Cardioversion Of Atrial Fibrillation Research Articles

Optimizing Energy Delivery in Cardioversion: A Randomized PROTOCOLENERGYTrial of 2 Different Algorithms in Patients With Atrial Fibrillation

BackgroundThe optimal energy protocol for direct current cardioversion of atrial fibrillation remains uncertain. The Rational vs Maximum Fixed Energy (PROTOCOLENERGY) randomized trial compared a stepwise escalating energy algorithm (RaA, 150 J, 360 J, and 360 J) with a maximum fixed energy algorithm (MfA, 3 x 360 J). MethodsIn a 1:1 randomized trial, 300 patients with atrial fibrillation received biphasic discharges via hand-held paddles in the anterolateral position. Primary endpoints were sinus rhythm at 1 minute and neurologic complications at 2 hours; secondary endpoints included sinus rhythm at 2 hours, skin changes and chest discomfort at 24 hours. ResultsSinus rhythm at 1 minute was achieved in 92.7% of RaA and 94.0% of MfA patients (P = 0.643) and maintained at 2 hours in 91.3% of both groups. There were no neurologic complications. The protocols differed significantly after the first shock (72.7% in RaA vs 83.3% in MfA; P = 0.026) but equalized after subsequent maximum energy shocks. Fewer RaA patients experienced skin redness compared with MfA patients (19.3% vs 36.0%, P = 0.001), which was attributed to the lower initial 150-J shock and total energy delivered (r = 0.243, P < 0.0001). Chest discomfort at 24 hours was not different between groups (P = 0.378). In multivariate analysis, lower body mass index (P < 0.001, cutoff 29 to 34 kg/m2) was associated with cardioversion success after the initial 150-J shock. ConclusionsBoth protocols showed similar high cumulative efficacy, but RaA with the initial 150-J shock proved to be beneficial in patients with body mass index less than 29 to 34 kg/m2 because of fewer skin complications. Clinical Trial Registration NoNCT05148923

Cavutilide (Refralon) for pharmacological cardioversion of early recurrence atrial fibrillation and flutter in blanking period after pulmonary veins isolation

Objective. Evaluate efficacy and safety of cavutilide (Refralon) for pharmacological cardioversion in patients with recurrent atrial fibrillation and flutter (AF/AFL), in 90days blanking period of catheter ablation.Materials and methods. included 56 patients: 46 patients with recurrent paroxysmal AF/AFL and 10 patients with recurrent persistent AF/AFL. In 45 patients (80.3%), sinus rhythm (SR) restoration was performed within 7 days from the moment of catheter ablation. Intraoperative confirmation of pulmonary vein (PV) isolation was noted in 85.7% cases (n=48). After excluding contraindications, cavutilide was administrated in the intensive care unit according to a 4-stage protocol (5 µg/kg – 5 µg/kg-10 µg/ kg – 10 µg/kg). Effectiveness of pharmacological cardioversion was assessed as the fact of restoring SR and the fact of preservation of SR 24 hours after cavutilide administration. Safety points – QT prolongation, ventricular arrhythmogenic effects, pauses and bradyarrhythmias.Results. The overall effectiveness of cavutilide among all included patients reached 98.2% (n=55), and preservation of SR 24 hours after cavutilide administration was observed in 94.5% (n=53) patients. All the patients with recurrent persistent AF/AFL successfully restored and maintained SR 24 hours after cavutilide administration 100% (n=10). In patients with recurrent paroxysmal AF/AFL restoration of SR observed in 97.8% (n=45) and preservation of SR after 24 hours – in 93.4% (n=43), respectively. The effectiveness of cavutilide did not depend on the results of the catheter ablation. Recurrences of AF/AFL after SR restoration were more common in patients without successful PV isolation. QT prolongation &gt;500ms observed in 8.9% (n=5) of cases, including 1 case of self-terminating torsade de pointes, managed by MgSO4 infusion. Bradyarrhythmias that did not require urgent therapy were noted in 10.7% (n=6) of cases.Conclusion. Pharmacological cardioversion with Cavutilide (Refralon) is highly effective and safe method of SR restoration in patients with recurrent AF/AFL in 90days blanking period after catheter ablation.

Improvement in atrial functional and ventricular functional tricuspid regurgitation following catheter ablation or cardioversion of atrial fibrillation

