recommendations included “inflationof patient’s lungs and application of electric shock to the chest inthe area of the heart” [see Fig. 2(b)]. By 1802, the use of electricresuscitation was endorsed by the Royal Humane Society [16].

The invention of the voltaic battery by Alessandro Volta(Italy), based on the analysis of John Hunter’s elegant dissec-tions of the electric organ of the electric fish [17], providedanother critical technological advance [11] [see Fig. 1(c)]. Theproblem of how to provide an adequate and compact powersource to the discharge device will remain a significant aspectof the design of all future developments of defibrillators, in-cluding those used today. With the first reliable steady sourceof current, electrotherapists could now travel easily with their

device and carrying such a device, e.g., in a cane, became morepopular among amateurs and physicians in the early 1800s.

B. Dark Days for Electrotherapy

However within a century, fascination with electrotherapywould drastically fall in public opinion to such a degree that allinterest in researching defibrillation would be wiped out fromboth lay and scientific communities. The new negative outlookon electrotherapy emerged following the widespread unedu-cated application of electricity to all manners of disease withoutrageous claims of miraculous results. The credibility of de-fibrillation suffered greatly because of close ties with raisingthe dead and restoring life, which acquired widespread noto-riety through popular literature. The public easily misunder-stood and misappropriated defibrillation to sorcery and quack-ery. John Shoemaker (United States) wrote the following onelectrotherapy, “No remedy of equal value has been so misused;so much exaggerated as to intrinsic worth; or so greatly decriedas worthless. . . the mechanism for operating electric force hasimproved much more rapidly than the intelligent use of it” [18].Ostentatious experiments such as John Aldini’s, whose experi-ments on hanged or guillotined criminals in England and Francemany deemed grotesque, further damaged the public opinion ofelectrotherapy [1]. When defibrillation came back into favor acentury later it would no longer focus on portable field appli-cations but instead would be confined to the ac wall outlets ofresearch laboratories and operating rooms. It would take anothercentury to bring the therapy back to public access. Eventuallydefibrillation is put back to the hands of the layperson, deliveredin the community as well as the hospital, with the distributionof Automated External Defibrillators in the late 1990s and early2000s. In 1999, the American Red Cross included defibrillatortraining as part of the standard CPR training course to increaseawareness on how to use the publicly accessible devices. Thesuccess of these devices relies on sophisticated detection algo-rithms that do not require medical training to identify fibrillationand deliver shocks only when safe and appropriate.

Although the appeal of electrotherapy declined, research in-vestigating the condition underlying cardiac death continued.In the second half of the 19th century, several key European


physiologists including Carl Ludwig (Germany), JohnMacWilliam (Great Britain), and Edme Vulpian (France) pub-lished fundamental observations on the onset and progressionof arrhythmias, including electrically induced (“faradization”)ventricular and atrial fibrillation. In 1899, physiologists Prevostand Batelli at the University of Geneva reported the first appli-cation of experimental defibrillation in a footnote of a paper onventricular fibrillation (VF) initiation by faradization. Prevostand Batelli used a capacitor discharge in the range of 2400–4800 V, delivered along a vector from the small intestine to themouth, to defibrillate a canine in faradization-induced VF [19].Regrettably this important observation, which was essentially arediscovery of defibrillation, went largely unnoticed for a num-ber of years due to poor presentation and perhaps, lack of unmetclinical need. Defibrillation only gained relevance when elec-tricity companies like Consolidated Edison and Bell TelephoneLaboratories offered funding for research on electrocution toprotect their workers [20], and doctors, whose patients were ac-cidentally overdosed on anesthetics, began looking into how torevive them [21].

C. Drawing Geographical Lines in the Development Path

At this point in history, the development of defibrillation di-verges geographically. For many years there are simultaneous,isolated developmental paths in the Western world and the So-viet Union, both of which contribute to the current state ofdefibrillation.

