Cardioversion Of Persistent Atrial Fibrillation Research Articles

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 (<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=<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.

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

Achieving 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. Twenty 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. MI 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. The 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.

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.

Effectiveness of electrical cardioversion for persistent atrial fibrillation in the ongoing protocolenergy: hawthorne effect trial

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Electrical cardioversion (DCCV) is a long-used and proven method for the acute termination of atrial fibrillation episodes. The methodology for optimal performance of DCCV with the highest level of effectiveness while maintaining maximum safety is still under investigation. To validate our proposed methodology for performing DCCV, we have initiated the PROTOCOLENERGY clinical trial, which is currently ongoing. Objective To test the effect of conducting a clinical trial on the effectiveness of cardioversion in patients who were not included in the study for any reason. Methodology A retrospective analysis of the DCCV registry from the indications of persistent atrial fibrillation (long-term persistent excluded) from 2015-8/2022. Statistical comparison of the demographics and overall effectiveness of the DCCV cohort before and after study initiation and comparison of the cohort, enrolled and not enrolled since study initiation (no interim analysis of the study cohort proper). Heart rate 1 min after the last discharge is assessed. Cohort A total of 2402 procedures were analyzed in 829 women (34.5%) and 1573 men (65.5%) aged 67 (+/-10) years, with CHADSVASC score of 3,0 (+/− 1), BMI 31.2 (+/-7.7). Results DCCV efficiency in the whole cohort was 91.1%. Before the study, SR was achieved in 90% of the 1981 patients; since the start of the clinical trial, DCCV efficacy increased to 96.4% (in a cohort of 421 patients) (p &amp;lt;0.001). There was no statistically significant effect in efficacy between patients included in the clinical trial (312 pt.) and those not included (109 pt.) (96.5% vs. 96.3% p=0.944). Conclusion The presented data suggest an effect of developing and controlling the methodology of DCCV performance in a clinical trial on increasing the efficacy of DCCV, even in the cohort of patients not enrolled in the clinical trial. That phenomenon is called the HAWTHORNE effect and is related to the improvement of the outcome of the investigated phenomenon due to the influence of the actual investigation. In this case, probably due to strict adherence to the study protocol ( paddle pressure during DCCV, cardioversion in expiration, adherence to predetermined cardioversion energies, etc. even in patients not included in the study).

213: ONE SHOCK TREATED WITH ANOTHER: NEW-ONSET ATRIAL FIBRILLATION AFTER HIGH-VOLTAGE ELECTRICAL INJURY

Introduction: Development of atrial fibrillation following electrical injury has been rarely reported in literature. This can place medical providers in a situation where they are uncertain on how to manage such event. We present a case of high voltage electrical injury (7200V) resulting in new onset atrial fibrillation. Description: A 38-year-old electric line worker with no previous medical history came in with complaint of new onset palpitations and lightheadedness that started an hour prior to arrival. Patient stated he was standing on a boom lift, pressure-washing a church’s tower when his lance touched an electrical wire overhead. The lines were coming from a main electric pole estimated to be 7200V that connected to the transformer. Patient felt a shock pass through his right hand down to the rest of his body for a few seconds, and then he fell. He was not wearing any gloves. He denied any loss of consciousness, alcohol use, chest pain or any previous heart condition. In the ED, he was found to be in atrial fibrillation with heart rate ranging from 110-150. His CPK was 295 units/L and troponin was < 6 ng/L. Patient received IV diltiazem 15mg and IV amiodarone 150mg. He was started on amiodarone drip, admitted to ICU for monitoring and transitioned to Metoprolol 25mg BID and Xarelto 15mg daily the next day before discharge. Three weeks later, he underwent transesophageal echocardiogram (TEE) guided electrical cardioversion for persistent atrial fibrillation. Discussion: Electrical injury can induce cardiac arrhythmias via different mechanisms. The sheer energy of the electric current could directly stimulate the myocytes. It could also impair the sodium-potassium adenosine triphosphatase transporter which plays a major role in electrical-mechanical activity of cardiac muscle. Myocardial necrosis can also lead to production of new arrhythmogenic foci. Troponin and CPK are not always strong indicators of myocardial injury, however, high CK levels >400 units/L may be associated with longer hospitalization, and a greater risk of skin grafting or amputation. Atrial fibrillation in setting of electrical injury is managed with the use of beta blockers, anti-arrhythmics and in some cases, electrical cardioversion.