Abstract Background The majority of cases of significant tricuspid regurgitation (TR) are secondary to tricuspid annular dilation and leaflet tethering in the context of RV remodeling due to pressure or volume overload, as seen in patients with pulmonary hypertension (primary or secondary to left-sided heart disease) or dilated cardiomyopathies. Secondary TR induced by tricuspid valve annular dilatation secondary to right atrial dilatation is referred to as atrial functional TR, while secondary TR caused by RV remodeling is referred to as ventricular functional TR. In current guidelines, GDMT (Guideline-Directed Medical Therapy) is effective for secondary TR attributable to HF with reduced LVEF. Normal sinus rhythm should be restored for secondary TR caused by AF-related annular dilatation. In patients with ventricular functional TR, however, AF may also accompany the clinical condition. It is unknown whether restoring sinus rhythm will reduce tricuspid regurgitation in these patients. Purpose The objective of this study was to investigate the degree of tricuspid regurgitation change in patients with atrial and ventricular functional tricuspid regurgitation after sinus rhythm restoration. Methods A retrospective cohort study of patients undergoing AF ablation and cardioversion at a single center between 2019 and 2023 was performed. Patients with at least grade 1 TR on echocardiography and a baseline echocardiogram and a follow-up echocardiogram after ablation were included. A-FTR and V-FTR were defined according to the latest ACC/AHA guidelines. According to the latest guidelines, patients with mild to severe FTR were classified as A-FTR if they had atrial fibrillation, left ventricular ejection fraction &amp;gt;60%, pulmonary artery systolic pressure (PASP) &amp;lt;50 mm Hg, no left-sided valve disease, and normal-appearing tricuspid leaflets. FTR patients who did not meet at least one of these three criteria were defined as ventricular FTR (V-FTR). Results A total of 88 patients were enrolled. The prevalence of A-FTR in our cohort was 62% (53 patients), and 38% of the patients were in the V-FTR group. There was no significant difference between the A-FTR and V-FTR groups regarding age, gender, and NYHA class. 21 of the patients underwent DCCV, and 67 underwent catheter ablation. The prevalence of severe FTR was similar (%17 in A-FTR vs. %8,6 in V-FTR, p= 0.205). There was no difference in preintervention TR grade between the two groups. TR severity improved significantly from baseline to follow-up in both V-FTR and A-FTR patients. These outcomes were observed in patients who underwent both DCCV and catheter ablation. Conclusion The degree of tricuspid regurgitation is reduced with sinus rhythm restoration in patients with both ventricular functional and atrial functional TR.Changes in TR severity with interventionGraph of changes in severity of TR

Ventricular arrhythmias associated with electrical cardioversion for atrial fibrillation, a multicenter study

Abstract Background Cases of ventricular arrhythmias (VAs) associated with QT prolongation after electrical cardioversion (ECV) for atrial fibrillation have been reported. Purpose To assess the incidence, timing and clinical characteristics of patients with VAs post-ECV for AF. Methods This is a multicenter international study. Seventy-seven centers were approached. Data was received from 13 worldwide centers. VAs included were torsades de pointes (TdP), NSPVT&amp;gt;3 beats or SCD within 7 days of ECV. The total number of ECVs performed at each center during the time period for which data was sent was provided. Results VAs occurred after ECV at an estimated incidence of 0.16%, range 0- 1.3% at different centers. Twenty-three patients with VAs were identified from 8 European centers, from 2008-2023, of whom 18 (78%) were from 2019-2023. There were 13 (56.5%) females, aged 71+11 years, mean LVEF=45+9%. AF duration prior to ECV was 72+65 days. Antiarrhythmic drugs (AADs) used prior to ECV were amiodarone in 9 (39%), sotalol in 4 (17%), class Ic in 3 (13%), beta blockers in 19 (83%), CCB in 1(4%) and digoxin in 4 (17%) patients. Five (22%) patients received QT prolonging drugs other then AADs. Baseline hypokalemia &amp;lt;3.5mmol/L was seen in 3(13%) patients (range 2.9-3.4mmol/L). ECV was elective, urgent and emergent in 10 (43%), 12 (52%) and 1(4%) patient, respectively. The arrhythmias documented were TdP in 17(74%), NSPVT &amp;gt;3 beats in 5(22%) and 1(4%) SCD. Arrhythmia documentation was available in 19 (83%) patients. Baseline mean HR pre-ECV was 115+30bpm and QT 388+61ms, both significantly differed from post-ECV mean HR which was 58+11bpm and QT 469+63ms, P&amp;lt;0.0001. Arrhythmia occurred 45+54 hours post-ECV, median 28.5 hours, range 5 minutes- 10 days. Figure 1 demonstrates an example of serial ECG changes from baseline to TdP occurrence. An arrhythmic storm occurred in 11 (48%) patients. Arrhythmia reoccurred in 9 (39%) patients, mean 13.25 + 15 (range 0.5-48) hours after the index event. The arrhythmias which reoccurred were TdP in 5 (22%), VF in 2 (9%), NSPVT in 1 (4%) and monomorphic VT in 1 (4%) patient. Acute therapy with DCCV was needed in 10 (43%) patients. AADs were discontinued in 16 patients. IV electrolytes were helpful in arrhythmia control in 16 (89%) of 18 patients, IV isoproterenol was helpful in 1 (25%) of 4 patients, temporary pacing with arrhythmia control in 2(40%) of 5 patients in whom it was used. ICD was implanted in 7 patients and a pacemaker in 4 others. Two (8.7%) patients expired, 1 died suddenly at home 12 hours after ECV and 1 suffered from acute heart failure and fatal TdP 72 hours after ECV while hospitalized. Conclusion VAs associated with QT prolongation after ECV for AF occur mainly 24-48 hours after ECV and may reoccur. Prolonged monitoring prior to discharge should be considered for prevention of fatal outcomes in patients with any evidence of QT prolongation following ECV.Figure 1

