Beyond Standard Shocks: A Critical Review of Alternative Defibrillation Strategies in Refractory Ventricular Fibrillation

Background: Refractory ventricular fibrillation (RVF) is a life-threatening condition characterized by the persistence of ventricular fibrillation despite multiple defibrillation attempts. It represents a critical challenge in out-of-hospital cardiac arrest management, with poor survival outcomes and limited guidance from current resuscitation guidelines. In recent years, alternative defibrillation strategies (ADSs), including dual sequential external defibrillation (DSED) and vector change defibrillation (VCD), have emerged as potential interventions to improve defibrillation success and patient outcomes. However, their clinical utility remains debated due to heterogeneous evidence and limited high-quality data. Methods: This narrative review explores the current landscape of ADSs in patients with RVF. MEDLINE, Google Scholar, the World Health Organization, LitCovid NLM, EMBASE, CINAHL Plus, and the Cochrane Library were examined from their inception to April 2025. Results: The available literature is dominated by retrospective studies and case series, with only one randomized controlled trial (DOSE-VF). This trial demonstrated improved survival to hospital discharge with ADSs compared to standard defibrillation. DSED was associated with higher rates of return of spontaneous circulation and favorable neurological outcomes. However, subsequent meta-analyses have produced inconsistent results, largely due to the heterogeneity of the included studies. The absence of sex-, gender-, and ethnicity-specific analyses further limits the generalizability of the findings. In addition, practical barriers, such as equipment availability, pose significant challenges to implementation. Conclusions: ADSs represent a promising yet still-evolving approach to the management of RVF, with DSED showing the most consistent signal of benefit. Further high-quality research is required to enhance generalizability and generate more definitive, high-level evidence.