Impact of Pre-Ablation Direct Current Cardioversion for Persistent Atrial Fibrillation to Predict Recurrence of Atrial Fibrillation after Catheter Ablation.

The efficacy of direct current (DC) cardioversion before catheter ablation (CA) for persistent atrial fibrillation (PerAF) patients remains controversial. We hypothesized that maintenance of sinus rhythm (SR) by pre-ablation DC cardioversion may predict the outcome of CA in patients with PerAF. A total of 383 PerAF patients with no or mild symptoms (EHRA I/II) who had undergone DC cardioversion before CA (301 males, 65 ± 10 years old, mean atrial fibrillation (AF) duration: 25 ± 47 months) were retrospectively enrolled. Whether or not SR was maintained at least 24 hour after DC cardioversion, patients were divided into two groups, namely, the DC-SR group and DC-AF group, and then all were followed until AF recurrence after CA. After DC cardioversion, 281 (73%) patients were categorized into the DC-SR group, and 102 (27%) were categorized into the DC-AF group. A total of 195 patients underwent CA at an average of 83 (54-145) days after DC cardioversion, including 161 (83%) in the DC-SR group and 34 (17%) in the DC-AF group. During follow-up (median: 15 [10-25] months), the number of patients who were free from AF was significantly higher in the DC-SR group compared with the DC-AF group (61.5% versus 38.3%, P < 0.0001). Multivariate analysis revealed that the DC-SR group (hazard ratio [HR]: 0.45, 95% confidence interval [CI]: 0.21-0.99, P = 0.047) and age at first AF diagnosis (HR: 0.95, 95% CI: 0.91-1.00, P = 0.039) were the independent predictors for being AF-free after CA. In conclusion, the 24-hour rhythm outcome of pre-ablation DC cardioversion and age at first AF diagnosis may predict the recurrence of AF after CA in patients with PerAF.

QTc Dynamics Following Cardioversion for Persistent Atrial Fibrillation.

BackgroundCardioversion (CV) for atrial fibrillation (AF) is common. We aimed to assess changes in QTc over time following electrical CV (ECV) for persistent AF, and to compare the benefit of using continuous Holter monitoring vs. conventional follow-up by ECG.MethodsProspective observational cohort study. We comprised 90 patients admitted to our center for elective ECV due to persistent AF who were prospectively enrolled from July 2017 to August 2018. All patients underwent 7-days Holter started prior to ECV. Baseline QTc was defined as median QTc during 1 h post ECV. The primary endpoint was QTc prolongation defined as QTc ≥500 ms, or ≥10% increase (if baseline QTc was >480 ms). Conventional monitoring was defined as 2-h ECG post ECV.ResultsMean age was 67 ± 11 years and 61% were male. Median baseline QTc was 452 ms (IQ range: 431–479 ms) as compared with a maximal median QTc of 474 ms (IQ range: 433–527 ms; p <0.001 for the change in QTc from baseline). Peak median QTc occurred 44 h post ECV. The primary endpoint was met in 3 patients (3%) using conventional monitoring, compared with 39 new patients (43%) using Holter (p <0.001 for comparison). The Holter monitoring was superior to conventional monitoring in detecting clinically significant QTc prolongation (OR = 13; p <0.001).ConclusionsECV of patients with persistent AF was associated with increased transient risk of QTc prolongation in nearly half of the patients. Peak median QTc occurs during end of second day following ECV and prolonged ECG monitoring provides superior detection of significant QTc prolongation compared with conventional monitoring.