Comparative effectiveness of different management strategies for left atrial appendage thrombus in patients on optimal NOAC therapy

Abstract Background Left atrial appendage (LAA) thrombus is the primary cause of stroke and systemic embolism in atrial fibrillation (AF). Novel oral anticoagulants (NOACs) effectively reduce the prevalence of LAA thrombosis and stroke risk. Nonetheless, there is no clear advice for patients with a NOAC-resistant thrombus, necessitating individualized decision-making without strong support of the current guidelines. Aims To analyze patients diagnosed with an LAA thrombus despite adequate NOAC therapy and to compare the efficacy of various therapeutic strategies in achieving thrombus resolution. Methods We retrospectively analyzed patients scheduled for cardioversion or catheter ablation of AF between 2014 and 2023 who were diagnosed with LAA thrombus despite being on optimal NOAC therapy. These patients underwent follow-up transesophageal echocardiography (TEE) or cardiac CT angiography. Changes in treatment modalities were divided into four groups: transition to an alternative NOAC, switch to a vitamin K antagonist (VKA), the addition of an antiplatelet agent, or the deliberate maintenance of the current treatment. Results We analyzed the data of 90 patients comprising 103 cycles of treatment. The patients were either on rivaroxaban (41%), apixaban (32%), dabigatran (15%) or on edoxaban (12%) at the time of the initial TEE. A change to a different NOAC was observed in 37% of cases, transition to a VKA in 22%, supplementation with antiplatelet therapy in 16%, while deliberate absence of treatment modification in 25% of cases. Subsequent follow-up TEE (or CT angiography in a minority of cases) was performed at a median of 68 [43 – 94] days from the baseline evaluation. Successful thrombus resolution was achieved in 72% of cases. Evaluation of therapeutic strategies revealed that any modification of treatment was three times more effective than deliberate no change in treatment; thrombus resolution was observed in 60 (81%) vs. 17 (59%) cases (OR 3.03 [1.18 - 7.75], p = 0.021). Nevertheless, no particular strategy demonstrated superior efficacy over others. Conclusions Resolution of LAA thrombus in patients already on adequate NOAC treatment may require a revision of the prior anticoagulation strategy; however, none of the commonly employed strategies appears to exhibit distinct superiority over the rest.

Clinical and instrumental factors associated with sinus rhythm maintenance following direct current cardioversion of late persistent non-valvular atrial fibrillation at 6-months follow-up

Abstract Purpose To study the clinical and instrumental factors, associated with sinus rhythm (SR) maintenance following direct current cardioversion (DCCV) in patients with late persistent non-valvular atrial fibrillation (AF) at 6-months follow-up. Methods The cohort single-center study analyzed clinical and instrumental data from 59 late persistent AF patients (with duration of its episode ≥90 days [up to 12 months]), who underwent an elective DCCV. At 6-months follow-up, 32 (54 %%) patients succeeded to maintain SR, in contrast to 27 (46 %) patients with a failure to its maintenance. Results The univariate logistic regression analysis revealed, that the absence of heart failure (HF) stage C (i.e., the presence of its stage B), the higher left ventricular ejection fraction (LVEF) (by transthoracic echocardiography [TTE]), left atrial appendage flow velocity (LAAFV) &amp;gt;40 cm/s and the freedom from left atrial spontaneous echo contrast (LASEC) (by transesophageal echocardiography), ‒ all were associated with the higher chance to maintain SR at 6-months follow-up (Figure). At the same time, the higher baseline left atrial dimension (LAD) and more advanced pulmonary hypertension (PH) (by TTE) were associated with the failure of its maintenance to be more probable (Figure). At multivariate analysis, the following predictors of SR maintenance after DCCV at 6-months follow-up were identified: higher LVEF (OR 1,07 (95 % CI 1,01-1,13); р=0,021); LAAFV &amp;gt;40 cm/s (OR 4,33 (95 % CI 1,06-17,78); р=0,042), and less advanced PH (OR 0,24 (95% CI 0,06-0,93); р=0,038). Conclusion Better LV systolic function, LAAFV &amp;gt;40 cm/s and less advanced PH were the predictors of SR maintenance following DCCV in patients with late persistent (with duration of its episode ≥90 days) non-valvular AF at 6-months follow-up.

