Cardioversion Research Articles

Does Cardioversion of Acute “Unstable” Atrial Fibrillation Improve Hemodynamics?

The standard wisdom says that patients with atrial fibrillation (AFib) and hemodynamic compromise should undergo immediate cardioversion, but data are

CHAMBER REMODELING AFTER SUCCESSFUL CARDIOVERSION FOR ATRIAL FIBRILLATION AND IMPACT ON TRICUSPID REGURGITATION

Atrial fibrillation (AF) is associated with worsening tricuspid regurgitation (TR) in part due to adverse chamber remodeling. We sought to determine the impact of successful cardioversion (CV) for AF on chamber remodeling and TR. We prospectively evaluated 55 patients with AF (median duration of AF

TREATMENT USING NOAC VERSUS VKA AS A PREDICTOR OF LEFT ATRIAL THROMBUS FORMATION

The practice of three weeks of NOACs or VKAs in patients with atrial fibrillation prior to cardioversion (CV) was not compared earlier. A total of 360 (135 female) consecutive patients, aged 69.3±8.88 years, admitted for CV were enrolled in the study. Warfarin or acenocoumarol or dabigatran or

Electrical or Chemical Cardioversion for Atrial Fibrillation in the Emergency Department

Emergency department (ED) management of patients with atrial fibrillation (AF) is highly variable. As part of a sustained effort to determine best

Observation of the effect of postural modified Valsalva manoeuvre in terminating paroxysmal supraventricular tachycardia

Objective To observe the efficacy and safety of postural modified Valsalval manoeuvre in terminating paroxysmal supraventricular tachycardia (PSVT). Methods From January 2017 to June 2018, a total of 98 patients with PSVT were selected in the Affiliated Hospital of Xuzhou Medical University.They were randomly allocated to standard Valsalval manoeuvre group(48 cases) and postural modified Valsalval manoeuvre group(50 cases) according to sealed envelope method.The patients in standard Valsalval manoeuvre group carried out standard semi-recumbent Valsalva manoeuvre, while the other group received semi-recumbent with supine repositioning and passive leg raise immediately after the Valsalva strain.The general clinical data, total cardioversion success rate, first-time cardioversion success rate and the incidence of adverse reactions were compared between the two groups. Results There were no statistically significant differences in male proportion, age, history of PSVT or coronary heart disease, incidence of hypertension, diabetes and heart rate, systolic and diastolic blood pressure at attack between the two groups(all P>0.05). The total cardioversion success rate [40.0%(20/50)], first-time cardioversion success rate [28.0%(14/50)] in the modified group were significantly higher than those in the standard group [16.7%(8/48), 12.5%(6/48)](χ2=27.924, 16.308, all P 0.05). Conclusion Postural modified Valsalval manoeuvre can effectively improve the cardioversion success rate of PSVT, and has high safety, which is worthy of clinical promotion. Key words: Tachycardia, supraventricular; Valsalval manoeuvre; Syringe; Mechanical stimulation; Vagus nerve; Treatment outcome; Comparative effectiveness research

A CLINICAL CASE OF LYSIS OF THROMBUS IN THE LEFT ATRIAL APPENDAGE IN A PATIENT WITH ATRIAL FIBRILLATION PREVIOUSLY TREATED WITH WARFARIN

The article describes the clinical observation of LAA thrombosis in a 46-year-old patient with atrial fibrillation that first occurred during taking warfarin; discusses further management of the patient. Due to inefficacy of medical cardioversion (CV) and the need to restore sinus rhythm, electric CV was planned. Before the planned restoration of the rhythm, transesophageal echocardiography was performed and a thrombus in the LAA was detected. Given that the patient had been on adequate warfarin therapy for a long time, it was decided to prescribe a drug from the direct oral anticoagulants group dabigatran etexilate at a dose of 150 mg BID for 8 weeks. The control transesophageal echocardiographic examination showed evidence of complete lysis of thrombus.

Recurrence of Atrial Fibrillation in Dependence of Left Atrial Volume Index.