PO-690-03 ATRIAL ELECTROMECHANICAL DISSOCIATION AS A NOVEL NON-INVASIVE PARAMETER OF EARLY REMODELING PROGRESSION DURING ATRIAL FIBRILLATION

Electromechanical assessment during atrial fibrillation (AF) remains a significant knowledge gap in patient-specific characterization of atrial remodeling. Study electromechanical remodeling progression in a long-term pig model of AF and establish the clinical prognostic value of the atrial electromechanical relationship. Experimental group of pigs with AF (N=15) and a prospective clinical cohort (N=95) of symptomatic AF patients (episode duration ≤6 months) undergoing atrial remodeling characterization. Atrial electromechanical remodeling was assessed using simultaneous surface ECG recordings and tissue Doppler imaging (TDI) signals during echocardiography studies in AF. Electromechanical dissociation (EMD) was defined as faster atrial electrical activation rates (EAR) than the simultaneous counterpart TDI-derived mechanical activation rates (MAR). In patients, the primary outcome was cardioversion within a 24-h window after flecainide. Secondary outcomes were cardioversion of persistent AF and recurrences at 1-year. Pigs developed progressive EMD during the first weeks of AF-related remodeling (5-to-21 weeks after protocol initiation). EMD reached 2.29±2.47 Hz (p=0.04) at 12 weeks after the first recorded AF episode lasting ≥6 seconds. In pigs with long-lasting AF (342.5±86.6 d of self-sustained AF), high-resolution electroanatomical mapping and transesophageal echocardiography imaging demonstrated overt EMD (EAR-MAR=3.49±0.67 Hz) between local EARs from unipolar electrograms and the corresponding spatially and temporally synchronized MARs. In patients (55.0±11.6 years old), regardless of AF classification (paroxysmal or persistent AF), EMD was associated with failure of pharmacological cardioversion within the 24-h window after flecainide. EMD provided the highest increase in certainty for the primary outcome when added to AF classification compared to the increase provided by clinical variables and EARs. EMD was also associated with long-term AF recurrences both in the overall AF population and in the patient subset with persistent AF. Figure 1 summarizes the main study results. Atrial EMD is an early indicator of AF remodeling progression with prognostic value in acute and long-term rhythm control.

Electrical Cardioversion for Persistent Atrial Fibrillation in the Era of Catheter Ablation: A Real-world Observational Study

Background: Electrical cardioversion (ECV) is frequently performed to treat persistent atrial fibrillation (AF). Although several large trials have suggested that rate control in AF may be non-inferior to rhythm-based strategies, individual patients may have better outcomes in terms of quality of life if sinus rhythm (SR) is achieved and maintained. This real-world, retrospective, observational study aimed to define the success rate and role of ECV in the management of persistent AF in the era of catheter ablation. Methods: All patients who underwent ECV for symptomatic persistent AF at our institution between January 2014 and August 2019 were analysed. Clinical and echocardiographic baseline characteristics were used to identify independent predictors for AF recurrence at 12 and 24 months using a Cox multivariate model. Results: We identified 1,028 consecutive patients with symptomatic persistent AF, 319 of whom were subsequently excluded from the study because they either spontaneously reverted to SR prior to ECV or declined ECV. We evaluated 701 patients (mean age 71 ± 10.8 years, male 70.2%). Acute success was achieved in 96.8% of patients. SR at 12 and 24 months was seen in 26.6% and 14.3% of patients (p&lt;0.0001), respectively. SR at 12 months was seen in 20.4% of patients with a left atrium (LA) diameter of ≤4 cm and in 6.2% of patients with an LA diameter of &gt;4 cm (p&lt;0.0001). At 24 months, SR was seen in 11.5% of patients with a LA diameter of ≤4 cm and in 2.8% with a diameter of &gt;4 cm (p&lt;0.0001). Predictors of SR at 12 months on univariate analysis were normal left ventricular systolic function and mild left ventricular systolic impairment (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.08–2.45, p=0.021 and OR 0.5, 95% CI 0.24–0.94, p=0.043, respectively). In addition, flecainide and sotalol therapy improved the chances of SR at 12 months (OR 2.87, 95% CI 1.16–7.12, p=0.021 and OR 2.25, 95% CI 0.98–5.05, p=0.049, respectively). Multivariate analysis revealed no further positive predictors for SR maintenance in 24 months. Conclusion: ECV was not an effective long-term strategy for the maintenance of SR.