Objective randomised blinded investigation of therapeutic ablation versus cardioversion for persistent atrial fibrillation- outcomes of the feasibility

Abstract Background Patients with persistent atrial fibrillation (pers.AF) commonly undergo catheter ablation (CA) for symptom relief and improved quality of life(QoL). However,the benefits of CA compared to DC cardioversion (DCCV) or medical therapy lack substantial evidence from blinded randomized trials. Purpose Conducting such a large-scale trial presents substantial challenges in terms of recruitment, maintaining blinding, and implementation.To address this, we conducted a pilot study prior to a definitive larger study. Methods This feasibility trial is a single-centre, prospective, randomised, double-blinded placebo control study. Patients with early pers AF (&amp;lt;2 years) eligible for pulmonary vein isolation (PVI) or DCCV were enrolled. Twenty patients were recruited, accounting for 10% of the proposed larger trial based on power calculation. The intervention arm (PVI + DCCV) and placebo arm (Placebo + DCCV) were randomised in a 1:1 manner after ultrasound-guided vascular access with local anaesthetic and deep sedation (Midazolam + opioid). All procedures were performed as day cases on uninterrupted oral anticoagulation. Phrenic nerve pacing was performed in the Placebo group, mimicking lab interactions and fluoroscopy system movements. Implantable loop monitors were inserted immediately after heparin reversal and groin sheath removal. A 6-week(wk) blanking period was observed post-procedure. Blinding was assessed using Bang's blinding index (BI) for both patients and medical staff and a successful blinding is considered BI between -0.2 to 0.2. Health-related quality of life (HRQoL) was evaluated using SF12, EQ5D-5L, and AF PROMS. The study obtained ethical approval (REC ref 19/LO/0775),adhered to the principles of the Declaration of Helsinki,and obtained written informed consent from all participants. Results A remarkable 92% of patients approached, expressed a willingness to participate in the study. Procedure time and time to discharge were similar between groups. The study successfully achieved blinding among the patients at day0 (BI = PVI-0.2 vs placebo- 0) and was maintained throughout the 6-wk and 3M follow-up, among the patients as well as clinical staff. HRQoL improved in the active group in terms of AF PROMS [Improved difference from baseline PVI 23 (±22); vs Placebo 2 (±10), p=&amp;lt;0.001 and SF-12 mental component (MCS) at 12M (PVI 11.8 (±11) vs placebo 8.54(±11.5), p= 0.017). Over a follow up period of 12M, there was a trend towards greater recurrence (60% vs 30%; p=0.07) and repeat procedures (70% vs 40%; p=0.4) in the placebo group. Conclusion: Performing a blinded placebo-controlled interventional study to assess the efficacy of PVI is feasible and high recruitment rates are achievable. CA appears to result in better arrhythmic and QoL outcomes;a full-scale follow-on study will assess the true efficacy of CA in patients with early pers.AF and allow consideration of whether there is a role for DCCV in many patients.

Stroke after implantable cardioverter-defibrillator shocks in patients with heart failure

Abstract Introduction In patients with atrial fibrillation (AF), an elevated risk of stroke has been demonstrated in the first days after successful electrical cardioversion of AF. Shock therapies delivered by implantable cardioverter-defibrillators (ICD) often result in termination of AF, potentially increasing the risk of stroke in those patients. However, the association between ICD shocks and the risk of stroke in patients with AF is unknown. Purpose To define whether there is any temporal association between ICD shocks and strokes in remotely monitored patients with heart failure (HF) and AF. Methods The clinical data of patients enrolled in the remote monitoring (RM) programme after implantation of an ICD were obtained from the single-centre COMMIT-HF registry. The data regarding the occurrence of the first stroke after inclusion to the registry were obtained (based on the International Classification of Diseases codes I63-I64) from the healthcare provider. The RM data of all patients were obtained from the investigator-initiated and -maintained registry of RM, which summarizes all major findings in remotely monitored patients in our department. Each patient with a stroke had the RM history evaluated for the period of the prior 30 days, with emphasis on the last 10 days preceding stroke. Results During the period between 2011 and 2020, 1,299 patients with detailed clinical characteristics were enrolled in the RM programme, and their clinical data are summarized in Table 1.There were 33.4% patients with AF at baseline, and AF de novo was identified during follow-up in further 14.0% of patients. Among patients without and with AF at baseline, respectively 30.9% and 34.1% received any ICD shocks during follow-up (p=NS). In 38.2% of patients without AF at baseline, who developed de novo AF, at least one shock occurred. The median follow-up was 4.4 years, and the incidence of stroke was 45 (3.5%) in the studied population, with a rate of stroke of 2.8% (25/865) in patients without AF at baseline and 4.6% (20/434) in patients with AF (p=NS), as presented in Figure 1. The median (Q1-Q3) time from ICD implantation to stroke was 1.5 (0.8-2.5) years. Strokes occurring less than 10 days from ICD shock were noted in only two patients (0.5% of patients with any ICD shock) and both occurred within 24 hours from the shock. In the first case, the device appropriately terminated ventricular tachycardia which degenerated to ventricular fibrillation after antitachycardia pacing, and in the second case, a shock therapy was delivered due to VF in a 59-year-old male with HF and concomitant paroxysmal AF, who was on chronic treatment with warfarin. Conclusions Our findings indicate an overall low risk of stroke associated with ICD shocks, both in patients with and without AF.Baseline population characteristicsAnalysed population flowchart

Efficacy of smart device heart rhythm monitoring to detect spontaneous conversion to sinus rhythm in patients scheduled for electric cardioversion of atrial fibrillation. Kardiover Study

