Cardioversion Of Atrial Fibrillation Research Articles

Abstract 12418: Effect of Atrial Fibrillation Cardioversion on the Severity of Mitral Insufficiency

To evaluate the effect of cardioversion with restoration of sinus rhythm in patients with atrial fibrillation (AF) and significant mitral regurgitation (MR) may improve the severity of MR. Atrial fibrillation (AF) is chronic, progressive and, may cause "permanent remodeling of the heart muscle, without structural abnormalities of the valve, reverse remodeling of the left atrium (LA) may be successful in AF. This retrospective cohort study included patients with atrial fibrillation who were hospitalized for cardioversion, received echocardiography during AF in mitral insufficiency, demonstrated significant mitral regurgitation, and underwent additional echocardiography within six months. Indices of the two echocardiograms were compared and used to investigate the effect of cardioversion on the severity of MR. A total of 417 patients were enrolled with a mean age of 74.6 ± 12, with 192 men (46%). On a 6 month follow-up echo, 254 patients (61%) returned to sinus rhythm. An improvement of two or more degrees of severity of MR was observed in 100 patients (24%). Of that number, 72 patients (72%) returned to sinus rhythm, compared with 28 patients (28%) who remained in AF (p = 0.009). Multivariate analysis found that the restoration of sinus rhythm was independently associated with an improvement of two or more degrees of severity, MR p = 0.01, OR = 1.9, CI 95% [1.2-3.0]. There was improvement in the end systolic left ventricular diameter from 3.79 ± 0.99 to 3.58 ± 0.91, p < 0.01, a decrease in the diameter of the left atrium from 4.97 ± 0.64 to 4.79 ± 0.76, p < 0.02, a decrease in the jet area from 11.37 ± 3.7 to 5.9 ± 1.7, p < 0.01, a decrease in vena contracta from 0.66 ± 0.08 to 0.56 ± 0.07, p < 0.01, and a decrease in the TIG from 41.85 ± 12.9 to 36.5 ± 10.7, p < 0.01. There was also an improvement in the FS indices from 28.70 ± 10.17 to 32.17 ± 9.28, p < 0.01.In the group with a slight improvement or no improvement in MR, there was an increase in end diastolic diameter from 5.10 ± 0.77 to 5.19 ± 0.79, p < 0.02, and an increase in the diameter of the left atrium. There was no difference in the other indices. Cardioversion of atrial fibrillation to sinus rhythm in patients with significant mitral regurgitation was positively related to improvement in the severity of mitral insufficiency.

Comparison of clinical outcomes of Ibutilide-guided cardioversion and direct current synchronized cardioversion after radiofrequency ablation of persistent atrial fibrillation.

Ibutilide has already been used for cardioversion of persistent atrial fibrillation (PsAF) after radiofrequency catheter ablation (RFCA). The purpose of this study was to determine the effect of Ibutilide-guided cardioversion on clinical outcomes after individualized ablation of PsAF. From October 2020 to September 2021, consecutive patients with PsAF accepted for RFCA were prospectively enrolled. After individualized ablation including pulmonary vein isolation plus left atrial roof line ablation and personalized linear ablation based on left atrial low-voltage zones, patients were divided into the spontaneous conversion (SCV) group, direct current synchronized cardioversion (DCC) group and Ibutilide group according to different cardioversion types during ablation. The rates of freedom from atrial tachyarrhythmia (ATT) among the three groups were evaluated after follow-up. In this study, 110 patients were enrolled, including 12 patients with SCV, 50 patients receiving DCC and 48 patients receiving Ibutilide cardioversion after individualized ablation. Among the three groups, the SCV group had shorter AF duration {12 months [interquartile range (IQR) 12-16], P = 0.042} and smaller left atrial diameter (LAD) [35 mm (IQR: 33-42), P = 0.023]. A 12-month freedom from ATT rate was 83.3% in SCV group, 69.4% in DCC group, and 79.2% in Ibutilide group, respectively (Log-rank, P = 0.745). During the follow-up [17 months (IQR: 15-19)], the rate of freedom from ATT of SCV group (83.3%), and Ibutilide group (72.9%) were both higher than that of DCC group (53.1%, P = 0.042). Moreover, Kaplan-Meier analysis showed a significantly higher sinus rhythm (SR) maintenance in Ibutilide group than in DCC group (Log-rank, P = 0.041). After adjusting for risk factors of AF recurrence, the hazard ratio for AF recurrence of the DCC group with reference to the Ibutilide group was 4.10 [95% confidence interval (CI) (1.87-8.98), P < 0.001]. Furthermore, subgroup analysis showed that freedom from ATT rate in effective Ibutilide subgroup was significantly higher than noneffective Ibutilide subgroup (Log-rank, P < 0.001). For the treatment of the patients with PsAF, Ibutilide-guided cardioversion after individualized RFCA may be benefit for maintenance of SR compared to conventional DCC, especially for the patients who are effective for administration of Ibutilide.