Abstract 11863: History of Paroxysmal Atrial Fibrillation is Associated With Earlier Recurrence After Initial Cardioversion Compared to New-Onset Persistent Atrial Fibrillation

Introduction: Recurrence of atrial fibrillation (AF) after direct current cardioversion (DCCV) for persistent AF is common. A preceding history of paroxysmal AF before persistent AF may predispose to recurrence of AF after DCCV. However, whether the absence of paroxysmal AF before new-onset persistent AF (primary persistent AF) affects the recurrence of AF is currently poorly defined. Hypothesis: Patients with persistent AF and a preceding history of paroxysmal AF will have a higher rate of recurrence after DCCV compared to patients with primary persistent AF. Methods: Prospective clinical database at a Veterans Hospital was used to compare recurrence rates of AF after initial DCCV in patients with primary persistent AF to patients with a history of prior paroxysmal AF. Results: Among 484 patients who underwent initial cardioversion for persistent AF, 21% had a history of paroxysmal AF (n = 101). 80% of patients with a history of paroxysmal AF had a recurrence within one year, compared to 58% of patients with a history of primary persistent AF (p=0.0001). Those with a history of paroxysmal AF had a smaller left atrium, 4.47 cm, compared to those with primary persistent AF, 4.64 cm (p=0.04) and were more likely to be taking anti-arrhythmic drugs (AAD) at the time of DCCV (p=0.00002). Although those with prior paroxysmal AF were more likely to have a history of CKD (p=0.03), OSA (p=0.0004), and CVA (p=0.001), the presence of these respective comorbidities did not affect recurrence rates (p=0.3055, 0.8253, 0.1689). Conclusions: Patients with prior paroxysmal AF were more likely to have a recurrence of AF after DCCV compared to patients without a history of primary persistent AF, despite smaller left atriums and higher rates of AAD use. Although those with prior paroxysmal AF had higher prevalence of CKD, OSA, and CVA, the presence of these comorbidities was not predictive of recurrence.

Novel rhythm conversion approach in unsuccessful electric cardioversion of persistent atrial fibrillation

Abstract The average effectiveness of electrical cardioversion in persistent atrial fibrillation (AF) is considered about 90%. The success is limited by arrhythmia longevity, essential heart pathology, excessive body mass, concomitant deceases. A novel developed in Russia class III intravenous medication “Refralon” (4-nitro-N-(1RS)-1(4-fluorophenyl)-2-(1-ethylpiperidin-4-ethyl) benzamide hydrochloride) seems to be promising in sinus rhythm restoration in such patients. The aim of the study was to assess the effectiveness of a novel class III intravenous medication “Refralon” in conversion to sinus rhythm in patients with permanent AF in whom electrical cardioversion was unsuccessful. Materials and methods 19 patients were included: 16 male and 3 female aged from 45 to 68 years old (59,9±5,84 (M±SD)). Left atrial size was 47±3,2 × 59±2,8 mm, BMI 38,5±7,0 kg/m2, arrhythmia duration from 2 to 21 months (6,7±4,99). Refralon was injected according to the approved manual in ICU; heart rhythm and rate, blood pressure, SpO2 were monitored. Dynamic assessment of QT and QRS duration was performed. Results In 17 of 19 patients (89,4%) sinus rhythm was restored. In 7 patients (41%) sinus rhythm was restored before 10 min, in 4 patients (24%) before one hour, in 4 patients (24%) before two hours, in 2 patients (11%) before six hours. In two patients sinus rhythm was not restored. In both target dose was not infused due to non-sustained ventricular tachycardia in one case, and QT prolongation in another. Conclusion In a small pilot study Refralon was highly effective in patients with persistent atrial fibrillation when electrical cardioversion was ineffective. All the patients had significantly increased BMI. The results may suggest the indication for Refralon usage in obese patients. Funding Acknowledgement Type of funding sources: None.