Abstract Introduction the management of patients with recent-onset atrial fibrillation (AF) is to achieve sinus rhythm (SR) by electrical or pharmacological cardioversion (CV). However, frequently SR is spontaneously restored, making scheduled admission and/or transesophageal echocardiogram (TEE) unnecessary and therefore causing misutilization of healthcare resources. Emerging medical technology has allowed for monitoring of heart rhythm abnormalities. Objective A prospective multicenter study was designed to evaluate the diagnostic ability of a smart device ECG monitor to detect spontaneous conversion to SR in AF patients, preventing unnecessary admission and providing an earlier management. Methods A prospective multicenter study was designed including patients with first diagnosed, paroxysmal or persistent AF scheduled for ambulatory electrical cardioversion in cardiology departments of 7 hospitals of Spain. Patients were asked to submit ECG recordings to a central Corelab daily, twice a day and whenever they present symptoms, until cardioversion (spontaneous or scheduled) and a week afterwards. Whenever a spontaneous conversion to SR was detected, investigators were contacted to confirm SR and abort admission, likewise when AF recurrence after cardioversion was detected. Patients’ satisfaction was evaluated using a test for perceived utility and value, convenience, and accessibility. Results A total of 62 patients were enrolled (age 62±10 years). Baseline characteristics of the study population are described in the Table. Fifteen patients (24%) did not undergo CV as they showed spontaneous conversion to SR. Among 47 patients admitted for CV, it was successful in 41 (87%). One patient aborted CV because of atrial thrombus on TEE. During follow up after conversion to SR (spontaneous or electrical), recurrences of AF occurred in 20 of 56 patients (36%) correctly detected by the devices. At the end of the follow-up 41 of 56 patients (73%) remained in SR. Due to the early detection of spontaneous conversion to SR, a total of 15 admissions and 9 TEE were prevented and these resources used for other patients. Adherence was high with a rate of ECG transmission over 80% in 56 patients (90%). Perceived satisfaction was also high with an overall punctuation of 9 over 10 in the patient’s feedback test. Conclusion Digital devices for heart rhythm monitoring can optimize the management of AF patients scheduled for CV, avoiding unnecessary admissions and providing a more rational use of healthcare resources.Table

Dual vs Single Cardioversion of Atrial Fibrillation in Patients With Obesity

Atrial fibrillation and obesity are common, and both are increasing in prevalence. Obesity is associated with failure of cardioversion of atrial fibrillation using a standard single set of defibrillator pads, even at high output. To compare the efficacy and safety of dual direct-current cardioversion (DCCV) using 2 sets of pads, with each pair simultaneously delivering 200 J, with traditional single 200-J DCCV using 1 set of pads in patients with obesity and atrial fibrillation. This was a prospective, investigator-initiated, patient-blinded, randomized clinical trial spanning 3 years from August 2020 to 2023. As a multicenter trial, the setting included 3 sites in Louisiana. Eligibility criteria included body mass index (BMI) of 35 or higher (calculated as weight in kilograms divided by height in meters squared), age 18 years or older, and planned nonemergent electrical cardioversion for atrial fibrillation. Patients who met inclusion criteria were randomized 1:1. Exclusions occurred due to spontaneous cardioversion, instability, thrombus, or BMI below threshold. Dual DCCV vs single DCCV. Return to sinus rhythm, regardless of duration, immediately after the first cardioversion attempt of atrial fibrillation, adverse cardiovascular events, and chest discomfort after the procedure. Of 2079 sequential patients undergoing cardioversion, 276 met inclusion criteria and were approached for participation. Of these, 210 participants were randomized 1:1. After exclusions, 200 patients (median [IQR] age, 67.6 [60.1-72.4] years; 127 male [63.5%]) completed the study. The mean (SD) BMI was 41.2 (6.5). Cardioversion was successful more often with dual DCCV compared with single DCCV (97 of 99 patients [98%] vs 87 of 101 patients [86%]; P = .002). Dual cardioversion predicted success (odds ratio, 6.7; 95% CI, 3.3-13.6; P = .01). Patients in the single cardioversion cohort whose first attempt failed underwent dual cardioversion with all subsequent attempts (up to 3 total), all of which were successful: 12 of 14 after second cardioversion and 2 of 14 after third cardioversion. There was no difference in the rating of postprocedure chest discomfort (median in both groups = 0 of 10; P = .40). There were no cardiovascular complications. In patients with obesity (BMI ≥35) undergoing electrical cardioversion for atrial fibrillation, dual DCCV results in greater cardioversion success compared with single DCCV, without any increase in complications or patient discomfort. ClinicalTrials.gov Identifier: NCT04539158.

Antiarrhythmic preferences and outcomes post DC cardioversion for atrial fibrillation, an Australian rural perspective.

