Direct Current Cardioversion Research Articles

What does one need to survive with Anomalous origin of left coronary artery from pulmonary trunk (ALCAPA) beyond infancy.

A 53-year old man presented with sustained monomorphic ventricular tachycardia which was restored with 200 joules of direct current cardioversion. Complete haemogram, liver, and kidney function tests, and serum electrolytes were within normal limit. His past history was insignificant except exertional dyspnoea NYHA class-I for last one year. Transrthoracic echocardiography revealed dilated left ventricle and atrium with severe systolic dysfunction (EF=28%). There was continous flow entering the pulmonary trunk. Origin of right coronary artery was dilated and left coronary artery was originating from main pulmonary artery suggestive of anomalous origin of left coronary artery from pulmonary trunk (ALCAPA). Coronary angiogram showed dilated and tortuous right coronary artery (RCA) with absence of a left coronary ostium in aortic sinus. During the delayed filling phase, abundant intercoronary anastomoses (Rentrop grade 3) were seen, communicating with left coronary artery which was later opacifying the main pulmonary artery thus establishing diagnosis of ALCAPA. Multidetector computed tomography angiography confirmed its diagnosis. Implantable cardioverter defibrillator was implanted. ALCAPA is a rare congenital cardiovascular anomaly which occurs 1 in 300,000 live births with rare survival to adulthood as 90% succumbs by third decade.Those with this syndrome who manages to survive beyond childhood are often incapacitated by myocardial ischemia, arrhythmias and severe ischemic cardiomyopathy. Survival beyond fourth or fifth decade with ALCAPA without surgical intervention is exceedingly rare as low pulmonary artery pressure results in coronary steal phenomenon. Rarely some remain asymptomatic until adulthood due to superdominant RCA, although they generally become symptomatic in early adulthood due to fixed myocardial ischemia and coronary steal phenomenon. In utero, as the systemic and pulmonary arterial pressures are equal, there is anterograde flow in both the left and the right coronary. In the neonatal period as the pulmonary artery pressure falls and ductus arteriosus closes, the flow in the left coronary artery reverses. The more collateral channels exist between RCA and anomalous left coronary system (ALCA), the longer the patient may survive. Another contributing factor may be the area supplied by the ALCA as the smaller the area supplied by the ALCA, the less extensive the myocardial ischemia is likely to be. In few adult cases, RCA supplies not only the posterior wall of the left ventricle but also its lateral wall. May be this reduction in the area of the myocardium supplied by the ALCA would favour survival. However, even extensive collateral circulation may not totally prevent ischemic damage though can delay it as low pulmonary artery pressure may still result in coronary steal phenomenon, which may cause sudden deaths. We believe right coronary artery may have “supernormal” flow reserve to account for his survival. Surgical correction such as direct transfer of the left coronary artery from pulmonary artery (like in arterial switch operation), Takeuchi repair (creating aorto-pulmonary window), and bypass graft when these two are not possible, it is one of the coronary anomalies not compatible to life. In our case, it was decided not to intervene surgically as risk of cardiac surgery was outweighing the benefit.

New oncet infant SVT unresponsive to DC cardioversion

5-week-old male infant referred by the GP for poor feeding and increasing lethargy. On admission was poorly perfused, lethargic and further investigation showed metabolic acidosis and narrow complex tachycardia with a HR of 270 and delta waves. Chest X-ray showed enlarged cardiac shadow with congested lung fields and poor cardiac function on echocardiography. Furosemide at 1 mg/kg and several doses of adenoside up to 350 mcg/kg were given followed by propranolol and digoxin in order to achieve cardioversion. Only transiently sinus rhythm was achieved so DC shock was attempted and referral to PICU. Still cardioversion was not achieved and the patient on admission to PICU received a further dose of adenosine and magnesium which uncovered a ventricular rate of 90 and an atrial flutter. An echocardiogram was performed which showed a structurally normal heart with reduced cardiac function. Three further unsuccessful attempts of DC cardioversion were followed by esmolol infusion and oesophageal pacing without capture. The patient was started on amiodarone, receiving a loading dose and an infusion. The tachycardia resolved (HR 130), but atrial flutted 2:1 persisted. The SVT continued while on digoxin and amiodarone. Flecainide was started and the patient was discharged from PICU on amiodarone and flecanide. Echocardiography showed a gradually improving cardiac function and after amiodarone and flecanide were gradually weaned off within a year of life.