Improvement of atrial and ventricular strain after cardioversion of persistent atrial fibrillation

We aimed to detect early atrial morphologic and functional changes after successful electric cardioversion of atrial fibrillation (AF) and to correlate them to alterations of left and right ventricular strain All patients with successful electric cardioversion of persistent AF were included in a prospective monocentric study between August 2018 and August 2019. They had a transthoracic echocardiography before cardioversion (TTE 1) and 2 months later (TTE2). Left atrial (LA) and ventricular volumes, left ventricular ejection fraction (LVEF), left and right ventricular global longitudinal strain (GLS), LA strain and ejection fraction (LAEF) were measured. Recurrent AF was ruled out by a 24-hours ECG monitoring after 2 months We included 29 men and 7 women 66 +-9.7 yo, with CHA2DS2VASC Score 2.5 (0-8),AF lasting for 21.2 ± 27.7 months and LVEF 53.7 ± 14.7%. At 2 months follow-up, sinus rhythm was maintained in 28 patients (78%). Patients with recurrent AF had no modification of volumes and function when comparing TTE 1 and TTE2. Patients with sustained sinus rhythm improved their LA volume (TTE1: 43 ± 14.5 ml/m 2 ; TTE2: 34.5 ± 13 ml/m 2 ; P = 0.001), LAEF (TTE1: 38.4 ± 15.7%; TTE2: 61.4 ± 15.7%; P = 0.0001) and LA strain (TTE1: 13.8 ± 7.4%; TTE2: 30.7 ± 17.5%; P = 0.0001). The left ventricular GLS (TTE 1: -12 ± 5%; TTE 2: -19.1 ± 5.6%; P = 0.0001) and right ventricular GLS (TTE 1: -10 ± 4.5%; TTE2: -17.6± 4.5%; P = 0.0001) were also improved while there was no significant change in LVEF (TTE 1: 55.5 ± 15.8%; TTE2: 59.1 ± 10.8%; P = 0.128). There was a correlation between LA strain changes and left ventricular GLS improvement ( r = 0.53; P = 0.001) and between left and right GLS improvements ( r = 0.6; P = 0.0001) Sinus rhythm maintenance after AF cardioversion is associated to early improvement of, not only LA volume and function, but also left and right ventricular strain

Pharmacological Cardioversion after Pre-Treatment with Antiarrythmic Drugs Prior to Electrical Cardioversion in Persistent Atrial Fibrillation: Impact on Maintenance of Sinus Rhythm.

Background: Antiarrhythmic drugs (AADs) are frequently initiated in patients with persistent atrial fibrillation (AF) prior to electrical cardioversion (ECV), achieving pharmacological cardioversion (PCV) in some cases. Little is known about the mode of cardioversion and the effect of the type of AAD used in the maintenance of sinus rhythm (SR). Methods: From three national surveys of patients with persistent AF referred for ECV, we selected those who were pre-treated with AADs (amiodarone or group Ic AADs). We analyzed the effect of the type of cardioversion (pharmacological vs. electrical) and the AAD used in the maintenance of SR at three months. Results: Among the 665 patients selected, 151 had a successful PCV prior to the planned ECV. In the remaining 514 patients, 460 had a successful ECV. A successful PCV was related to a higher rate of SR maintenance than a successful ECV (77.9% vs. 57.5%; p < 0.0001). After a successful PCV, the maintenance of SR was identical in those patients treated with amiodarone and those treated with group Ic AADs (77.4% vs. 77.5%; p = 0.99), whereas after a successful ECV, amiodarone was clearly superior to group Ic AADs (61.3% vs. 43.0%; p = 0.001). Considering patients with successful PCV and ECV together, PCV was an independent factor related to the maintenance of SR. Conclusions: In patients with persistent AF, successful PCV selects a subgroup with a high probability of maintenance of SR. With regard to drugs, amiodarone was superior to group Ic AADs in patients with ECV, whereas in PCV, no differences were observed.