Direct current cardioversion (DCCV) remains one of the recommended management strategies for symptomatic atrial fibrillation (AF). Antiarrhythmic drugs (AAD) are prescribed post procedure to maintain sinus rhythm (SR). Limited literature exists on the AAD prescribing practices and their efficacy, post-DCCV in rural Australia. The primary aim was to determine the preferred AAD post-DCCV and the factors affecting AAD prescribing practices. The secondary aim was to assess the efficacy of the AAD in maintaining SR. A retrospective observational audit of patients with non-valvular AF who underwent successful elective DCCV for symptomatic AF, during 2015-2020 at a regional hospital in New South Wales (NSW) (Dubbo Base Hospital). Patients were followed up for a duration of 12 months post-DCCV. 233 patients underwent successful DCCV during the study duration. Amiodarone was the preferred AAD of choice post-DCCV followed by sotalol and flecainide, respectively (36.5% vs. 27.8% vs. 1.3%). 35.2% patients were not prescribed AAD. Amiodarone and sotalol had similar but modest efficacies and neither were superior to no AAD, in maintaining SR 12 months post-DCCV (AF recurrence rate 61.5% vs. 68.2% vs. 71.6% respectively, p = 0.37). Antecedent cerebrovascular accident (CVA), pulmonary disease, smoking, prior treatment with digoxin, diuretics and left ventricular (LV) dysfunction were factors that influenced AAD prescribing practices. The study demonstrates equal efficacies of amiodarone, sotalol and no AAD in maintaining SR 12 months post-DCCV. Prescribing practices post-DCCV at Dubbo Base Hospital differ from observed national trends and guidelines. AAD prescription requires a multifaceted approach with a key consideration to prioritise safety over efficacy, being mindful of challenges in delivering optimal healthcare in a rural setting.

Predictive value of procalcitonin for early atrial fibrillation recurrence post-cardioversion at the emergency department

Abstract Funding Acknowledgements None. Background Cardioversion of acute atrial fibrillation (AF) in the emergency department (ED) has been shown to be a safe and effective treatment strategy that allows direct discharge from the ED thereby reducing avoidable hospitalizations. However, early AF recurrence may present a limitation, thereby necessitating the identification of predictors of AF recurrence post-ED cardioversion. Methods 117 patients with acute AF (first detected or recurrent paroxysmal) of &amp;lt;48 hours duration, managed by pharmacological (PC) or electrical cardioversion (EC) at the ED were prospectively enrolled upon ED presentation. Clinical, echocardiography, routine laboratory and NT-proBNP and procalcitonin assessments were performed upon presentation. We investigated the utility of inflammatory biomarker procalcitonin as predictor of acute success of cardioversion and early AF recurrence up to 30 days post-cardioversion. Results Study group consisted of 50% males, of mean(±SD) age 67±12years, 41% with first episode and 59% with paroxysmal AF, left ventricular ejection fraction (LVEF) 54±7% and left atrial diameter (LAD) 39±5mm. Median (IQR) creatinine, NTproBNP, hsTroponinT and procalcitonin were: 0.9(0.8-1.1)mg/dl, 517(137-1454)pg/ml, 11.8(6.7-19)pg/ml and 0.03(0.02-0.05)pg/ml, respectively. Of the total group, 59% had paroxysmal and 41% first-episode AF, whereas 70% received EC and 30% PC. Acute cardioversion success was achieved in 81%, while sinus rhythm was maintained in 84% at 8 days and in 86% in 30 days post-cardioversion. In univariate regression analysis, lower procalcitonin levels were associated with higher acute cardioversion success [HR, 95%CI: 0.208(0.050-0.863), p=0.031] as well as lower risk of AF recurrence at 8 days [HR, 95%CI: 0.142(0.028-0.730), p=0.019] and 30 days post-cardioversion [HR, 95%CI: 0.190(0.044-0.818), p=0.026]. Predictive value of procalcitonin was maintained after adjustment for LAD in multivariate regression (all p&amp;lt;0.05). Conclusions In acute AF managed by cardioversion in the ED, procalcitonin, a marker of inflammatory stimulation, may predict acute non-response as well as early AF recurrence up to 30 days post-cardioversion.

Antazoline for pharmacologic cardioversion of atrial fibrillation: teaching an old drug new tricks.

Antazoline for pharmacologic cardioversion of atrial fibrillation: teaching an old drug new tricks.

Remote rhythm monitoring using a photoplethysmography smartphone application after cardioversion for atrial fibrillation.

Direct current cardioversion (DCCV) is a commonly utilized rhythm control technique for atrial fibrillation. Follow-up typically comprises a hospital visit for 12-lead electrocardiogram (ECG) two weeks post-DCCV. We report the feasibility, costs, and environmental benefit of remote photoplethysmography (PPG) monitoring as an alternative. We retrospectively analysed DCCV cases at our centre from May 2020 to October 2022. Patients were stratified into those with remote PPG follow-up and those with traditional 12-lead ECG follow-up. Monitoring type was decided by the specialist nurse performing the DCCV at the time of the procedure after discussing with the patient and offering them both options if appropriate. Outcomes included the proportion of patients who underwent PPG monitoring, patient compliance and experience, and cost, travel, and environmental impact. Four hundred sixteen patients underwent 461 acutely successful DCCV procedures. Two hundred forty-six underwent PPG follow-up whilst 214 underwent ECG follow-up. Patient compliance was high (PPG 89.4% vs. ECG 89.8%; P > 0.999) and the majority of PPG users (90%) found the app easy to use. Sinus rhythm was maintained in 71.1% (PPG) and 64.7% (ECG) of patients (P = 0.161). Twenty-nine (11.8%) PPG patients subsequently required an ECG either due to non-compliance, technical failure, or inconclusive PPG readings. Despite this, mean healthcare costs (£47.91 vs. £135 per patient; P < 0.001) and median cost to the patient (£0 vs. £5.97; P < 0.001) were lower with PPG. Median travel time per patient (0 vs. 44 min; P < 0.001) and CO2 emissions (0 vs. 3.59 kg; P < 0.001) were also lower with PPG. No safety issues were identified. Remote PPG monitoring is a viable method of assessing for arrhythmia recurrence post-DCCV. This approach may save patients significant travel time, reduce environmental CO2 emission, and be cost saving in a publicly-funded healthcare system.

