Cardioversion Of Atrial Fibrillation Research Articles

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

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

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

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

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

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

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

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

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

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.

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

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

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

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

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

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

New possibilities of antiarrhythmic therapy of atrial fibrillation: A review

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

Computed Tomography to Exclude Cardiac Thrombus in Atrial Fibrillation-An 11-Year Experience from an Academic Emergency Department.

Computed tomography (CT) could be a suitable method for acute exclusion of left atrial appendage thrombus (LAAT) prior to cardioversion of atrial fibrillation (AF) and atrial flutter (AFL) at the emergency department. Our aim was to present our experiences with this modality in recent years. This registry-based observational study was performed at the Department of Emergency Medicine at the Medical University of Vienna, Austria. We studied all consecutive patients with AF and AFL who underwent CT between January 2012 and January 2023 to rule out LAAT before cardioversion to sinus rhythm was attempted. Follow-ups were conducted by telephone and electronic medical records. The main variables of interest were the rate of LAAT and ischemic stroke at follow-up. A total of 234 patients (143 [61%] men; median age 68 years [IQR 57-76], median CHA2DS2-VASc 2 [IQR 1-4]) were analyzed. Follow-up was completed in 216 (92%) patients after a median of 506 (IQR 159-1391) days. LAAT was detected in eight patients (3%). A total of 163 patients (72%) in whom LAAT was excluded by CT were eventually successfully cardioverted to sinus rhythm. No adverse events occurred during their ED stay. All patients received anticoagulation according to the CHA2DS2-VASc risk stratification, and no patient had suffered an ischemic stroke at follow-up, resulting in an incidence risk of ischemic strokes of 0% (95% CI 0.0-1.2%). LAAT was rare in patients admitted to the ED with AF and AFL who underwent cardiac CT prior to attempted cardioversion. At follow-up, no patient had suffered an ischemic stroke. Prospective studies need to show whether this strategy is suitable for the acute treatment of symptomatic AF in the emergency setting.

Predictors of long-term outcomes in patients with persistent atrial fibrillation undergoing electrical cardioversion.

Cardioversion for atrial fibrillation (AF) is routinely implemented in daily practice; however, it can be associated with the development of recurrent AF. In this study we aimed to evaluate the predictors of AF recurrence after electrical cardioversion, and to compare the outcomes of patients with or without AF recurrence during follow-up. Patients with persistent AF were enrolled from March 2015 to September 2018. Patients with recurrent AF within 6 months after the index cardioversion were considered as AF recurrence (AFR) group, and those with normal sinus rhythm were defined as normal sinus rhythm (NSR) group. Thereafter, all patients were followed up for the incidence of adverse events, including death, requiring dialysis, coronary artery intervention/surgeries, cerebrovascular events, heart failure, and recurrent AF beyond 6 months. Of 129 patients, 11 patients had failed cardioversion and 7 patients lost to follow-up. So, 34 and 77 patients were categorized as the NSR and the AFR groups. During a median follow-up time of 54 (46-75) months, there was a trend for a higher incidence of major adverse events in the AFR group compared to the NSR group (P=0.063). Lower body mass index (odds ratio [OR] 0.885, 95% confidence interval [CI] 0.794-0.986, P=0.027) and coarse AF before the index cardioversion (OR 3.846, 95% CI 1.189-12.443, P=0.025) were the independent predictors of recurrent AF. In patients with persistent AF undergoing cardioversion, the presence of coarse AF and the lower values of body mass index were found to be associated with the AF recurrence.

Central retinal artery occlusion after cardioversion of atrial fibrillation.

Central retinal artery occlusion (CRAO) is a vascular ophthalmic emergency. Often caused by a sudden interruption of blood flow to the eye, with profound and painless vision loss, resulting in irreversible cell damage. An impacted embolus at the narrowest part of the central retinal artery is the most common cause. Cardioversion is a medical procedure used to restore a normal heart rhythm in individuals with atrial fibrillation (AF). In some cases, cardioversion can lead to thromboembolic complications. If an embolus reaches the central retinal artery, it can block the blood flow to the retina, resulting in CRAO and subsequent vision loss.