Advanced interatrial block predicts ineffective cardioversion of atrial fibrillation: a FinCV2 cohort study

Aims Rhythm control using electrical cardioversion (CV) is a common treatment strategy for patients with symptomatic atrial fibrillation (AF). To guide clinical decision making, we sought to assess if electrocardiographic interatrial blocks could predict CV failure or AF recurrence as the phenomenon is strongly associated with atrial arrhythmias. Methods This study included 715 patients who underwent a CV for persistent AF lasting >48 h. P-wave duration and morphology were analyzed in post-procedure or the most recent sinus rhythm electrocardiograms and compared with rates of CV failure and AF recurrence within 30 days after CV as well as their combination (ineffective CV). Results CV was unsuccessful in 63 out of 715 patients (8.8%) and AF recurred in 209 out of 652 (29.2%) patients within 30 days after CV. Overall, 272 (38.0%) CVs turned out ineffective. Advanced interatrial block (AIAB) defined as P-wave duration ≥120 ms and biphasic morphology in inferior leads (II, III and aVF) was diagnosed in 72 (10.1%) cases. AIAB was an independent predictor for CV failure (OR 4.51, 95%CI 1.76–11.56, p = .002), AF recurrence (OR 2.93, 95%CI 1.43–5.99, p = .003) and ineffective CV (OR 3.87, 95%CI 2.04–7.36, p < .001). Conclusion AIAB predicted CV failure, AF recurrence as well as their composite. This study presents an easy electrocardiographic tool for the identification of patients with persistent AF who might not benefit from an elective CV in the future. KEY MESSAGES Interatrial blocks are very common in patients with atrial fibrillation. Advanced interatrial block predicts ineffective cardioversion.

Active compression versus standard anterior-posterior defibrillation for external cardioversion of atrial fibrillation: A prospective randomized study

Electrical cardioversion is the first-line rhythm control therapy for symptomatic persistent atrial fibrillation (AF). Contemporary use of biphasic shock waveforms and anterior-posterior positioning of defibrillation electrodes have improved cardioversion efficacy; however, it remains unsuccessful in >10% of patients. The purpose of this study was to assess the efficacy of applying active compression on defibrillation electrodes during AF cardioversion. We performed a bicenter randomized study including patients referred for persistent AF cardioversion. Elective external cardioversion was performed by a standardized step-up protocol with increasing biphasic shock energy (50-100-150-200 J). Patients were randomly assigned to standard anterior-posterior defibrillation or to defibrillation with active compression applied over the anterior electrode. If sinus rhythm was not achieved at 200 J, a single crossover shock (200 J) was applied. Defibrillation threshold, total delivered energy, number of shocks, and success rate were compared between groups. We included 100 patients, 50 in each group. In the active compression group, defibrillation threshold was lower (103.1 ±49.9 J vs 130.4 ± 47.7 J; P = .008), as well as total delivered energy (203 ± 173.3 J vs 309 ± 213.5 J; P = .0076) and number of shocks (2.2 ± 1.1 vs 2.9 ± 1.2; P = .0033), and cardioversion was more often successful (48 of 50 patients [96%] vs 42 of 50 patients [84%]; P = .0455) than that in the standard anterior-posterior group. Crossover from the compression group to the standard group was not successful (0 of 2 patients), whereas crossover from the standard group to the compression group was successful in 50% of patients (4 of 8). Active compression applied to the anterior defibrillation electrode is more effective for persistent AF cardioversion than standard anterior-posterior cardioversion, with lower defibrillation threshold and higher success rate.