Strategy to achieve mitral isthmus flutter ablation by radiofrequency: the SHERIFF plan

BackgroundAchieving mitral isthmus (MI) block can be challenging. This prospective study evaluated the feasibility and efficacy of a systematic strategy comprising three consecutive steps to achieve MI block.MethodsTwenty consecutive patients (mean (± SD) age 71.4 ± 6.98 years) undergoing ablation of perimitral atrial tachycardia (PMAT) between December 2019 and November 2021 were included. MI was ablated using a systematic strategy comprising up to three consecutive steps: (1) endocardial ablation from the superolateral mitral annulus to the left pulmonary veins; (2) additional epicardial ablation in the coronary sinus (CS) on the opposite side of the endocardial line; and (3) ablation of early activation sites between endocardial and epicardial breakthroughs.ResultsMI block was successfully achieved in 19/20 patients (95%). MI block after endocardial radiofrequency ablation alone (step 1) was observed in 7/20 patients (35%). Epicardial ablation within the CS on the other side of the endocardial line (step 2) resulted in bidirectional MI block in three more patients. Endocardial ablation of epicardial conduction was successful for nine additional patients (95% success). At the 12-month follow-up, five patients (25%) displayed recurrence of arrhythmia after a single procedure. One patient had electrical cardioversion for persistent atrial fibrillation. Four patients had a redo procedure for left atrial flutter and only two patients (10%) had conduction across the MI and showed recurrence of PMAT. No complications occurred.ConclusionsThe three-step ablation strategy resulted in a high rate of acute and durable MI block. PMAT recurrence after a single procedure was 10% at 1-year follow-up.Graphical The three-step ablation strategy had a success rate of bidirectional MI conduction block of 95%. Recurrence of PMAT after a single procedure was 10% at 1-year follow-up.

Orally Inhaled Flecainide for Conversion of Atrial Fibrillation to Sinus Rhythm: INSTANT Phase 2 Trial

BackgroundINSTANT (INhalation of flecainide to convert recent-onset SympTomatic Atrial fibrillatioN to sinus rhyThm) was a multicenter, open-label, single-arm study of flecainide acetate oral inhalation solution (FlecIH) for acute conversion of recent-onset (≤48 hours) symptomatic atrial fibrillation (AF) to sinus rhythm. ObjectivesThis study investigated the efficacy and safety in 98 patients receiving a single dose of FlecIH delivered via oral inhalation. MethodsPatients self-administered FlecIH over 8 minutes in a supervised medical setting using a breath-actuated nebulizer and were continuously monitored for 90 minutes using a 12-lead Holter. ResultsMean age was 60.5 years, mean body mass index was 27.0 kg/m2, and 34.7% of the patients were women. All patients had ≥1 AF-related symptoms at baseline, and 87.8% had AF symptoms for ≤24 hours. The conversion rate was 42.6% (95% CI: 33.0%-52.6%) with a median time to conversion of 14.6 minutes. The conversion rate was 46.9% (95% CI: 36.4%-57.7%) in a subpopulation that excluded predose flecainide exposure for the current AF episode. Median time to discharge among patients who converted was 2.5 hours, and only 2 patients had experienced AF recurrence by day 5. In the conversion-no group, 44 (81.5%) patients underwent electrical cardioversion by day 5. The most common adverse events were related to oral inhalation of flecainide (eg, cough, oropharyngeal irritation/pain), which were mostly of mild intensity and limited duration. ConclusionsThe risk-benefit of orally inhaled FlecIH for acute cardioversion of recent-onset AF appears favorable. FlecIH could provide a safe, effective, and convenient first-line therapeutic option. (INhalation of Flecainide to Convert Recent Onset SympTomatic Atrial Fibrillation to siNus rhyThm [INSTANT]; NCT03539302)

Efficacy and Safety of Intravenous Vernakalant in Rapid Cardioversion of Recent Onset Atrial Fibrillation: A Retrospective Single-Centre Study.