Efficacy of sole pulmonary vein isolation in patients with nonparoxysmal atrial fibrillation without significant left atrium scar

Catheter ablation strategies for nonparoxysmal atrial fibrillation (NPAF) are in varied forms. The mechanisms that circumferential pulmonary vein isolation (CPVI) alone could achieve success in some of the patients with NPAF are not well studied. This study sought to assess the clinical outcome of only CPVI approach in NPAF patients without significant left atrium scar. A total of 241 consecutive patients with NPAF undergoing an initial ablation procedure were studied. After CPVI, cavotricuspid isthmus ablation and direct current cardioversion, high-density atrial voltage mapping was performed during sinus rhythm. Transitional-voltage zone (TZ) was defined as 0.4-1.3mV, and low-voltage zone (LVZ) as<0.4mV. No LVZs were identified in 101 patients (41.9%), and only CPVI was performed. Among the patients without LVZs, single-procedure freedom from atrial fibrillation (AF)/atrial tachycardia was achieved in 73 patients (72%), while 28 patients (28%) had AF recurrence with mean follow-up of 29 ± 14 months. TZ index (TZi) was deduced by calculating the ratio of all TZ points over the total number of points and was found to be a univariate predictor of recurrence after a single procedure (P=0.047). The CPVI alone strategy for patients with NPAF can be performed in highly selective patients without LVZs. TZi may reflect healthy extent of left atrium, which has trend toward the association with AF recurrence.

Left atrial thrombus despite continuous direct oral anticoagulant or warfarin therapy in patients with atrial fibrillation: insights into rates and timing of thrombus resolution.

Left atrial thrombus (LAT) may be detected by transesophageal echocardiography (TEE) in patients with atrial fibrillation (AF) or flutter (AFL) despite continuous anticoagulation therapy. We sought to examine the rates and timing of LAT resolution in response to changes in anticoagulation regimen. A retrospective study of 1517 consecutive patients on ≥ 4weeks continuous oral anticoagulation (OAC) undergoing TEE prior to either direct current cardioversion or catheter ablation for AF or AFL was performed. Patients who had LAT on index TEE imaging and had follow-up TEEs were analyzed. Despite ≥ 4weeks of continuous anticoagulation therapy, 63 (4.2%) patients had LAT. Forty-four patients (median age 67 [IQR 58, 74]; 33 [75%] male; 25 [57%] on direct oral anticoagulant [DOAC]) had follow-up TEEs performed. Upon detection of LAT on index TEE, 8 patients switched from warfarin to a DOAC, 21 patients switched from a DOAC to warfarin or another DOAC, and 15 patients remained on the same OAC. Over median 4.2months (IQR 2.9, 6.6), LAT resolution was seen in 25 (57%) patients. Of the 25 patients who had LAT resolution, 7 (28%) required TEE imaging > 6months after index TEE to show clearance of thrombus. Rates of LAT resolution were similar between patients who had alterations in OAC and those who did not (52 vs. 60%; P = 0.601). After initial detection of left atrial thrombus despite uninterrupted anticoagulation for atrial fibrillation or flutter, > 40% patients have persistent clot despite additional extended anticoagulation.

P2925Outcomes of direct current cardioversion in adults with cardiac amyloidosis

P2925Outcomes of direct current cardioversion in adults with cardiac amyloidosis

P4828Clinical impact of response of intracardiac direct current cardioversion just before pulmonary vein isolation in persistent atrial fibrillation patients

P4828Clinical impact of response of intracardiac direct current cardioversion just before pulmonary vein isolation in persistent atrial fibrillation patients

Effectiveness and usability of an online tailored education platform for atrial fibrillation patients undergoing a direct current cardioversion or pulmonary vein isolation