In America, William Kouwenhoven and physicians at JohnsHopkins University conducted experiments delivering ac toelectrodes in direct contact with the canine myocardium to in-duce fibrillation. An accidental second shock arrested the fib-rillation and reproduced Prevost and Batelli’s successful defib-rillation results. The American group then systematically in-vestigated the effects of the strength (2200 V, 0.4–8 A) andduration (0.1–5 s) of applying 60-Hz ac to canine hearts in fib-rillation [22]. These experiments were conducted with transtho-racic and epicardial electrodes, and concluded that transthoracicdefibrillation required five times the current as epicardial defib-rillation. They also tested the effects of the size of the electrodeson defibrillation success. Another American group, Ferris et al.,compared 60-Hz ac, 25-Hz ac and dc and found that 60 Hzrequired the least current [23]. However, they were testing longduration shocks of >1 s. They hypothesized that there was nodifference in defibrillation threshold (DFT) for shorter shocks,without performing the study. This may be why ac shocks per-sisted much longer in the West. In the 1930s, Carl Wiggersfrom Western Reserve University in Cleveland further investi-gated the causes of defibrillation failure, which still occurred in40%–50% of the previous studies. He meticulously describedthe compounding effects of VF-induced ischemia on the abilityto defibrillate successfully. Wiggers also observed that a verybrief and strong countershock was most successful and intro-duced an idea he called serial defibrillation, which delivered aseries of 3–7 weaker alternating current shocks with a 1–2 sinterval between shocks [24]. Ultimately Wiggers’ work led tothe first clinical success.

In Russia, we owe a great deal of development to Lina Shternand Naum Gurvich. Lina Shtern had a direct connection tothe Prevost and Batelli experiments, as she formerly studieddefibrillation under Prevost’s direction in Geneva. When shemoved her lab to Russia, she primarily focused on her favoritesubject—neuroscience. However, following a 1933 report fromJohns Hopkins University, which provided compelling supportfor resuscitation and reignited interest in public, scientific, andindustrial communities, she assigned a project on defibrillationefficacy of traditional ac stimulation to her new graduate studentNaum Gurvich. In 1939, Gurvich and Yunyev published resultson the superiority of monophasic dc shocks over the traditionalac, delivering shocks in a range from 2000 to 6000 V [25], [26].DC provided safety advantages as well as a decreased risk ofreinduction. The Russian group became the first to notice ev-idence of more pronounced shock-induced mechanical stun-ning after exposure to ac compared to dc [27]. Gurvich alsointroduced more complexity into the capacitor circuit used todeliver the transthoracic shock by adding an in-line inductor(see Fig. 3) [25], [26]. This design was the first significant stepin waveform optimization to reduce DFT and cardiac damageassociated with strong electric shocks. Improving the circuit inthis way dispersed the energy better in time, decreasing the peakcurrent, and lengthening the duration.

D. Drawing Geographical Lines in the Development Path

Although defibrillation in the research setting was gainingtraction, doctors did not successfully apply defibrillation in apatient until 1946 by Claude Beck and his team from WesternReserve University Hospital [28]. When conducting a thoracicsurgical procedure on a 14-year-old boy, the patient’s heart be-gan to fibrillate. Since Beck already had direct access to theheart, he applied 110 V, 1.5 A ac shock, after using an ECGto confirm VF. He did not include the duration of the shock inhis case report. Upon delivery of the second shock, the heartreturned to a fast but regular rhythm and the patient made afull recovery. In the 1950s, Claude Beck produced a compellingeducational film, which provided detailed instruction of intraop-erative open-chest resuscitation and presented personal accountsof a dozen of patients saved by defibrillation. In this film, he alsoexpressed the need for wide public education and deploymentof resuscitation.

In 1956, Paul Zoll expanded the successful clinical use of de-fibrillation to include transthoracic application on humans with710 V, 15 A ac for 0.15 s [29]. The widespread use of electrocar-diography provided a method to confirm VF as well as a way toconfirm the successful defibrillation. The data associated withthe repeated successes would promote the public perception ofdefibrillation as a viable therapeutic option instead of repeatingthe earlier 18th and 19th century failed attempts for legitimacyand acceptance.