Despite advances in the treatment strategies of patients with atrial fibrillation (AF), the risk of AF recurrences is still over 50%. An increased left atrial volume index (LAVI) reflects left ventricular diastolic dysfunction (DD) and deterioration of the LA function. This study aims to determine AF recurrence following cardioversion (CV) or catheter ablation for AF (pulmonary vein isolation; PVI) in dependence of DD and LAVI. One hundred and sixty-two patients with paroxysmal or persistent AF in whom either CV or PVI were performed were included and followed over a mean of 22.9±3.8 months. Recurrence was defined as any recurrence of AF that occurred 3 months following the procedure. DD and LAVI were assessed using transthoracic echocardiography (TTE). Recurrent AF occurred in 100 (61.7%) patients, predominantly following CV [CV 41 (76.2%) vs. PVI 59 (54.6%), p<0.0001]. Both DD and an increased LAVI were more common in the recurrence-group [DD 46.0% vs. 14.5%, p=0.0001; LAVI (ml/m2) 49.0±18.6 vs. 26.3±7.0, p<0.0001]. ROC analysis revealed LAVI>36 ml/m2 as cut-off (p<0.0001, AUC=0.92, 95%CI=0.87-0.97, sensitivity=76%, specificity=94%). In the multivariate analysis, DD (HR=1.6, 95%CI=1.3-2.1, p=0.04) and LA enlargement (defined as LAVI>36 ml/m2 with HR=2.1, 95%CI=1.8-2.7, p<0.0001) could be identified as independent predictors of AF recurrence after attempting to control the heart rhythm. LA enlargement and DD are independent risk factors associated with AF recurrence after initial successful rhythm control attempt. These findings have implications for timing of either ablation or CV.

Is there any Link Between Vitamin D and Recurrence of Atrial Fibrillation after Cardioversion?

IntroductionAtrial fibrillation (AF) is the most common chronic arrhythmia in the elderly population. In symptomatic patients, restoration and maintenance of sinus rhythm improve quality of life. Unfortunately, AF recurrence still occurs in a considerable number of patients after cardioversion (CV). In this study, we aimed to evaluate the association between vitamin D (VitD) and AF recurrence after electrical or medical CV.MethodA total of 51 patients who underwent CV for symptomatic AF were included in the study. AF recurrence was defined as an AF pattern in 12-lead electrocardiography (ECG) recording after CV within 6 months or ECG Holter recording of AF lasting more than 30 seconds at 6-month follow-up.ResultsMean vitD level was 21.4 ng/ml in our study population. VitD level was lower in the AF recurrence group than in the non-recurrence group (18 ng/ml vs. 26.3 ng/ml, respectively; P=0.001). Additionally, left atrial diameter was larger in the AF recurrence group compared to the non-recurrence group (4.4 vs. 4.1, P=0.025). Patients with AF recurrence were older than patients without AF recurrence, and, although the prevalence of hypertension is higher in the AF recurrence group, there was no statistically significant difference (P=0.107, P=0.867).ConclusionIn our study, there is a strong association between vitD level and AF recurrence after CV. VitD deficiency might be a predictor of high risk of AF recurrence after CV and vitD supplementation during the follow-up might help the maintenance of sinus rhythm.

323 Do We Still need TOE Assessment Prior to Cardioversion on DOACs?

323 Do We Still need TOE Assessment Prior to Cardioversion on DOACs?

P1895Predictors of left atrial thrombosis in patients undergoing planned electrical cardioversion of atrial fibrillation treated with direct anticoagulant