Electrical energy by electrode placement for cardioversion of atrial fibrillation: a systematic review and meta-analysis

ObjectiveElectrode patch position may not be critical for success when cardioverting atrial fibrillation (AF), but the relevance of applied electrical energy is unclarified. Our objective was to perform a meta-analysis...

101 Is it necessary to begin with the maximum energy? High efficacy of the low-escalating energy shocks strategy in the cardioversion of atrial fibrillation

101 Is it necessary to begin with the maximum energy? High efficacy of the low-escalating energy shocks strategy in the cardioversion of atrial fibrillation

Anti‐arrhythmic drugs before, during and after transvenous electrical cardioversion of atrial fibrillation in horses: Weighing the benefits and risks

Anti‐arrhythmic drugs before, during and after transvenous electrical cardioversion of atrial fibrillation in horses: Weighing the benefits and risks

Medical cardioversion of atrial fibrillation and flutter with class IC antiarrhythmic drugs in young patients with and without congenital heart disease.

The use of flecainide and propafenone for medical cardioversion of atrial fibrillation (AF) and atrial flutter/intra-atrial reentrant tachycardia (IART) is well-described in adults without congenital heart disease (CHD). Data are sparse regarding their use for the same purpose in adults with CHD and in adolescent patients with anatomically normal hearts and we sought to describe the use of class IC drugs in this population and identify factors associated with decreased likelihood of success. Single center retrospective cohort study of patients who received oral flecainide or propafenone for medical cardioversion of AF or IART from 2000 to 2022. The unit of analysis was each episode of AF/IART. We performed a time-to-sinus rhythm analysis using a Cox proportional hazards model clustering on the patient to identify factors associated with increased likelihood of success. We identified 45 episodes involving 41 patients. As only episodes of AF were successfully cardioverted with medical therapy, episodes of IART were excluded from our analyses. Use of flecainide was the only factor associated with increased likelihood of success. There was a statistically insignificant trend toward decreased likelihood of success in patients with CHD. Flecainide was more effective than propafenone. We did not detect a difference in rate of conversion to sinus rhythm between patients with and without CHD and were likely underpowered to do so, however, there was a trend toward decreased likelihood of success in patients with CHD. That said, medical therapy was effective in >50% of patients with CHD with AF.

Lone atrial fibrillation: A case report on a rare complication of pregnancy

Atrial fibrillation (AF) is one of the most common arrhythmias and is a rare phenomenon seen in pregnant patients unless there is an underlying cardiopulmonary abnormality. Lone AF in pregnancy is a diagnosis of exclusion. A thorough workup including history, physical examination, imaging, and laboratory workup should be done diligently to exclude cardiopulmonary diseases (like hypertensive heart disease, congenital heart disease, valvular heart disease, asthma or chronic obstructive pulmonary disease, pulmonary embolism, rheumatic heart disease) and non-cardiac diseases (such as hyperthyroidism or electrolyte abnormalities or medications). There are very few case reports and studies published so far on this topic. This case report is on a pregnant patient without any significant past medical history who developed new-onset lone AF without any known cause and was managed with Diltiazem, which resulted in chemical cardioversion of atrial fibrillation with rapid ventricular rate to normal sinus rhythm.

Electric cardioversion in patients treated with oral anticoagulants: embolic material in the left atrial appendage.

Atrial fibrillation (AF) remains the most common arrhythmia. The sinus rhythm restoration procedure without adequate anticoagulant preparation may lead to a thromboembolic event in approximately 5-7% of patients. The initiation of oral anticoagulation significantly reduces this risk by inhibiting formation of embolic material in the heart cavities, especially in the left atrial appendage (LAA). However, there is a group of patients who develop embolic material in the LAA despite oral anticoagulation treatment. The best treatment method to dissolve thrombus in the LAA is not clear, due to the lack of studies with adequate power and endpoints that can determine the best management strategy. We present clinical trials comparing the efficacy and safety of oral anticoagulants in patients undergoing AF cardioversion. We evaluate the frequency of LAA thrombus formation in patients with AF on treatment with oral anticoagulants. Furthermore, we discuss the effectiveness of various treatment strategies on LAA thrombus resolution.