Dominant frequency predicts sinus rhythm maintenance after electrical cardioversion for persistent atrial fibrillation in men but not in women

Abstract Background Women are usually underrepresented in studies evaluating rhythm control strategies in patients with atrial fibrillation (AF). Subsequently, the same holds true for studies looking at predictors for success of a rhythm control strategy for AF. Purpose To study the predictive power of the non-invasively determined dominant frequency (DF) on the electrocardiogram (ECG) in men and women undergoing electrical cardioversion (ECV) for persistent AF. Methods We matched 105 female patients undergoing elective ECV for persistent AF and 105 male control patients based on age and cardiovascular comorbidity profile. We determined the DF on all 12 leads of a standard digital 10 seconds ECG recorded on the day of ECV. Recurrences of AF within the first year after ECV were documented. Results There were no differences in comorbidities, AF duration, left ventricular systolic function, indexed left atrial volume and anti-arrhythmic drugs between male and female patients. The dominant frequency was significantly lower in male patients without an AF recurrence on all leads. The best performing lead to identify patients with recurrences was lead III with an AUC 0.752. The optimal cut-off point was a DF &amp;lt;5.98 Hz with a sensitivity 84% and a specificity 67%. There was no significant difference in DF between female patients with and without an AF recurrence. The AUC in lead III was 0.47 (Figure 1). Conclusion The non-invasively measured dominant frequency is able to predict AF recurrence after electrical cardioversion in male patients with persistent AF but not in a matched female cohort. This difference might be explained by different pathophysiological mechanisms underlying AF in male and female patients. Therefore, future research is needed on pathophysiological differences between men and women that can explain and might overcome these challenges. Figure 1 Funding Acknowledgement Type of funding source: Public grant(s) – EU funding. Main funding source(s): European Network for Translational Research in Atrial Fibrillation (grant no. 261057), the Center for Translational Molecular Medicine (COHFAR),

The prognostic value of soluble suppression of tumourigenicity 2 and galectin-3 for sinus rhythm maintenance after cardioversion due to persistent atrial fibrillation in patients with normal left ventricular systolic function.

Soluble suppression of tumourigenicity 2 (sST2) and galectin-3 are involved in cardiac fibrosis, inflammation, and remodelling. However, the place of sST2 and galectin-3 in predicting the outcomes of electrical cardioversion of atrial fibrillation (AF) is uncertain. We evaluated whether these biomarkers could predict sinus rhythm (SR) maintenance after cardioversion of persistent AF in patients with normal left ventricular systolic function. The study included 80 patients with persistent AF, who underwent cardioversion from February 2016 to August 2018. The blood concentrations of sST-2 and galectin-3 were measured with ELISA and the ASPECT-PLUS assays. Clinical and electrocardiographic follow-up was performed at months 1, 6, and 12. Patients who maintained SR at 12 months had significantly lower concentrations of sST2, measured by ELISA and ASPECT-PLUS assays, than the remaining patients (16.9 ± 9.8 vs. 28 ± 22.9 ng/mL; P < 0.001; 28.7 ± 13.4 vs. 40 ± 25.1 ng/mL; P = 0.003); the concentration of galectin-3 did not differ between these patients. Multivariable logistic regression showed that log-transformed sST2 ELISA was a significant predictor of SR maintenance at 12 months [odds ratio 0.14; 95% confidence interval (CI) 0.03-0.58; P = 0.006]. On receiver-operating characteristic curve analysis, the areas under the curve for the concentration of sST2 was 0.752 (95% CI 0.634-0.870; P < 0.001). The concentrations of sST2 measured with the two assays were strongly correlated (rho = 0.8; CI 95% 0.7-0.87; P = 0.001). Soluble suppression of tumourigenicity 2, but not galectin-3, can be used to predict SR maintenance after cardioversion of AF in patients with normal left ventricular systolic function. The measurements of sST2 concentrations with the rapid lateral flow and enzyme-linked immunoassays were consistent.

Paradigm shifts in pathophysiology and management of atrial fibrillation-atale of the RACE trials in the Netherlands.