Abstract Background Scheduled electrical cardioversion (CV) of persistent atrial fibrillation (AF) can be performed after an adequate period of oral anticoagulation (OAC) therapy to reduce thromboembolic complications. Exclusion of left atrial appendage (LAA) thrombi can be achieved by transoesophagel echocardiography (TOE), that is indicated if early CV is desired in patients (pts) with ≥48 hours-lasting arrhythmia, while is not recommended after at least 3 weeks of OAC. Purpose We investigated with TOE the presence of LAA thrombi in a consecutive series of ambulatory pts scheduled for electrical CV of AF and treated with DOAC for at least 3 weeks. Methods We evaluated 93 pts referred to our Clinic for CV of persistent AF (October 2017–December 2018), all treated with DOAC. We collected clinical history, physical examination, 12-lead ECG, lab tests and transthoracic echocardiography measures. Right before cardioversion we systematically performed TOE to exclude LAA thrombi. If absent, we proceeded to CV, while in case of grade III echo-contrast and/or thrombotic stratification we didn't perform the procedure. All values are reported, as appropriate, as mean±SD or number and percentage. All results were considered statistically significant when p&lt;0.05. The entire analysis was performed using the Statistical Package for Social Sciences package, version 19.0 (SPSS, Chicago, Illinois). Results 76 out of 93 pts (82% – group A) were free from intracavitary thrombi and underwent successful electrical CV; the other 17 pts (18% – group B) had thrombi in LAA that contraindicated electrical CV. Group B pts (74±10 years old, 65% male sex) had higher CHA2DS2-VASc score (4,1±2 vs 3,1±1,4, p=0,014), they were significantly more affected by chronic kidney disease (CKD, 59% vs 32%, p=0.035), peripheral artery disease (PAD, 35% vs 12%, p=0.017), they had larger LA dimension (48±5 vs 45±5 mm, p=0,09 - non significant) and as expected they had reduced LAA emptying velocity (76% vs 30%, p&lt;0.001) compared to group A pts (73±8 years old, 70% male sex). There was no significant difference neither in duration (median 7 weeks) nor in type of DOAC therapy between the two groups. Conclusions Current Guidelines recommend at least three weeks of OAC before electrical CV of persistent AF. TOE is recommended only if early cardioversion is needed. We observed that in a significant part of pts treated with DOAC for more than 3 weeks TOE still identified LAA thrombi, especially in pts with multiple comorbidities. Even if we currently don't have data on clinical endpoints in this population, CV of patients with LAA thrombi despite adequate DOAC therapy may lead to an increased risk of thromboembolic events. We think it's necessary to identify more accurate predictors (i.e. CKD) to stratify the thromboembolic risk. Further randomized studies are needed to identify whether there are patients in which CV shouldn't be performed without TOE, irrespective of anticoagulation duration.

Risk for Thromboembolic Events Might Not Be Higher After Cardioversion

These investigators considered whether cardioversion causes thromboembolic events or is a risk marker of patients' vulnerability; in a causal

Diagnosis and management of left atrial appendage thrombus in patients with atrial fibrillation undergoing cardioversion or percutaneous left atrial procedures: results of the European Heart Rhythm Association survey.

Practices regarding indications and timing for transoesophageal echocardiography (TOE) before cardioversion (CV) of atrial fibrillation (AF) or left atrial (LA) interventional procedures, and preferred imaging techniques and pharmacotherapy, in cases of thrombus resistant to chronic oral anticoagulation (OAC) treatment, are largely unknown. The European Heart Rhythm Association (EHRA) conducted a survey to capture contemporary clinical practice in those areas of AF care. A 22-item online questionnaire was developed and distributed among the EHRA electrophysiology research network centres. The survey contained questions regarding indications, type and timing of imaging before CV or LA procedures and management of LA appendage (LAA) thrombus with special emphasis on thrombus resistant to OAC. Of 54 responding centres 63% were university hospitals. Most commonly, TOE would be performed in cases of inadequate or unclear pre-procedural anticoagulation, even in AF lasting <48 h (52% and 50%, respectively), and 15% of centres would perform TOE before AF ablation in all patients. If thrombus was diagnosed despite chronic OAC, the prevalent strategy was to change current OAC to another with different mechanism of action; 51% of centres would wait 3-4 weeks after changing the OAC before using another imaging test, and 60% of centres reported two attempts to dissolve the thrombus. Our survey showed a significant utilization of TOE before CV or AF ablation in European centres, extending beyond AF guidelines-suggested indications. When thrombus was diagnosed despite chronic pre-procedural OAC, most centres would use another anticoagulant drug with different mode of action.

CHA2DS2-VASc score predicts 30-day readmission due to thromboembolic complications following cardioversion of atrial fibrillation: insights from US National Readmissions Database.