Atrial pacing minimization in sinus node dysfunction and risk of incident atrial fibrillation: a randomized trial.

High percentages of atrial pacing have been associated with an increased risk of atrial fibrillation. This study is aimed at evaluating whether atrial pacing minimization in patients with sinus node dysfunction reduces the incidence of atrial fibrillation. In a nationwide, randomized controlled trial, 540 patients with sinus node dysfunction and an indication for first pacemaker implantation were assigned to pacing programmed to a base rate of 60 bpm and rate-adaptive pacing (DDDR-60) or pacing programmed to a base rate of 40 bpm without rate-adaptive pacing (DDD-40). Patients were followed on remote monitoring for 2 years. The primary endpoint was time to first episode of atrial fibrillation longer than 6 min. Secondary endpoints included longer episodes of atrial fibrillation, and the safety endpoint comprised a composite of syncope or presyncope. The median percentage of atrial pacing was 1% in patients assigned to DDD-40 and 49% in patients assigned to DDDR-60. The primary endpoint occurred in 124 patients (46%) in each treatment group (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.76-1.25, P = .83). There were no between-group differences in atrial fibrillation exceeding 6 or 24 h, persistent atrial fibrillation, or cardioversions for atrial fibrillation. The incidence of syncope or presyncope was higher in patients assigned to DDD-40 (HR 1.71, 95% CI 1.13-2.59, P = .01). Atrial pacing minimization in patients with sinus node dysfunction does not reduce the incidence of atrial fibrillation. Programming a base rate of 40 bpm without rate-adaptive pacing is associated with an increased risk of syncope or presyncope.

Pharmacological cardioversion of atrial fibrillation: practical considerations.

The choice between rhythm and rate control strategy represents one of the most intriguing dilemmas in the management of atrial fibrillation (AF). Although the advantage of rhythm over rate control in terms of outcome has not been equivocally proven, the initial management of patients with symptomatic episodes of AF frequently involves an attempt of early cardioversion. As electrical cardioversion (EC) is challenging in terms of fasting status and involvement of anesthesiology team, pharmacological cardioversion (PC) is usually selected as the first step towards rhythm conversion. Proper qualification for PC or EC is similar and should comprise assessment of hemodynamic status, estimation of duration of arrhythmic episode, evaluation of anticoagulation regimen, exclusion of other supraventricular arrhythmias and assessment of the chance of rhythm conversion and persistence of sinus rhythm. Finally, the choice of adequate antiarrhythmic drug (AAD) depends on the presence of structural heart disease and local experience. In patients without structural heart disease, complications occur rarely, hence traditional (propafenone, flecainide) or nonclassical Vaughan-Williams class I (antazoline) or class III (vernakalant, ibutilide or dofetilide) drugs are preferred. The presence of structural heart disease consistent with any left ventricular hypertrophy, heart failure, myocardial ischemia or valvular heart disease confines the choice of AAD to amiodarone. Given the risk of ventricular proarrhythmia of AAD, safety should always prevail over the enticing possibility of rhythm conversion. The present review aims to provide a comprehensible summary of proper qualification for PC, selection of suitable AAD and state-of-the-art periprocedural management of patients with recent-onset AF.

Relation between 25-Hydroxy Vitamin D Deficiency and Success of Cardioversion for Lone Atrial Fibrillation (AF)