Functional tricuspid regurgitation and efficacy of electrical cardioversion in patients with atrial fibrillation and atrial functional mitral regurgitation.

Atrial functional mitral regurgitation (afMR) is common in patients with atrial fibrillation (AF). The presence of functional tricuspid regurgitation (fTR), which arises as a secondary effect of afMR, has the potential to impact the effectiveness of procedures aimed at restoring normal heart rhythm. In this study, we sought to evaluate the efficacy of electrical cardioversion (CVE) in AF regarding the presence and degree of fTR in patients with afMR. Retrospective analysis included 521 patients with persistent AF on optimal medical therapy undergoing CVE. 157 (30.1%) patients had afMR (characterized by left ventricle ejection fraction ≥ 50% and LA dilatation) and were divided into 2 groups: the group with fTR (107, 68.2%) and the group without fTR (50, 31.9%). Patients with afMR and fTR had a higher prevalence of metabolic syndrome (p = 0.02) and greater right atrial area (p < 0.01) compared to patients without fTR. The efficacy of CVE was lower in the group with fTR in comparison to patients with isolated afMR (82.2% vs. 94%; p = 0.048) and it was unrelated to the degree of fTR (p = 0.15) and RVSP (p = 0.56). The energy required for successful CVE was comparable regardless of the presence (p = 0.26) or severity of fTR (p = 0.94). The fTR frequently coexists with afMR and it significantly diminishes the effectiveness of CVE for treating AF. The degree of fTR does not appear to influence the efficacy of CVE.

Atrial Thrombosis Prevalence Before Cardioversion or Catheter Ablation of Atrial Fibrillation: An Updated Systematic Review and Meta-Analysis of Direct Oral Anticoagulants Versus Vitamin K Antagonists

Left atrial or left atrial appendage thrombosis (LAT) is contraindicated for cardiac ablation (CA) or cardioversion (CV) of atrial fibrillation (AF). This study was aimed to compare the frequency of LAT detected by transesophageal echocardiography (TEE) before CA or CV in patients with AF treated with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). We searched PubMed, Scopus, Web of Science, and Cochran Library databases from inception through July 13, 2023 to select studies reporting data on LAT identification before CA or CV using TEE in patients with AF treated with DOACs or VKAs. Pooled odds ratios (ORs) with 95% confidence interval were calculated with a random-effects model. Studies retrieved were 50 (38 observational), 29 on CA, 15 on CV, and 6 on both procedures (17,096 patients on DOACs and 13,666 on VKAs). The overall prevalence of LAT was smaller in DOACs than in VKAs, with an OR of 0.66 (0.52 to 0.84), confirmed at sensitivity analysis and in most subgroups. This finding was consistent for the 3 most reported DOACs: the pooled OR for LAT was 0.68 (0.50 to 0.90) in apixaban, 0.67 (0.51 to 0.88) in dabigatran, 0.61 (0.43 to 0.89) in rivaroxaban, and 1.10 (0.74 to 1.64) in edoxaban (not significant). In conclusion, in this large meta-analysis in patients with AF, the prevalence of LAT by TEE evaluation performed before CV or CA appears lower in those treated with DOACs than in those on VKAs. Additional research may help in better understanding differences between these classes of anticoagulant drugs in the setting of protection against AF-related left atrial thrombotic formation.

Response to Nguyen et al.'s letter regarding "Anteriolateral versus anterior-posterior electrodes in external cardioversion of atrial fibrillation: A systematic review and meta-analysis of clinical trials".

Response to Nguyen et al.'s letter regarding "Anteriolateral versus anterior-posterior electrodes in external cardioversion of atrial fibrillation: A systematic review and meta-analysis of clinical trials".

Safety and Effectiveness of Antidysrhythmic Drugs for Pharmacologic Cardioversion of Recent-Onset Atrial Fibrillation: a Systematic Review and Bayesian Network Meta-analysis.