Determine whether the CHA2DS2-VASc score predicts rates of hospitalization associated with thromboembolic complications (TEC) in the 30, 60, and 90days following cardioversion (CV) for atrial fibrillation (AF). The 2014 National Readmissions Database was analyzed to identify readmissions following the index hospitalization for AF and CV. A CHA2DS2-VASc score was calculated for each patient from diagnosis codes associated with the index admission. The primary outcome was the incidence of readmission due to TEC in the 30, 60, and 90days after CV stratified by CHA2DS2-VASc scores ≤ 1, 2-3, and ≥ 4; the secondary outcome was specific clinical risk factors independently associated with TEC within 30days of CV. A total of 109,420 weighted index admissions for AF and CV were identified in between January 1, 2014, and November 30, 2014. Of these, 16,535 (15.1%) had a CHA2DS2-VASc score of 0-1, 39,544 (36.1%) had a score of 2-3, and 53,340 (48.8%) had a score of ≥ 4. Readmission due to TEC occurred in 48 (0.29%), 167 (0.42%), and 394 (0.74%) patients with CHA2DS2-VASc scores ≤ 1, 2-3, and ≥ 4, respectively, in the 90-day period after CV. The only significant predictor for 30-day TEC-associated readmission after CV was age > 65years old. This study demonstrated the utility of CHA2DS2-VASc score in predicting TEC-associated readmission rate following CV and the temporal relationship of TEC to CV. Patients > 65years old without other comorbidities may benefit from 30-day OAC following successful CV irrespective of the duration of AF episodes.

Unmasking Brugada Syndrome with Oral Flecainide Provocation. A Case Series of Three Patients

The present case series discuss three patients who had brugada type 2/ type 3 like ECG pattern that was converted to type 1 pattern with oral flecanide challenge test. Brugada syndrome is associated with a high incidence of sudden cardiac death, typical ECG pattern being ST-segment elevation in the right precordial leads with T wave inversion. Pharmacological provocation should only be performed when the baseline ECG is not diagnostic of Brugada Syndrome. PR prolongation in the baseline ECG is also a contraindication because of the risk of inducing AV block. Drug challenge is performed under strict monitoring of BP and 12-lead ECG and facilities for cardio version and resuscitation are available. Atypical RBBB pattern/type 2/3 Brugada pattern on ECG in patients of syncope or family history of sudden cardiac arrest is commonly encountered by a cardiologist. This can be performed to provoke type 1 brugada pattern on ECG. Diagnosed cases of Brugada may be treated with ICD with proper indication if needed and thus prevent sudden cardiac death.

Status of treatment for atrial fibrillation in a community health service center in Shanghai Pudong New Area

Objective To analyze the status of the treatment for atrial fibrillation (AF) in a community health service center in Shanghai Pudong New Area. Methods Clinical data of all patients with AF attended in Hudong Community Health Service Center of Shanghai Pudong from August 2016 to August 2017 were retrospectively reviewed. The gender, age, smoking history, drinking history, concomitant diseases, antithrombotic therapy, rhythm control, ventricular rate control drugs, health education, needs for setting up AF clinics in the community were analyzed. Result The study included 220 patients, with average age of (59.7±10.4) years; 34.1% (75/220) patients had hypertension and the blood pressure was controlled in 41.3% (31/75) ; 20.5% (45/220) patients had diabetes mellitus and glycosylated hemoglobin (HbA1c) was controlled well in 26.7% (12/45) . Three cases of mitral stenosis were treated with warfarin anticoagulation. Among 217 patients without valvular atrial fibrillation, 157 had thromboembolic risk score≥2, 20.4% (32/157) of whom used warfarin anticoagulation, 10.8% (17/157) used new oral anticoagulant (NOAG) and 58.1% (91/157) had never used warfarin or NOAG anticoagulation. The reasons were as follows:doctors did not prescribe (41.9%, 39/91), patients did not accept (35.2%, 32/91), and so on. There were 21.8% (48/220) of patients undergoing drug cardioversion, and 5.9% (13/220) undergoing electrical cardioversion. For control of ventricular rate, 55.9% (123/220) patients used beta blockers, 13.6% (30/220) used non-dihydropyridine calcium antagonists, and 23.6% (52/220) used digitalise. Less than 55% of patients were given health education of physical exercise, weight management and medicine use. For AF clinic in community hospital, 56.8% (125/220) of patients needed, and 17.3% (38/220) very need; 50.0% (110/220) patients trusted and 12.3% (27/220) very trusted in anticoagulation management in community hospitals. Conclusion The anticoagulant rate is relatively low, treatment of concomitant diseases is less satisfactory and the health education might be incomplete in the community surveyed in this study. Key words: Atrial fibrillation; Community health services; General practitioner; Treatment