III. ERA OF OPTIMIZATION

With a proven clinical application, the question began tochange from “Can we defibrillate VF?” to “How can we de-fibrillate VF better?” Defibrillation research entered an era of


Fig. 3. Naum Gurvich’s impulse defibrillator. (a) Capacitor–inductor circuit implemented to create a biphasic dc discharge, (b) the various waveforms used inanimal experiments, and (c) the transthoracic biphasic defibrillator built in 1962. All panels adapted from [27].

incremental optimizations of the waveform delivered. Americanresearchers finally caught up to the Soviet research, concludingthat dc was superior to ac shock. Bernard Lown led the in-vestigations in the United States, 25 years after Gurvich [26],reaching the same conclusion that using an inductor to attenuatethe capacitor discharge was necessary to limit myocardial dam-age [30]. He proposed the Lown waveform, an underdamped im-pulse with duration of 2.5 ms for clinical use to reduce rise timeand pulse duration. Lown also published his ideal circuit com-ponents: a capacitance of 16 μF and an inductance of 100 mHto allow for widespread replication of his results [31]. BohumilPeleska (Czechoslovakia) also conducted rigorous instrumenta-tion evaluations to minimize peak voltage and current as wellas minimize total energy [32]. These two goals remain the prin-ciple aim of current defibrillation development. John Schuderfrom the University of Missouri at Columbia introduced the ideaof short-circuiting the capacitor after a time delay to remove thelow voltage decreasing exponential tail after observing that itcould reinduce fibrillation [33]. The truncated exponential pulsewaveform gained popularity because the relatively simple cir-cuit lent itself to implementation of a fully implantable, auto-mated, catheter-based defibrillator conceived independently byboth Schuder et al. [34] and Mirowski et al. [35] in 1970 andsuccessfully implanted in the first human patient by Mirowskiet al. [36]. Ironically, the idea of an implantable automatic defib-rillator was greeted with a great degree of skepticism by Lownand Axelrod [37].

A. Theory Shapes Therapy

Concurrent with the timeline of the implementation of de-fibrillation, there is a parallel account of the evolution of the

mechanistic underpinning of successful defibrillation, alsodriven by key advances in technology and physiology. Defibril-lation is not a therapy that was born out of a strong biophysicalfoundation. The mechanistic studies trailed far behind the em-pirical clinical use of the tool. Many recent studies still try toclarify the interaction between applied shocks and arrhythmicpropagation.

The original motivation behind applying a shock across theheart was to incapacitate or stun the tissue. The temporary elec-trical stunning hypothetically allowed the heart time to “reset.”Gurvich was the first to propose that the shock actually stim-ulated the heart [27] but even this description did not offer alot of guidance for designing an optimal shock delivery system.Traditionally, defibrillator design has been driven by the needto simplify and minimize the circuitry necessary to provide arelatively safe shock that can achieve high shock strength abovethe DFT. Scientists did not begin to investigate what influencesthe DFT or to propose hypotheses to improve defibrillation ef-ficacy based on biophysical mechanisms until the mid 1960s,when Gurvich proposed the use of a biphasic waveform [38].Based on these observations, he developed the first transtho-racic biphasic defibrillator, which became the standard of carein Soviet Union in early 1970s, as shown in Fig. 3 [27].

Early 20th century experiments at Washington University inSaint Louis led Garrey to postulate that the inducibility and con-tinuation of VF was related to the mass of myocardium [39]. In1975, Douglas Zipes presented experimental evidence in sup-port for this theory as it applied to chemical defibrillation mech-anisms. By selectively depolarizing regions of tissue chemically,Zipes demonstrated that a critical mass of myocardium couldmaintain VF and lead to defibrillation failure [40]. Therefore,a “critical mass” theory was proposed that a shock simply had