The available evidence to determine which antidysrhythmic drug is superior for pharmacologic cardioversion of recent-onset (onset within 48h) atrial fibrillation (AF) is uncertain. We aimed to identify the safest and most effective agent for pharmacologic cardioversion of recent-onset AF in the emergency department. We searched MEDLINE, Embase, and Web of Science from inception to February 21, 2023 (PROSPERO: CRD42018083781). Eligible studies were randomized controlled trials that enrolled adult participants with AF ≤ 48h, compared a guideline-recommended antidysrhythmic drug with another antidysrhythmic drug or a different formulation of the same drug or placebo and reported specific adverse events. The primary outcome was immediate, serious adverse event - cardiac arrest, sustained ventricular tachydysrhythmia, atrial flutter 1:1 atrioventricular conduction, hypotension, and bradycardia. Additional analyses included the outcomes of conversion to sinus rhythm within 4h and 24h. We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effect model and vague prior distribution to calculate odds ratios with 95% credible intervals. We assessed confidence using CINeMA. We used surface under the cumulative ranking curve (SUCRA) to rank agent(s). The systematic review initially identified 5545 studies. Twenty-five studies met eligibility criteria, and 22 studies (n = 3082) provided data for NMA, which demonstrated that vernakalant (SUCRA = 70.9%) is most likely to be safest. Additional effectiveness NMA demonstrated that flecainide (SUCRA = 89.0%) is most likely to be superior for conversion within 4h (27 studies; n = 2681), and ranolazine-amiodarone IV (SUCRA 93.7%) is most likely to be superior for conversion within 24h (24 studies; n = 3213). Confidence in the NMA estimates is variable and limited mostly by within-study bias and imprecision. Among guideline-recommended antidysrhythmic drugs, the combination of digoxin IV and amiodarone IV is definitely among the least safe for cardioversion of recent onset AF; flecainide, vernakalant, ibutilide, propafenone, and amiodarone IV are definitely among the most effective for cardioversion within 4h; flecainide is definitely among the most effective for cardioversion within 24h. Further, randomized controlled trials with predetermined and strictly defined, hemodynamic adverse event outcomes are recommended.

One-year outcomes of anterior–posterior vs. anterior-lateral method of cardioversion for atrial fibrillation: a tertiary center experience

This retrospective cohort study aimed to compare the one-year outcomes of anterior–posterior (AP) and anterior—lateral (AL) methods of cardioversion for atrial fibrillation (AF). A total of 2168 patients were included, with 1125 patients in the AP cardioversion group (Group 1) and 1043 patients in the AL cardioversion group (Group 2). Baseline characteristics, primary and secondary outcomes, safety outcomes, and logistic regression predictors of sinus rhythm were analyzed. The results showed comparable rates of maintaining sinus rhythm at the one-year follow-up between the two groups (65.8% in Group 1 vs. 65.7% in Group 2, p = 0.042). There were no significant differences in the incidence of AF recurrence or safety outcomes between the groups. Logistic regression analysis identified the duration of AF and the presence of coronary artery disease as significant predictors of sinus rhythm maintenance. Additionally, the use of the AL method was associated with a higher likelihood of AF recurrence compared to the AP method (p = 0.043). These findings suggest that both the AP and AL methods of cardioversion are effective in achieving and maintaining sinus rhythm in AF patients. The duration of AF and the presence of coronary artery disease should be considered when selecting the cardioversion approach. These results contribute to the understanding of optimal treatment strategies for AF and support personalized management decisions based on individual patient characteristics.

Gender Differences With Ibutilide Effectiveness and Safety in Cardioversion of Atrial Fibrillation

IntroductionFew studies have examined the use of ibutilide in noncardiac surgical populations. Our study considered the effectiveness and safety of ibutilide in cardioversion of atrial fibrillation (AF) in medical and surgical intensive care patients. MethodsA retrospective chart review was performed for patients with a confirmed diagnosis of AF who were hemodynamically stable and received ibutilide after the initial diagnosis. Patients were administered 1 mg of ibutilide fumarate intravenous for 10 min with a second dose administered if AF persisted after 30 min. Patients were pretreated with intravenous magnesium sulfate if their blood magnesium level was <2 mg/dL. ResultsFifty seven total female patients and 99 male patients received ibutilide. Females had an 88% conversion rate to normal sinus rhythm (NSR) compared to 68% in males (P = 0.008). A 70% successful return to NSR was observed in patients from all groups pretreated with magnesium sulfate (P = 0.045). One year after discharge, 74% of the patients stayed in the NSR. ConclusionsWithin our population, pretreatment with magnesium sulfate followed by ibutilide was associated with increased conversion to NSR. Additionally, we noted that females had a higher conversion rate to NSR compared to males, regardless of whether they were pretreated with magnesium sulfate.