RECURRENCE OF PERSISTENT ATRIAL FIBRILLATION AFTER PROGRAMMED ELECTRICAL CARDIOVERSION AND RELATIONSHIP WITH QUALITY OF LIFE

Objective:We propose the experience of performing electrical cardioversion (CVE) programmed for the treatment of Persistent Atrial Fibrillation (AF) in an Emergency Service (ED), comparing it with the usual one performed through hospital admission. The aim is to determine the incidence of recurrence

Serum fatty acid binding proteins as a potential biomarker in atrial fibrillation.

Atrial fibrillation (AF) is a commonly occurring arrhythmia which significantly reduces patients' quality of life and substantially shortens life expectancy. Although long chain fatty acids (LCFAs) are the basic energy substrates for myocardial metabolism, their excess can result in lipotoxicity, which increases the risk of arrhythmia. Intracellularly, LCFAs are bound by fatty acid biding proteins (FABPs) and this results in low level of free LCFAs in the cytoplasm. Based on this principle, FABPs are considered "safeguards" against overwhelming accumulation of esterified into different bioactive lipid fractions (e.g. ceramide, diacylglycerols) LCFAs. So far, several FABPs have been discovered in humans. Currently, in relation to cardiovascular diseases heart-type fatty acid binding protein (H-FABP) and adipocyte fatty acid binding protein (A-FABP) play significant roles. Nowadays, A-FABP is of great interest for research related with obesity, diabetes and coexisting disorders including cardiovascular diseases. Concomitantly, H-FABP is already well-established marker in the early diagnosis of myocardial infarction. Moreover, FABPs were assigned as a potential biomarker of AF in patients with de novo diagnosed arrhythmia, chronic heart failure (CHF), and in patients undergoing cardiac surgery. Another group of studies where the concentrations of plasma FABPs were analyzed are patients subjected to electrical cardioversion (ECV) and radio-catheter ablation therapy (RFA). It is worth mentioning that, in addition to traditional anti-arrhythmic drugs (AADs) or ECV, ablation techniques are used with good effects. Even though the treatment of arrhythmias is constantly developing, the maintenance of the sinus rhythm (SR) is still a serious problem. Therefore, it is worth looking for a biomarker which is suitable for the patient's treatment qualifications as well as assessing its effectiveness. Thus, the aim of this work is to present current data on the clinical significance of FABPs in terms of the development and treatment of AF.

Effect of an Educational Program on Nurses' Knowledge and Practice Regarding Defibrillation and Cardioversion

Electrical cardio version and defibrillation is a critical treatment for the survival of patients with cardiac arrest. Therefore, critical care nurses not only have to know how to monitor and operate the defibrillator, but also to provide interventions for preventing possible complications. The Aim of the present study was to evaluate the effect of educational program on knowledge and practice of nurses regarding defibrillation and cardio version. Method A convenient sample of 50 nurses working in coronary care unit and emergency care unit at Assiut University Heart Hospital. A structured interview questionnaire sheet and Nurses practice observational checklist tools were used to collect the data. Results the present study revealed that total mean scores of the nurses knowledge and practices were improved from a preprogram level of (26.04 ± 9.51) to knowledge and (75.54 ± 10.90) for practice to an immediate post of (68.84 ± 1.75) for knowledge and (134.70 ± 1.52) for practice. Conclusion Nurses' level of knowledge and practice in caring of patients was unsatisfactory before the program and significantly improved immediately post program and at follow up phase in all items. Recommendation: Orientation program should be utilized for newly graduated nurses'.

Improvement of peripheral microcirculation after cardioversion of atrial fibrillation.