to capture enough tissue to succeed. Alternatively, the theoryof upper limit of vulnerability [41], [42] supported the ideathat regions of weak potential gradient were critical to pro-viding a source for maintaining a large enough area for earlyactivation and the continuation of fibrillation. Several groupsdesigned defibrillation schemes and new lead configurations totarget areas of low potential gradient after shock delivery toreach the critical mass necessary for success [43]–[45]. Both ofthese theories supported the claim that high voltage shocks werenecessary for success. However, as evidence emerged to sup-port a delicate balance between defibrillation and myocardialdamage, scientist began to look for new ways to decrease theenergy required for success. Many studies have been conductedusing a diverse set of parameters to measure myocardial dam-age; some of which have had contradictory conclusions aboutwhether clinical shocks are innocuous. However, shock strengthis also positively correlated with the perception of pain, whichcan be severe for defibrillation shocks. The potential risk ofmyocardial damage and the pain, both physical and psychologi-cal, associated with implantable devices has driven research forlower energy defibrillation schemes.

In the 1980s and 1990s, empirical studies began to emerge,supporting the idea that Gurvich’s biphasic damped sinewaveform and other biphasic waveforms were superior overmonophasic pulses [46]–[48]. As high-power amplifier designsimproved, new shape waveforms could be easily implemented inresearch environments; rectilinear, triangular, trapezoidal, andtriphasic waveforms were tested [46], [47], [49]–[51]. Scien-tists began to probe the response to applied shocks at variousscales, especially with computational studies. Using resistor–capacitor simulations to model the cardiac cell membrane’s re-sponse to applied shocks, several groups demonstrated a shapedependence on efficient delivery of energy [52]–[54], whichwas supported by empirical observations. Based on these pre-dictions the truncated biphasic exponential waveform deliversenergy inefficiently due to the time constant of the cell andan ascending trapezoidal waveform has the lowest DFT. Yearslater, this waveform would also be shown to cause less damageindependently of the decrease in efficacy [52].

B. Revolution in Scientific Methodology Drives the Evolutionof Defibrillation

Still, further advances required a more in-depth understand-ing of the mechanism of defibrillation success and failure. For-tunately, two new scientific research methodologies were in-troduced that revolutionized the field’s ability to study cardiacstimulation mechanistically with high resolution. The first wasa computational approach called the bidomain model [55]; thesecond was an experimental technique using potentiometric flu-orescent voltage-sensitive dyes embedded in the membrane [56]called optical mapping [57]. Both of these tools were integral insupporting a new hypothesis that emerged describing the trans-membrane response to applied stimulation. This new theoreticalhypothesis, called the virtual electrode polarization (VEP) the-ory, transformed the direction of defibrillation research. VEP isreviewed in detail elsewhere [58], [59], [60]. Briefly, the external

application of an electric field induces regional polarizationsknown as the virtual cathodes and virtual anodes, often op-posing the regions of structural or functional heterogeneity. Arepresentative example is shown in Fig. 4 [61]. As a secondaryeffect, new wavefronts and phase singularities can be initiatedfrom these regions that can lead to defibrillation failure [62].The theoretical foundation of this idea was formulated by Sobieet al., which they termed “generalized activating function” [63].The landmark implication of this new theory was that defibril-lation efficacy was not only dependent on the properties of theelectric field but also on the intrinsic properties of the tissuestructure and conductivity in a predictable fashion.

One such computational study that was vital to the accurateprediction of a VEP tissue response to externally applied cur-rents was conducted by Sepulveda, Roth, and Wikswo almost adecade before Sobie generalized the VEP idea to 3-D. The au-thors published critical simulations on how unequal anisotropyin tissue conduction results in a complex spatial dependenceof potential distribution in response to large currents, whichinfluences the location and, equally importantly, the shape ofthe virtual electrodes [64]. Experiments and simulations con-ducted in the 1990s and early 2000s, explained the position ofshock-induced phase singularities and the chirality of shock-induced reentrant circuits [62], [65], [66], [67]. New studiesemerged demonstrating shock polarity dependence [68], [69]and optimal timing sequences targeting vulnerable phases of anarrhythmia [70]–[72]. In contrast to earlier studies, these newoptimizations could be mechanistically explained.