Comparison of efficacy of pharmacological cardioversion with antazoline and propafenone versus electrical cardioversion in atrial fibrillation during cryoablation.

Antazoline with propafenone may be an alternative to electrical cardioversion (ECV) in restoring sinus rhythm in patients with atrial fibrillation (AF), including during balloon cryoablation. To compare the efficacy of antazoline with propafenone and ECV in restoring and maintaining sinus rhythm at discharge in patients with AF during cryoablation with special regard to type of AF. The study retrospectively analyzed 196 patients who underwent elective cryoablation. Eighty-nine patients who developed AF in the perioperative period were selected as the study group (32 women and 57 men). The study group was divided into two groups - 46 (51.7%) patients were given pharmacological cardioversion with 70 mg of propafenone and 100 or 200 mg of antazoline, whereas the other 43 (48.3%) patients underwent ECV. There were no statistically significant differences between the groups regarding: left atrial area, left atrium diameter, right atrial area and right atrium diameter. In the overall population, ECV was more effective than antazoline with propafenone therapy (31 [72.1%] vs. 20 [43.5%]; p = 0.01). A similar relationship was demonstrated in patients with persistent AF (13 [59.1%] vs. 3 [12.5%]; p = 0.002). There was no significant difference in the group of patients with paroxysmal AF (18 (85.6%) vs. 17 (77.3%); p = 0.7). In AF during the cryoablation procedure ECV appears to be more effective in restoring and maintaining sinus rhythm at discharge than antazoline with propafenone in the general AF patient population, especially in patients with persistent AF.

Predictors of nonpulmonary vein triggers for atrial fibrillation: A clinical risk score

BackgroundTargeting non-pulmonary vein triggers (NPVTs) after pulmonary vein isolation may reduce atrial fibrillation (AF) recurrence. Isoproterenol infusion and cardioversion of spontaneous or induced AF can provoke NPVTs but typically require vasopressor support and increased procedural time. ObjectiveThe purpose of this study was to identify risk factors for the presence of NPVTs and create a risk score to identify higher-risk subgroups. MethodsUsing the AF ablation registry at the Hospital of the University of Pennsylvania, we included consecutive patients who underwent AF ablation between January 2021 and December 2022. We excluded patients who did not receive NPVT provocation testing after failing to demonstrate spontaneous NPVTs. NPVTs were defined as non-pulmonary vein ectopic beats triggering AF or focal atrial tachycardia. We used risk factors associated with NPVTs with P <.1 in multivariable logistic regression model to create a risk score in a randomly split derivation set (80%) and tested its predictive accuracy in the validation set (20%). ResultsIn 1530 AF ablations included, NPVTs were observed in 235 (15.4%). In the derivation set, female sex (odds ratio [OR] 1.40; 95% confidence interval [CI] 0.96–2.03; P = .080), sinus node dysfunction (OR 1.67; 95% CI 0.98–2.87; P = .060), previous AF ablation (OR 2.50; 95% CI 1.70–3.65; P <.001), and left atrial scar (OR 2.90; 95% CI 1.94–4.36; P <.001) were risk factors associated with NPVTs. The risk score created from these risk factors (PRE2SSS2 score; [PRE]vious ablation: 2 points, female [S]ex: 1 point, [S]inus node dysfunction: 1 point, left atrial [S]car: 2 points) had good predictive accuracy in the validation cohort (area under the receiver operating characteristic curve 0.728; 95% CI 0.648–0.807). ConclusionA risk score incorporating predictors for NPVTs may allow provocation of triggers to be performed in patients with greatest expected yield.