Abstract Aim and objectives The aim of this study was to assess the relationship between vitamin D deficiency and extent of success of cardioversion in patients with lone atrial fibrillation (AF). Patients and Methods This observational cross-sectional study included 50 patients (18-60 years old) who presented to the cardiology department of Ain Shams university hospitals with lone atrial fibrillation with structurally normal heart for cardioversion after fulfilling the inclusion criteria, considering that failure of cardioversion was defined as failure of restoration to normal sinus rhythm after applying the cardioversion protocol that is being used in our cardiology department in Ain Shams University hospitals. Serum vitamin D level on admission was sampled for all patients before cardioversion, and cardioversion was assessed after then whether success or failure. Cardioversion success was restoration of normal sinus rhythm and that the patient was discharged in sinus rhythm. Cardioversion protocol that was being used was applied as Loading dose of Intravenous (IV) Amiodarone of 300 mg diluted in 250 ml 5% dextrose over 30-60 minutes, then follow up dose of 900 mg IV over 24 hours diluted in 500-1000 ml of normal saline, then if failed, application of biphasic synchronized direct current electrical cardioversion at 200 joules at anteriorlateral electrode positions. Results The success rate of cardioversion was 80% (40 out of 50) in all the patients presented, and the failure rate was 20% (10 out of 50). In the success group, majority of patients 23 (57.5%) had sufficient Vitamin D levels (≥30 ng/ml), 15 patients (37.5%) had insufficient vitamin D levels (21-29 ng/ml) and 2 patients (5%) had deficient vitamin D levels (≤20 ng/ml). Meanwhile, in the failure group, the majority of patients 8 (80%) had deficient vitamin D levels (≤20 ng/ml), 1 patient (10%) had insufficient vitamin D level (21-29 ng/ml), and 1 patient (10%) had sufficient vitamin D level (≥30 ng/ml).This difference was statistically significant with a P value of &amp;lt; 0.01. Vitamin D level measured (25-OH vitamin D) had values of mean ± SD of 29.41 ± 4.89 ng/ml in the success group vs 19.22 ± 4.68 ng/ml in the failure group, which was statistically significant with a P value of &amp;lt;0.01. A-P (antero-posterior) LAD (left atrial diameter) measured in parasternal long axis view during routine pre-cardioversion work-up study by echocardiography that has been done, had values of mean ± SD of 37.60 ± 3.20 mm in the success group vs 37.80 ± 2.86 mm in the failure group, which was statistically non- significant with a P value of 0.858. There was not a statistically significant difference between the 2 groups regarding age, sex, BMI, smoking, duration of AF(duration of onset of symptoms), number of previous trials of cardioversion, previous antiarrythmic drugs that have been administered and heart rate at time of cardioversion. Conclusion Failure rate of cardioversion was found to be higher in patients with vitamin D deficiency in comparison to patients with sufficient and insufficient vitamin D levels. Abbreviations AF: Atrial Fibrillation; A-P: Antero-posterior; BMI: Body mass index; LAD: Left atrial diameter; SD: Standard deviation

Study of ECG-derived atrial fibrillatory rate for prediction of the outcome of cardioversion of short duration atrial fibrillation (CASAF)

AimsThe present study aimed at testing the hypothesis that atrial fibrillatory rate (AFR) is predictive of sinus rhythm maintenance after electrical cardioversion. Methods and resultsThe study comprised 32 patients admitted for cardioversion of atrial fibrillation of short duration (mean duration 3.8 ± 7.7 days). AFR was estimated using frequency power spectrum analysis of QRST-cancelled ECG.At six-weeks follow-up 22% of the patients had relapsed to AF. The pre-cardioversion mean AFR of those was 332 ± 64 fpm compared to 378 ± 59 fpm among patients maintaining sinus rhythm (p = 0.12). ConclusionAFR was not predictive of sinus rhythm maintenance in patients of short duration AF undergoing cardioversion. This is in stark contrast with the earlier reported findings. Clinical trial registrationNCT02112318 (http://www.clinicaltrials.gov).

Changes in cardiac output, rhythm regularity, and symptom severity after electrical cardioversion of atrial fibrillation

Objectives Symptoms in atrial fibrillation (AF) range from none to disabling. The physiological correlates of AF symptoms are not well characterized. This study investigated the association between physiological parameters and symptom severity before and after electrical cardioversion (EC) of AF. Design We studied 44 patients with persistent AF (age 66.2 ± 7.9 years, 16% females) 4 ± 2 days before and 5 ± 2 days after EC. Physiological parameters included cardiac output (CO; non-invasive inert gas rebreathing), heart rate (HR), RR variability and resting and ambulatory blood pressure (BP). Symptoms and quality of life (QoL) were assessed by the modified European Heart Rhythm Association score (mEHRA), the Atrial Fibrillation Effect on Quality of Life (AFEQT) and the Symptom Checklist for frequency and severity of symptoms (SCL). Results 28 of 44 patients were still in sinus rhythm (SR) at post EC evaluation. Those in SR had a decreased HR (-15.4 ± 13.1 bpm, p < 0.001), and an increased CO (+0.8 ± 0.7 L/min, p < 0.001) as compared to those with recurrent AF. Changes in CO after EC correlated with symptom improvement as scored by AFEQT (r = 0.36; p < 0.05), AFEQT symptoms subscore (r = 0.46; p < 0.01), SCL for frequency (r = 0.62; p < 0.01) and severity (r = 0.33; p < 0.05) of symptoms, and the mEHRA score (r = 0.50; p < 0.01). A decrease in RR variability showed similar correlations with these measures of symptom improvement. Conclusions Improvements in symptoms and quality of life experienced by patients after electrical conversion of atrial fibrillation are correlated with an increase in CO and a decreased RR variability.

