Cardioversion Of Atrial Arrhythmias Research Articles

Abstract 86: Anterior-lateral Vs Anterior-posterior Electrode Positioning For Cardioversion Of Atrial Fibrillation And Atrial Arrythmias: A Systematic Review And Meta-analysis

Anterior-lateral Vs Anterior-posterior Electrode Positioning for Cardioversion of Atrial Fibrillation and Atrial Arrhythmias: A Systematic Review and Meta-analysis Introduction: Multiple randomized controlled trials (RCTs) have compared the efficacy of anterolateral (AL) and anteroposterior (AP) electrode positioning for cardioversion of atrial fibrillation and other atrial arrhythmias with conflicting results. We hypothesized that AP electrode positioning will have a superior efficacy for cardioversion due to better alignment of the energy vector with the atria. Methods: A systematic search was conducted in the MEDLINE and Embase databases utilizing the Ovid interface. Results were screened to identify RCTs comparing AL and AP position of electrodes for cardioversion for atrial arrhythmias. Studied outcomes included the success of cardioversion, number of shocks, and mean shock energy required for successful cardioversion to sinus rhythm. Mantel-Haenszel aggregated risk ratios (RR) with 95% CIs were calculated. Results: A total of 14 RCTs were included comprising 2445 patients (1329 AL, 1116 AP). There was no statistically significant difference between the two groups with respect to successful cardioversion (RR 1.02 [0.97-1.06]; p = 0.43), first shock success (RR 1.14 [0.99-1.32]; p = 0.06), second shock success (RR1.08 [0.94-1.23]; p = 0.29), mean shock energies (mean difference 6.49 [17.33-30.31]; p = 0.59). We additionally compared success at high; >150 J (RR 1.02 [0.92-1.14] and low; <150 J (RR 1.09 [0.97-1.22]; p = 0.64) cardioversion energies which also did not show any significant difference. Conclusions: There is no significant difference in the efficacy between AL vs. AP electrode position for cardioversion of atrial arrhythmias.

The effect of patient weight and amiodarone use on the energy of a successful shock in cardioversion of atrial arrhythmias – single-center experience study

Abstract Background Electrical cardioversion (DCCV) is an effective method of sinus rhythm restitution. Recently published data suggest higher efficiencies of higher discharge energies. The influence of individual parameters on the success of cardioversion is still studying. Purpose To evaluate the influence of individual patient parameters on the energy of a successful external defibrillator shock during cardioversion of atrial arrhythmias Methods The retrospective analysis cohort of all patients treated by DCCV due to atrial arrhythmias between 10/2015 and 1/2020. To evaluate potential predictors for the choice of a higher initial discharge using one-dimensional logistic regression and to include parameters significant at the 10% level of significance (p<0.1) in the multidimensional logistic regression model. Results 1986 electrical cardioversions of 984 patients (382 repeated procedures of the same patients in a cohort). 1292 (65.1%) men and 694 (34.9%) women aged 67.0 (±10.2) years. Mean energy of the first shock 118.9 (±19.2) J with a success rate of 77.8%, energy of the second shock 154.0 (±26.3) J, which increased the overall success to 80.0%, and mean high of the third shock 173.9 (±25.6) J, when the total efficacy of DCCV in sinus rhytm restitution reached 89.8%. From the univariate binary regression, parameters significant at the 10% level of significance (p<0.1) were selected and included in a multidimensional logistic regression model. Only the patient's weight and the use of amiodarone proved to be statistically significant. Weight with OR 1.21 and use of amiodarone with OR 1.43. Conclusion Patient weight and amiodarone use are predictors of the need to use higher energy electric cardioversion. Discussion Amiodarone medication does not appear to increase the defibrillation threshold, but rather is a feature that represents the group of patients treated with more aggressive antiarrhythmic therapy for advanced atrial arrhythmias with more significant structural impairment, but this attitude requires further study. Funding Acknowledgement Type of funding sources: Private hospital(s). Main funding source(s): VAVIA: IGS202009 - Racionální algoritmus při elektivní elektrické kardioverzi fibrilace síní.