In the past 20 years the Netherlands-based RACE trials have investigated important concepts in clinical atrial fibrillation (AF). Their scope ranged from rhythm versus rate control to early or delayed cardioversion and also included early comprehensive management of AF in two trials, one focusing on early ‘upstream therapy’ and risk factor management and the other on integrated chronic nurse-led care. Studies were mostly triggered by simple clinical observations including futility of electrical cardioversion in persistent AF; many patients with permanent AF tolerating day-after-day ‘uncontrolled’ resting heart rates of up till 110 beats/min; patients being threatened more by vascular risks than AF itself; and insufficient guideline-based treatments for AF. Also the observation that recent-onset atrial fibrillation generally converts spontaneously, obviating cardioversion, triggered one of the studies. The RACE trials shifted a number of paradigms and by that could change the AF guidelines. The initial ‘shock-and-forget’ attitude made place for increased attention for anticoagulation, and in turn, broader vascular risks were recognised. In a nutshell, the adage eventually became: ‘look beyond the ECG, treat the patient’.Electronic supplementary materialThe online version of this article (10.1007/s12471-020-01476-0) contains supplementary material, which is available to authorized users.

P429The efficacy of electrical cardioversion of long-standing persistent or permanent atrial fibrillation in cardiac resynchronization therapy recipients

Abstract Funding Acknowledgements Institute of Cardiology statutory grant (grant no.: 2.30/VII/13) Background Atrial fibrillation (AF) and heart failure (HF) often co-exist and influence each other. The presence of AF is often regarded as a marker of HF severity. Moreover, AF in cardiac resynchronization therapy (CRT) recipients hinders the CRT effectiveness in HF treatment by the reduction of the percentage of biventricular paced beats (BiVp%). Sinus rhythm (SR) restoration makes CRT more effective in HF treatment which may protect AF recurrence. Purpose To establish the effectiveness of electrical external cardioversion (EEC) in CRT patients with long-standing persistent AF or permanent, pre-treated with amiodarone. Methods The population of the study comprised of the Pilot-CRAfT study participants (NCT01850277), that is patients with CRT, long-standing persistent or considered as permanent AF and BiVp ≤ 95% who were randomly assigned to the "rhythm control" or the "rate control" strategy. The inclusion criteria included an AF paroxysm lasting at least 6 months. Both treatment arms received amiodarone beginning with the loading dose. Subsequently, patients assigned to the rhythm control strategy underwent electrical cardioversion. Rate control strategy included pharmacotherapy and atrioventricular node ablation, as needed. The follow up visit was performed 3 months after the enrolment visit. The EEC effectiveness, an AF recurrence within the 3 month period, BiVp% changes, the EEC parameters and the EEC related complications were analysed. Results Out of 48 participants enrolled in the Pilot-CRAfT study, 25 patients were assigned to the rhythm control arm. The mean age of the rhythm control arm patients was 69,5 years , the mean left ventricular ejection fraction was 30,6% , the mean left atrium diameter was 53 mm and the median duration of persistent AF was 16 months. SR was obtained in 12 out of 20 (60%) patients who underwent the EEC . On the 3 month visit 8 patients remained in SR (40%). In patients with an AF paroxysm lasting less than 1 year the success rate was 100% vs 50% in the AF lasting 1 year at least (p = 0,11 ). After 3 months, SR remained in 100% vs 25% of patients, respectively (p =0,015.). The effectiveness of anterior-posterior EEC electrodes placement was 20% and it was 71% for the anterior-lateral patch location . The EEC resulted in significant BiVp% rise - also in the whole intention-to-treat (ITT) group: 88,58% before the EEC vs 96,68% after the EEC (p = 0,002). No severe adverse events of the EEC were observed. Conclusions The electrical cardioversion of persistent atrial fibrillation lasting more than 6 months in patients with severe HF and treated with CRT is characterised by modest success rate, even after the amiodarone pre-treatment. However, the ECC ensures significant rise in BiVp% close to 97%, even in the whole EEC group based on the ITT principle. The AF paroxysm duration &amp;lt;1 year and the anterior-posterior patch placement may ensure better EEC efficacy in this group of patients.

Comparison of Efficacy and Safety of Different Doses of Nifekalant Instant Cardioversion of Persistent Atrial Fibrillation During Radiofrequency Ablation

Comparison of Efficacy and Safety of Different Doses of Nifekalant Instant Cardioversion of Persistent Atrial Fibrillation During Radiofrequency Ablation