Delayed vs early cardioversion in patients with paroxysmal atrial fibrillation: a population-based study (2015-2020).

Aim: There is limited data on clinical outcomes of delayed cardioversion (DCV) compared with early cardioversion (ECV) in paroxysmal atrial fibrillation (AF) patients. Methods: We utilized data from National Inpatient Sample (2015-2020) and propensity-score matched analysis to determine adjusted odds ratio (aOR) of major clinical outcomes, including 17,879 AF cases: 9725 and 8154 underwent ECV and DCV, respectively. Results: Compared with ECV, DCV was associated with higher odds of acute heart failure (AHF; aOR 1.79 [1.67-1.92]; p<0.01), median length of stay (4 vs 2days; p<0.01) and cost of hospitalization ($33,410 vs $21,738; p<0.01) with no significant difference in inpatient mortality and other cardiovascular and neurological outcomes. Conclusion: Compared with ECV, DCV was associated with more AHF and resource utilization.

Right Heart Structure and Function after Electrical Cardioversion for Atrial Fibrillation

Introduction: Atrial fibrillation (AF) adversely impacts right ventricular (RV) and right atrial (RA) structure and function. There are limited data on these changes after electrical cardioversion (ECV) and the relative contribution of heart rate to evaluate the immediate (1–2 h) and short-term (4–6 weeks) changes in right cardiac chamber dimensions and RV function after ECV in patients with persistent AF. Methods: Right cardiac chamber dimensions and RV function were measured in 64 patients using transthoracic echocardiography 1–2 h before, immediately after, and 4–6 weeks after ECV. Associations between changes in right-heart measures and rhythm status at follow-up were assessed using linear regression models. Results: For patients who remained in sinus rhythm 4–6 weeks after ECV (n = 48), median fractional area change (FAC) at baseline, immediately after ECV, and 4–6 weeks after ECV were 39 (Q1:35, Q3:42) %, 42 (Q1:39, Q3:46) %, 46 (Q1:43, Q3:49) % (p < 0.01); median tricuspid annular plane systolic excursion (TAPSE) values at the same time points were 18 (Q1:17, Q3:20) mm, 20 (Q1:18, Q3:23) mm, and 24 (Q1:22, Q3:26) mm (p < 0.01), respectively. There was no significant difference in RV end systolic area and RA volume index before and after ECV. However, RV end systolic area and RA volume index decreased significantly after 4–6 weeks from a median of 10 (Q1:8, Q3:13) cm² to 8 (Q1:7, Q3:10) cm² (p < 0.01), and from a median of 30 (Q1:24, Q3:36) mL/m² to 24 (Q1:20, Q3:27) mL/m² (p < 0.01). Changes in TAPSE were significantly associated with sinus rhythm at follow-up (p = 0.027), changes in FAC showed a strong trend to association with sinus rhythm (p = 0.053), and this was not true for RA measures (p = 0.64). Conclusions: Among AF patients who remained in sinus rhythm after ECV, RV function improved immediately after ECV with further improvement at 4–6 weeks following sinus rhythm restoration.

Light transmittance in human atrial tissue and transthoracic illumination in rats support translatability of optogenetic cardioversion of atrial fibrillation.

Optogenetics could offer a solution to the current lack of an ambulatory method for the rapid automated cardioversion of atrial fibrillation (AF), but key translational aspects remain to be studied. To investigate whether optogenetic cardioversion of AF is effective in the aged heart and whether sufficient light penetrates the human atrial wall. Atria of adult and aged rats were optogenetically modified to express light-gated ion channels (i.e., red-activatable channelrhodopsin), followed by AF induction and atrial illumination to determine the effectivity of optogenetic cardioversion. The irradiance level was determined by light transmittance measurements on human atrial tissue. AF could be effectively terminated in the remodeled atria of aged rats (97%, n=6). Subsequently, ex vivo experiments using human atrial auricles demonstrated that 565-nm light pulses at an intensity of 25mW/mm2 achieved the complete penetration of the atrial wall. Applying such irradiation onto the chest of adult rats resulted in transthoracic atrial illumination as evidenced by the optogenetic cardioversion of AF (90%, n=4). Transthoracic optogenetic cardioversion of AF is effective in the aged rat heart using irradiation levels compatible with human atrial transmural light penetration.