A case of cautery-version

Electrocautery has previously been reported to induce ventricular arrhythmias in rare cases.1–3 However, to our knowledge, induction or cardioversion of atrial arrhythmias has not been reported. We report a case of repeated cardioversion from atrial flutter to sinus rhythm during electrocautery in a patient with a dual-chamber pacemaker.

Myocardial Injury Following Elective Direct Current Cardioversion for Atrial Arrhythmias

Myocardial Injury Following Elective Direct Current Cardioversion for Atrial Arrhythmias

Chronic Fish Oil Ingestion in Humans Reduces Atrial Mechanical Stunning After Direct Current Cardioversion for Atrial Arrhythmias: Implications for Stroke Prevention

Methods:Patients (meanage44± 15years, 62% females) with no underlying structural heart disease undergoing electrophysiology study (EPS) for supraventricular tachycardia were randomized to standard therapy (n= 28), or fish oils (n= 30, dose of 2 g/day) for 2 months prior to the EPS. Electrophysiological parameters such as atrial refractoriness, conduction times, P wave duration and AF inducibility were assessed. Results:Plasmaeicosapentaenoic (EPA)anddocosahexaenoic acid (DHA) levels were significantly higher in the fish oil versus standard therapy group (EPA: 2.6± 1.1 vs. 0.9± 0.38 and DHA: 6.1± 2.01 vs. 2.9± 1.2, respectively, P< .001). Fish oil recipients had (1) significantly increased refractoriness at all pacing cycle lengths at the distal coronary sinus (mean ERP: 265± 42ms vs. 236± 26ms, P= .01) and proximal coronary sinus (mean ERP: 241± 24ms vs. 218± 22ms, P= .003) (2) increased refractoriness at the low lateral right atrium (meanERP 233± 30ms vs. 222± 45ms, P= .16) and increased P wave duration (105± 20ms vs. 95± 21ms, P= .13) but not significantly so (3) Less conduction delay within the coronary sinus (58± 12ms vs. 78± 27ms, P= .004) (4) Lower incidence of inducible AF (62% vs. 100%, P= .001 for AF≥ 10 s; 63% vs. 93%, P= .01 for AF≥ 30 s). Lower AF inducibility index (24% vs. 61%, P= .000 for AF≥ 10 s; 16% vs. 44%, P= .000, for AF≥ 30 s). Conclusions: Chronic ingestion of fish oils increases atrial refractoriness; reduces conduction anisotropy and reduces susceptibility to AF in humans. doi:10.1016/j.hlc.2010.06.902

Practical management of common atrial arrhythmias 1: cardioversion

This is the first in a series of four practical articles highlighting the important management steps for non-cardiologists and non-cardiac electrophysiologists dealing with patients with atrial fibrillation and common atrial flutter. This article will deal with care pathways and management principles for cardioversion of atrial arrhythmias.

The circadian variation of atrial defibrillation thresholds.

A circadian variation exists for ventricular defibrillation thresholds (DFTs) with a morning peak and a corresponding decrease in therapy success rates from implantable cardioverter defibrillators. Such a variation in atrial DFTs may have implications for the timing of internal cardioversion of atrial arrhythmias. The aim of this study was therefore to determine the circadian variation of atrial DFTs in patents with recurrent atrial fibrillation (AF). Data were collected as part of the worldwide Jewel AF-only study. Patients had recurrent persistent AF and no history of ventricular arrhythmias. The atrial DFT was assessed at device implantation using a step-up protocol and was recorded for 100 patients (age 63.0 +/- 11.7, 74% male, ejection fraction 49.6 +/- 17.8%, left atrial diameter 46 +/- 9 mm). The mean atrial DFT was 6.3 +/- 4.3 J. For the most commonly tested lead configuration (right atrium to coronary sinus in 56 patients), the atrial DFT for patients implanted in the morning (3.3 +/- 1.5 J) was significantly lower than for both the DFT measured in the afternoon (5.8 +/- 3.4 J, p < 0.01) and the DFT measured in the evening (7.4 +/- 5.9 J, p < 0.01). There may be a significant variation in measured atrial DFT for the right atrium to coronary sinus configuration, with a nadir in the morning. This is the converse to measurements of ventricular DFTs suggesting different regulatory electrophysiological mechanisms. Further investigation of this possible variation is warranted.