Near-infrared spectroscopy (NIRS) is a noninvasive method to measure regional tissue oxygenation (rSO2 ). In patients with atrial fibrillation (AF), cardiac output and endothelial function are altered. Peripheral tissue oxygenation may therefore be reduced. This study aims to describe the peripheral tissue oxygenation of the feet before and after synchronized electrical cardioversion (CV) of patients with AF using NIRS. Patients with AF undergoing CV were included and screened for peripheral arterial disease (PAD), diabetes mellitus (DM), and peripheral neuropathy (PN). NIRS was performed before and after CV under continuous ECG and monitoring of peripheral oxygen saturation. NIRS was registered on the dorsoplantar and plantar area of both feet. Capillary blood gas analysis was performed and left ventricular ejection fraction (LVEF) was determined. Twelve patients (five women, seven men, age 70.8 ± 10.8 years) participated. None had history of PAD. DM was present in three (25%) patients. Two patients (16.7%) had PN. CV was successful in 11 patients. Overall, rSO2 improved significantly in all patients after CV (P=.0003). Mean improvement was 7.17%. There were no significant changes in body temperature, ankle-brachial index, sO2 , pO2 , pCO2 , pH, or lactate after CV. Heart rate was significantly lower (P<.0001) and LVEF significantly higher (P=.0123) after CV. In patients with AF, peripheral tissue oxygen saturation improves significantly after successful CV. This suggests that patients with PAD may not only benefit from interventional or surgical improvement of arterial vascularization, but also from CV in case of AF.

Carnitine-acylcarnitine translocase deficiency with homozygous mutation of c.199-10T>G: a case report and literature review

Objective To investigate the clinical features of carnitine-acylcarnitine translocase deficiency (CACTD) with c.199-10T>G homozygous mutation and the characteristics of SLC25A20 gene mutation. Methods This study retrospectively analyzed the clinical data, biochemical and genetic features, treatment and outcome of a boy with CACTD with c.199-10T>G homozygous mutation, who admitted to Guangzhou Women and Children's Medical Center in September 2017. Pertinent articles were retrieved from China National Knowledge Infrastructure (CNKI), Wanfang Database, National Center for Biotechnology Information and PubMed from the establishment of these databases to April 2018 using key words including CACT, SLC25A20 and carnitine-acylcarnitine translocase. Clinical information of all affected cases in the retrieved publications was analyzed. Results (1) The full-term boy born vaginally at a local hospital was transferred to neonatal intensive care unit (NICU) of Guangzhou Women and Children's Medical Center at 2 days and 5 hours due to groaning, cyanosis and severe hypoglycemia (0.8 mmol/L) at 15 h after birth. His elder brother with similar symptoms died of unknown reason at 50 days of age. In this case, ammonemia, liver enzyme and creatine kinase were significantly elevated, amino acid analysis suggested liver damage, and high amounts of dicarboxylic aciduria, low free carnitine, markedly increased long-chain acylcarnitine and hypoketotic hypoglycemia were also observed. His electrocardiogram showed atrioventricular block and ventricular tachycardia. After a series of treatments, including repeated electrical cardioversion, lidocaine and amiodarone for arrhythmia, arginine for blood ammonia level reduction, formula supplement containing L-carnitine and medium-chain fatty acid, the patient whose conditions had significantly improved and was discharged at the request of his parents at 29 days old. Two weeks later, he was re-admitted due to diarrhea, and discharged two days later when he was 45 days old. He was lost to follow up since then. (2) A homozygous mutation of c.199-10T>G was detected in this boy in SLC25A20 gene, which was also carried by his parents. (3) Thirty-two publications in English were retrieved, involving 50 cases of CACTD and 100 sequenced alleles. A total of 40 mutations in SLC25A20 gene were found so far, and c.199-10T>G was the most common mutation with a frequency of 22/100. It was identified in 13 patients, including nine homozygous mutations and four compound heterozygous mutations. Symptoms presented within 72 h after birth (25 min-52 h) in all the 13 infants, such as hypoketotic hypoglycemia, hyperammonemia, elevated liver enzyme and creatine kinase, significantly decreased free carnitine level, markedly increased level of long-chain acylcarnitine, dicarboxylic aciduria, arrhythmia and cardiomyopathy. The mortality rate of CACTD was 11/12 (the outcome of one case was not reported). Conclusions c.199-10T>G is the most common SLC25A20 gene mutation reported in Asia population with severe phenotypes and poor outcomes. Early diagnosis and timely treatment of CACTD are crucial. Inborn metabolic diseases such as CACTD should be considered if unexplainable exacerbation of clinical signs in neonatal period, or sudden infant death occurs. Key words: Carnitine acyltransferases; Lipid Metabolism, Inborn Errors; Membrane transport proteins; Mutation