Auto left atrial strain by speckle tracking echocardiography and auto left atrial volumes by 3D transthoracic echocardiography after electrical cardioversion for atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction We have evidence that left atrial dysfunction and stunning occur after electric cardioversion for atrial fibrillation (CAF). Additionally, after successful cardioversion to sinus rhythm, a dissociation between electrical and mechanical recovery may be observed. Traditional pulsed Doppler and tissue Doppler imaging parameters demonstrate reduced atrial contractility immediately after cardioversion. Improvement in atrial function occurs within the first 4 weeks after sinus rhythm is restored. Recent advances in the assessment of myocardial function have facilitated the direct measurement of auto left atrial strain using speckle tracking echocardiography, and auto left atrial volumes measurements using dynamic heart model modern 3D transthoracic echo logistics. Purpose Aim of this study was to determine whether auto left atrial strain (auto LAs) by speckle tracking echocardiography, and auto left atrial volumes measurements, auto left atrial volume indices calculations (auto LAVI), could be used to evaluate global left atrial function and when a main improvement occurs after electrical cardioversion for CAF. Methods Auto LAs was measured from transthoracic echocardiography in 25 patients with CAF who had been cardioverted to sinus rhythm and followed up for 4 weeks, and in a cohort of 25 healthy individuals. Left atrial contractile strain (LACTS), conduit strain (LACDS) and reservoir strain (LARSS) were measured. Conventional measures of atrial function derived from transmitral pulsed wave doppler (PW) and tissue doppler imaging (TDI) of lateral mitral annulus were included, such as A wave velocity, A wave velocity time integral, A' wave velocity and A' velocity time integral. Results Immediately after cardioversion all PW, TDI and all three auto LAs parameters were significantly lower than in controls. On the other hand, auto LAVI was significantly higher in patients compared to controls immediately after cardioversion Atrial function was improved over time with maximal change observed 4 weeks after cardioversion and restoration to sinus rhythm. Auto LAs parameters were significantly higher in the group of patients. Auto LA volumes and auto LAVI with dynamic heart model logistics were lower in the same group, but with no statistical significance. Three patients with the lowest auto LAs values immediately after cardioversion, suffered recurrence of atrial fibrillation during the 4 weeks follow up. Conclusions Although left atrial electrical function is immediately restored after cardioversion in CAF patients, a persistent degree of atrial dysfunction remains for up to 4 weeks. This difference could explain the increased propensity for these patients to develop recurrent atrial fibrillation. Additional this dysfunction could indicate the longer-term use of antiarrhythmic and antithrombotic medication in the CAF cohort.

Rationale and Design of a Randomized Controlled Clinical Trial on the Safety and Efficacy of Flecainide versus Amiodarone in the Cardioversion of Atrial Fibrillation at the Emergency Department in Patients with Coronary Artery Disease (FLECA-ED).

Pharmacologic cardioversion is a well-established alternative to electric cardioversion for hemodynamically stable patients, as it skips the risks associated with anesthesia. A recent network meta-analysis identifies the most effective antiarrhythmics for pharmacologic cardioversion with flecainide exhibiting a more efficacious and safer profile towards faster cardioversion. Moreover, the meta-analysis of class Ic antiarrhythmics revealed an absence of adverse events when used for pharmacologic cardioversion of AF in the ED, including patients with structural heart disease. The primary goals of this clinical trial are to prove the superiority of flecainide over amiodarone in the successful cardioversion of paroxysmal atrial fibrillation in the Emergency Department and to prove that the safety of flecainide is non-inferior to amiodarone in patients with coronary artery disease without residual ischemia, and an ejection fraction over 35%. The secondary goals of this study are to prove the superiority of flecainide over amiodarone in the reduction in hospitalizations from the Emergency Department due to atrial fibrillation in the time taken to achieve cardioversion, and in the reduction in the need to conduct electrical cardioversion.