We use vernakalant, an intravenous anti-arrhythmic, to cardiovert paroxysmal atrial fibrillation (AF) into sinus rhythm. It is a relatively atrium-selective, early-activating potassium and frequency-dependent sodium channel blocker with a half-life of 2 to 3 hours. Due to concerns regarding its safety profile, it is not Food and Drug Administration (FDA)-approved. This study aims to assess the efficacy of intravenous vernakalant in cardioversion of paroxysmal AF and the safety of its use. Patients with paroxysmal AF who presented to the American University of Beirut Medical Center (AUBMC) between 2015 and 2020 and received vernakalant for cardioversion were included. Patients did not receive vernakalant if they had any of the following: QTc > 440 ms, heart rate < 50 bpm, acute coronary syndrome within the last 30 days, second- and third-degree atrioventricular (AV) block in the absence of a pacemaker, severe aortic stenosis (AS), use of intravenous antiarrhythmics (class I and class III) within four hours of vernakalant infusion, systolic blood pressure <100 mmHg, and heart failure (New York Heart Association (NYHA) III or NYHA IV class). The primary endpoint is conversion to sinus rhythm for at least one minute within 90 minutes of the start of the vernakalant infusion. The secondary endpoint included the presence of these side effects: bradycardia, QTc prolongation, AV block, ventricular arrhythmias, hypotension, taste alteration/dysgeusia, sneezing, nausea, vomiting, paresthesia, cardiogenic shock, or death. The study included 23 patients with paroxysmal AF (15 men, mean age 54 ± 14 years). Fourteen patients (61%) cardioverted to sinus rhythm within 90 minutes of the start of the Vernakalant infusion. Seven patients (30%) reverted to sinus rhythm within 15 minutes after the first infusion. After treatment with vernakalant, four patients (17%) developed sinus bradycardia, and four patients (17%) developed first-degree AV block. No patient had a QTc greater than 460 ms. None of the patients experienced sinus pauses, high-grade AV block, ventricular arrhythmias, hypotension, dysgeusia, sneezing, nausea, vomiting, paresthesia, cardiogenic shock, or death. Vernakalant had 61% efficacy in the rapid cardioversion of paroxysmal AF to sinus rhythm, was well tolerated, and had a low rate of adverse events in our study population.

Novel electrocardiographic classification for stroke prediction in atrial fibrillation patients undergoing cardioversion

BackgroundAbnormal conduction, structure, and function of the atrial myocardium predispose to atrial fibrillation (AF) and stroke. The usefulness of electrocardiographic indices in predicting stroke or systemic embolism (SSE) in patients undergoing cardioversion (CV) for AF remains unknown, especially in those at low estimated risk. ObjectiveWe systematically evaluated the performance of various P-wave abnormalities (PWAs) in predicting SSE 30 days after CV (derivation cohort) and in the long term (validation cohort). MethodsElectrocardiograms (n = 1773) of AF patients undergoing an acute CV were manually reviewed. The 30-day post-CV data were used to derive a composite PWA variable. The electrocardiographic findings were validated by the long-term follow-up of patients with no anticoagulation. Electrocardiograms of 27 CAREBANK study patients with right atrial appendage biopsies were further analyzed for histopathologic validation. ResultsDuring data derivation, the best performance was found with a combination of prolonged P-wave (≥180 ms), deflected P-wave morphology in lead II, biphasic P-waves in inferior leads, or increased P-terminal force (≥80 mm·ms) as markers for extensive PWA. In the validation cohort, 219 of 874 (25.1%) had extensive PWA. During a median follow-up of 4.9 years, there were 51 patients (5.8%) with SSE in total. In a competing risk model, PWA predicted SSE (adjusted hazard ratio, 2.1 per category; 95% CI, 1.4–3.1; P < .001). Areas under the curve for SSE at 3 years were 0.77, 0.79, and 0.86 for PWA, CHA2DS2-VASc, score, and their combination, respectively. On histologic evaluation, extensive PWA was associated with interstitial fibrosis (P = .033). ConclusionNovel electrocardiographic PWA classification provided additional prognostic insight in AF patients.

Weekly journal scan: the KCa2 potassium channel as a promising target for the pharmacologic cardioversion of atrial fibrillation.

Weekly journal scan: the KCa2 potassium channel as a promising target for the pharmacologic cardioversion of atrial fibrillation.

New possibilities of antiarrhythmic therapy of atrial fibrillation: A review

Atrial fibrillation (AF) is the most common heart rhythm disorder. According to current recommendations, the treatment of AF includes 3 main directions: "A" – the appointment of anticoagulant therapy with an increased risk of thromboembolic complications, "B" – control of arrhythmia symptoms, choice of a strategy for rhythm control or control of ventricular contractions, "C" – treatment of concomitant diseases and correction of risk factors. The rhythm control strategy includes performing cardioversion, prescribing long-term antiarrhythmic therapy, or performing radiofrequency catheter ablation. According to the latest recommendations of 2020, antiarrhythmic drugs of IC and III classes are currently used for pharmacological cardioversion of AF and long-term retention of sinus rhythm. The choice of a specific antiarrhythmic drug is based on its safety and effectiveness. â-Blockers, non-dihydropyridine calcium channel blockers and digoxin are used to control CHS. The results of modern research have significantly expanded our understanding of the molecular mechanisms underlying various forms of AF. Currently, the search for new drugs is actively underway that will allow preventing the development of AF and its progression at the molecular level.