IV. PROMISE OF FUTURE ADVANCES

Current research again focuses on optimizing serial defib-rillation, delivering a temporal sequence of low-energy shocksbased on the frequency of the arrhythmia, with great reduc-tions in DFT [73]–[76]. High-frequency ac strategies are alsobeing revisited [77]. All of these new strategies aim to develop apainless and damage-free solution to restoring a regular rhythmwithout losing efficacy. Due to the diversity of arrhythmia prop-erties, and the clear indication that DFT is dependent on intrinsictissue conditions, many of these research approaches look to de-velop patient-specific energy delivery schemes.

Mirroring the history of defibrillation, the clinical field has notbeen quick to adopt new defibrillation strategies. Even small butpowerful increments such as switching to a biphasic waveform,faced opposition to incorporation into clinical devices [78]. Newmethodologies that require a substantial shift in strategy alsorequire significant redesigns of circuitry and therefore, the re-duction in voltage and energy must be equally considerablewithout loss of safety to merit redesigns. That is not to saythat there has been no progression in implantable devices sincethe switch to biphasic waveforms. Clinical improvements havefocused on sensing algorithms, programmability, battery minia-turization, and lead development [79] with great success. Shockdelivery in both internal and external defibrillation has recentlybeen improved by incorporating impedance compensation intothe shape algorithm [80], [81]. Although simple in concept,the idea of altering the waveform to provide more consistent


Fig. 4. Representative example of shock-induced VEP pattern in optical mapping rabbit experiment. (a) Explanted rabbit heart with infarct, (b) VEP patternfor a 5 V/cm shock to the LV, (c) optical action potentials during shocks in panel b (red trace) and panel D (blue trace) overlaid on control action potentials, and(d) VEP pattern for a 5 V/cm shock to the RV (opposite polarity of panel b). All panels adapted from [61].

current delivery was the first step in patient-tailored defibril-lation strategies and provides hope that with future research,a convincing patient-specific defibrillation strategy will be de-veloped and implemented. Studies are also being conducted innovel energy strategies including a renewable or self-servingdevice and leadless defibrillation.

Efforts of many generations have carried us to our current useof defibrillation, and they have simultaneously demonstrated thetenacity of the field to overcome setbacks and the creativity nec-essary to drive development. Continuous new advancements inmonitoring and data acquisition techniques have shaped and willcontinue to shape the resolution and scale at which scientists canprobe the state of cardiac tissue. These advances will continueto drive the mechanistic understanding of defibrillation to newdepths and propel new innovations in the implementation of de-fibrillation. In the words of Vice-President Hubert Humphrey,who was responsible for eventually bridging the geopoliticaldivide between Soviet and American defibrillation groups, re-search on defibrillation can be described as “at least a partialconquest of death. . .[it is] the oldest category in the world—butone which commands our newest efforts” [82].

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Sarah R. Gutbrod received the B.S. degree inbiomedical engineering from Johns Hopkins Univer-sity in Baltimore, MD, USA, in 2009. She is currentlyworking toward the Ph.D. degree in biomedical engi-neering from Washington University in St. Louis, StLouis, MO, USA.

Her research interests include signal-processingtechniques to study the spatiotemporal dynamics ofatrial and ventricular arrhythmias.

Igor R. Efimov (M’98) received the M.Sc. and Ph.D.degrees from Moscow Institute of Physics and Tech-nology in 1986 and 1992, respectively.

He completed his postdoctoral training at the Uni-versity of Pittsburgh in 1994. Then he served on thefaculty at the Cleveland Clinic (1994–2000), CaseWestern Reserve University (2000–2004), and Wash-ington University in Saint Louis (2004–present). In2008, he founded a company Cardialen, which aimsto develop low energy pain-free electrotherapy forcardiac arrhythmias.

a shocking past: a walk through generations of defibrillation development

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