Colchicine usage for prevention of post atrial fibrillation ablation pericarditis in patients undergoing high-power short-duration ablation.

Radiofrequency ablation (RFA) for atrial fibrillation (AF) has been associated with variable incidence (0.88%-10%) of pericarditis manifested as chest pain, possibly more prevalent with the advent of high-power short-duration (HPSD) ablation. This has led to the widespread use of colchicine in preventative protocols for postablation pericarditis. However, the efficacy of preventative colchicine has not been validated yet. To evaluate the efficacy of a routine postoperative colchicine regimen (0.6 mg twice a day for 14 days post-AF ablation) for prevention of postablation pericarditis in patients undergoing HPSD ablation. We retrospectively evaluated consecutive single-operator HPSD AF ablation procedures at our institution from June 2019 to July 2022. A colchicine protocol was introduced in June 2021 for the prevention of postablation pericarditis. All ablations were performed with 50 watts. Patients were divided into colchicine and noncolchicine groups. We recorded incidence of postablation chest pain, emergency room (ER) visit for chest pain, pericardial effusion, pericardiocentesis, any ER visit, hospitalization, AF recurrence, and cardioversion for AF within the first 30 days following ablation. We also recorded colchicine-related side effects and medication compliance. Two hundred and ninety-four consecutive HPSD AF ablation patients were screened for the study. After implementing the prespecified exclusion criteria, a total of 205 patients were included in the final analysis, yielding 101 patients in the colchicine group and 104 patients in the noncolchicine group. Both groups were well-matched for demographic and procedural parameters. There was no significant difference in postablation chest pain (9.9% vs. 8.6%, p = .7), pericardial effusion (2.9% vs. 0.9%, p = .1), ER visits (11.9% vs. 12.5%, p = .2), 30-day hospitalization for AF recurrence (0.9% vs. 0.96%, p = .3), and 30-day need for cardioversion for AF (3.9% vs. 5.7%, p = .2). Fifteen (15) patients had severe colchicine-related diarrhea, out of which 12 discontinued it prematurely. There were no major procedural complications in either group. In this single-operator retrospective analysis, prophylactic colchicine was not associated with significant reduction in the incidence of postablation chest pain, pericarditis, 30 day hospitalization, ER visits, or AF recurrence or need of cardioversion within first 30 days after HPSD ablation for AF. However, its usage was associated with significant diarrhea. This study concludes no additional advantage of prophylactic use of colchicine after HPSD AF ablation.

Bayesian Network Meta-analysis of Randomized Controlled Trials on the Efficacy of Antiarrhythmics in the Pharmacological Cardioversion of Paroxysmal Atrial Fibrillation.

Since atrial fibrillation (AF) is one of the major arrhythmias managed in hospitals worldwide, it has a major impact on public health. The guidelines agree on the desirability of cardioverting paroxysmal AF episodes. This meta-analysis aims to answer the question of which antiarrhythmic agent is most effective in cardioverting a paroxysmal AF. A systematic review and Bayesian network meta-analysis, searching MEDLINE, Embase, and CINAHL, were performed, including randomized controlled trials (RCTs) enrolling a population of unselected adult patients with a paroxysmal AF that compared at least two pharmacological regimes to restore the sinus rhythm or a cardioversion agent against a placebo. The main outcome was efficacy in restoring sinus rhythm. Sixty-one RCTs (7988 patients) were included in the quantitative analysis [deviance information criterion (DIC) 272.57; I2 = 3%]. Compared with the placebo, the association verapamil-quinidine shows the highest SUCRA rank score (87%), followed by antazoline (86%), vernakalant (85%), tedisamil at high dose (i.e., 0.6 mg/kg; 80%), amiodarone-ranolazine (80%), lidocaine (78%), dofetilide (77%), and intravenous flecainide (71%). Taking into account the degree of evidence of each individual comparison between pharmacological agents, we have drawn up a ranking of pharmacological agents from the most effective to the least effective. In comparing the antiarrhythmic agents used to restore sinus rhythm in the case of paroxysmal AF, vernakalant, amiodarone-ranolazine, flecainide, and ibutilide are the most effective medications. The verapamil-quinidine combination seems promising, though few RCTs have studied it. The incidence of side effects must be taken into account in the choice of antiarrhythmic in clinical practice. PROSPERO: International prospective register of systematic reviews, 2022, CRD42022369433 (Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022369433 ).