The circadian variation of atrial defibrillation thresholds

Background: A circadian variation exists for ventricular defibrillation thresholds (DFTs) with a morning peak and a corresponding decrease in therapy success rates from implantable cardioverter defibrillators. Such a variation in atrial DFTs may have implications for the timing of internal cardioversion of atrial arrhythmias. The aim of this study was therefore to determine the circadian variation of atrial DFTs in patents with recurrent atrial fibrillation (AF). Methods and results: Data were collected as part of the worldwide Jewel AF-only study. Patients had recurrent persistent AF and no history of ventricular arrhythmias. The atrial DFT was assessed at device implantation using a step-up protocol and was recorded for 100 patients (age 63.0 ± 11.7, 74% male, ejection fraction 49.6 ± 17.8%, left atrial diameter 46 ± 9 mm). The mean atrial DFT was 6.3 ± 4.3 J. For the most commonly tested lead configuration (right atrium to coronary sinus in 56 patients), the atrial DFT for patients implanted in the morning (3.3 ± 1.5 J) was significantly lower than for both the DFT measured in the afternoon (5.8 ± 3.4 J, p < 0.01) and the DFT measured in the evening (7.4 ± 5.9 J, p < 0.01). Conclusion: There may be a significant variation in measured atrial DFT for the right atrium to coronary sinus configuration, with a nadir in the morning. This is the converse to measurements of ventricular DFTs suggesting different regulatory electrophysiological mechanisms. Further investigation of this possible variation is warranted.

Reversal of atrial mechanical stunning following radiofrequency ablation of chronic atrial flutter: Implications for the cardioversion of atrial arrhythmias

Reversal of atrial mechanical stunning following radiofrequency ablation of chronic atrial flutter: Implications for the cardioversion of atrial arrhythmias

Efficacy and safety of a new single dual-purpose diagnostic catheter for low energy cardioversion of atrial arrhythmias

Efficacy and safety of a new single dual-purpose diagnostic catheter for low energy cardioversion of atrial arrhythmias

Efficacy and safety of a new single dual-purpose diagnostic catheter for low energy cardioversion of atrial arrhythmias

Efficacy and safety of a new single dual-purpose diagnostic catheter for low energy cardioversion of atrial arrhythmias

Cardiac troponin T does not increase after electrical cardioversion for atrial fibrillation or atrial flutter

ObjectiveTo determine whether cardiac troponin T increases after electrical cardioversion in patients with atrial fibrillation or atrial flutter.DesignSerum creatine kinase (CK), creatine kinase-MB (CKMB), and cardiac troponin T were measured...

Factors predicting maintenance of sinus rhythm after direct current cardioversion of atrial fibrillation and flutter: a reanalysis with recently acquired data.

A prospective study was conducted to evaluate how many patients maintain normal sinus rhythm after direct current (DC) cardioversion of atrial arrhythmias and to assess factors predictive of long-term success. The study group consisted of 61 patients (45 men) aged 18-88 years (mean age 66 +/- 11 years) who underwent cardioversion at our department from October 1990 to June 1992. Prior to cardioversion, the patients' medical history, medications, heart size on chest X ray, and echocardiographic findings were reviewed. Overall, 41 (67.2%) patients were in atrial fibrillation, while 20 (32.8%) had atrial flutter. Only 15% of the patients had valvular heart disease. Sinus rhythm was restored by DC cardioversion in 47 (77%) patients, none of whom experienced an embolic event prior to discharge. Patients with atrial flutter had a higher conversion rate (95%) than those in atrial fibrillation (68.3%; p = 0.024), and also patients with an arrhythmia for less than 1 week (94.4%) compared to those with a longer or unknown duration (69.8%; p = 0.047). The primary success rate was not influenced by heart size on chest X ray or echocardiographic variables. The study protocol aimed at following up the patients for 1 year after cardioversion. Of the 47 patients who converted to sinus rhythm data are available on 44 for a mean follow-up of 11 +/- 3 months (range 1-14 months), at which time 25 (57%) still remained in sinus rhythm. Heart size on the chest X ray was significantly increased in the group that did not maintain sinus rhythm (p = 0.03) and their left atrial size on echocardiography was slightly increased (p = 0.10). Patients who originally had atrial flutter were more likely to remain in sinus rhythm than those who had been in atrial fibrillation (p = 0.12), as did patients with an arrhythmia for less than 1 week prior to cardioversion in comparison to those with a longer or unknown duration (p = 0.11). Thus, in contrast to previous reports, according to these recent data on a patient population with a low prevalence of valvular heart disease, DC cardioversion can be attempted in most patients with atrial tachyarrhythmias. Clinical factors, heart size on chest X ray and echocardiographic findings should, however, be considered before deciding to perform DC cardioversion.

Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study.

Transesophageal echocardiography (TEE) has been used recently to detect atrial thrombi before cardioversion of atrial arrhythmias. It has been assumed that embolic events after cardioversion result from embolism of preexisting atrial thrombi that are accurately detected by TEE. This study examined the clinical and echocardiographic findings in patients with embolism after cardioversion of atrial fibrillation despite exclusion of atrial thrombi by TEE. Clinical and echocardiographic data in 17 patients with embolic events after TEE-guided electrical (n = 16) or pharmacological (n = 1) cardioversion were analyzed. All 17 patients had nonvalvular atrial fibrillation, including four patients with lone atrial fibrillation. TEE before cardioversion showed left atrial spontaneous echo contrast in five patients and did not show atrial thrombus in any patient. Cardioversion resulted in return to sinus rhythm without immediate complication in all patients. Thirteen patients had cerebral embolic events and four patients had peripheral embolism occurring 2 hours to 7 days after cardioversion. None of the patients were therapeutically anticoagulated at the time of embolism. New or increased left atrial spontaneous echo contrast was detected in four of the five patients undergoing repeat TEE after cardioversion including one patient with a new left atrial appendage thrombus. Embolism may occur after cardioversion of atrial fibrillation in inadequately anticoagulated patients despite apparent exclusion of preexisting atrial thrombus by TEE. These findings suggest de novo atrial thrombosis after cardioversion or imperfect sensitivity of TEE for atrial thrombi and suggest that screening by TEE does not obviate the requirement for anticoagulant therapy at the time of and after cardioversion. A randomized clinical trial is needed to compare conventional anticoagulant management with a TEE-guided strategy including anticoagulation after cardioversion.

Return of atrial mechanical function following electrical conversion of atrial dysrhythmias

The return of atrial mechanical function and its relationship to embolic events following cardioversion of atrial arrhythmias is controversial. Fourteen patients with atrial arrhythmias were evaluated with pulsed Doppler echocardiography before and after direct current (DC) cardioversion. The atrial filling fraction increased significantly: 1.14 ± 4.3% at baseline versus 14.9 ± 13.3%, 13.4 ± 11.4%, and 21.9 ± 13.5% at 5 minutes, 30 minutes, and 24 hours, respectively, following cardioversion. Absent atrial mechanical activity was noted in four patients immediately after cardioversion. Mechanical activity resumed by 30 minutes in one patient and at 24 hours in two others. Those with delayed atrial function had lower stroke volumes and atrial filling fractions following cardioversion. An embolic event occurred in one patient who had immediate return of atrial mechanical activity. This patient also had the largest atrial filling fraction of any patient at 24 hours (41%). These data suggest that the degree of atrial mechanical activity following cardioversion is variable and that embolic episodes are not necessarily related to delayed return of atrial mechanical activity following cardioversion.

Pulmonary Edema Following Direct Current Cardioversion for Atrial Arrhythmias

Three patients developed acute pulmonary edema shortly after direct current cardioversion for atrail arrhythmias. All patients had marked left ventricular enlargement and evidence of left ventricular failure prior to cardioversion. Each patient received a single low-intensity shock. Two patients recovered, but the third failed to respond to intensive medical treatment for pulmonary edema, and death resulted. Cardioversion may result in critical depression of left ventricular function and may not be indicated for the treatment of atrial arrhythmias in the presence of severe disease of the left ventricle.