BackgroundAtrial fibrillation (AF) care should strive for more informed, involved and empowered patients. However, few effective educational programs are available. The aim of this study was to evaluate the effectiveness of an online tailored education platform to inform AF patients undergoing a direct current cardioversion (DCC) or a pulmonary vein isolation (PVI). Methods120 AF patients requiring DCC or PVI were allocated to an online education group (n = 35), a standard care group despite having online access (n = 36; randomized with group 1), and a group without a computer/tablet/smartphone receiving standard care (n = 49). The Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ), supplemented with procedure-specific questions, had to be completed 1–3 weeks before hospitalization, at hospitalization, and 6 and/or 12 weeks post-procedurally. ResultsMajor AF-related and procedure-related knowledge gaps were shown. The online tailored education group scored significantly better at hospitalization compared to baseline (P = 0.001). This knowledge increase was retained after 6 (P = 0.010) and 12 (P < 0.001) weeks. In the online standard care group there was no change in knowledge from planning till hospitalization (P = 1.000), although knowledge was improved 6 weeks post-procedurally (P = 0.010). Knowledge did not improve in the group without computer/tablet/smartphone at any time (P = 0.248). Most patients indicated that the platform was easy to use (87.9%), understandable (97.0%), and 72.7% indicated that an online platform was their preferred way to receive future AF-related information. ConclusionsTailored online education is an effective strategy to improve AF- and procedure-related knowledge with lasting effects up to 12 weeks post-procedurally. The platform was positively evaluated by patients.

Outcomes With Novel Oral Anticoagulants in Obese Patients who Underwent Electrical Cardioversion for Atrial Tachyarrhythmias

The efficacy of novel oral anticoagulants (NOACs) in severely obese patients is uncertain as volume of distribution is related to weight, and few such patients were enrolled in the pivotal trials. As the month after direct-current cardioversion (DCCV) for atrial fibrillation and atrial flutter is a high-risk period for stroke, we sought to evaluate the safety of performing DCCV in obese patients on NOAC. All patients who underwent DCCV after ≥3 weeks of NOAC or therapeutic warfarin treatment without a previous transesophageal echocardiogram over a 3-year period at a single center were included. Obesity groups were defined as normal (body mass index [BMI] < 25), overweight (BMI 25 to <30), class 1 obesity (BMI 30 to <35), class 2 obesity (BMI 35 to <40), and class 3 or severe obesity (BMI ≥ 40). The primary end point was stroke at 30days. Of 761 patients, 73 were severely obese, 78 class 2 obese, 197 class 1 obese, 254 overweight, and 159 in the normal weight group. Average age 66.4 ± 10.3years and 32.5% women. Mean CHA2DS2-VASc score was 2.6 ± 1.6, and 78.9% were on NOACs with no differences in groups. There were no strokes in the severely obese group, and 1 each in class 2 obesity and normal weight (p = 0.3). In conclusion, there was a low rate of stroke in all weight classes after DCCV in patients taking NOACs and warfarin. NOAC use in severely obese patients who underwent DCCV appears safe even in the absence of transesophageal echocardiogram.

Highlights From the Circulation Family of Journals.

Highlights From the Circulation Family of Journals.

Vaut-il la peine de délivrer un choc électrique aux patients de réanimation avec tachycardie supra-ventriculaire ?

Supra-ventricular tachyarrhythmia and its treatment have been poorly investigated in ICU patients. AimsTo evaluate efficacy and safety of cardioversion for supra-ventricular tachyarrhythmia in the intensive care unit (ICU). Patients and methodsProspective inclusion of all patients who presented supra-ventricular tachyarrhythmias lasting≥30seconds in a single medico-surgical ICU, except cardiac surgery. Anti-arrhythmic drugs and/or direct-current cardioversion were administered on a liberal basis. ResultsDuring the 15-month study period, 108/846 patients (12.8%) experienced supra-ventricular tachyarrhythmias. Anti-arrhythmic drugs were administered in 78 patients (72%); mostly amiodarone (92%), and/or magnesium (23%), resulting in an overall conversion rate of 68%. Direct-current cardioversion was used in 26 patients (24%), (24 patients received drug enhancement by anti-arrhythmic drugs) with an immediate 80.8%-success rate. ConclusionDirect-current cardioversion was associated with sustained conversion to sinus rhythm in 80.8% of ICU patients with supra-ventricular tachyarrhythmias, although most of them had already received drug enhancement.

Atrial fibrillation and heart failure with preserved ejection fraction: Insights on a unique clinical phenotype from a nationally-representative United States cohort

BackgroundAtrial fibrillation (AF) and heart failure often occur concomitantly, representing a clinical phenotype at high-risk for poor outcomes. Differences in the characteristics, management, and in-hospital outcomes of AF among those with heart failure with preserved ejection fraction (HFpEF) and those with heart failure with reduced ejection fraction (HFrEF) are not well characterized. Methods and resultsUsing the National Inpatient Sample, we identified hospitalizations in 2008–2012 for HFpEF and for HFrEF, with and without AF based on ICD-9-CM codes. We examined patient characteristics, procedural rates, and in-hospital outcomes. AF was common among both HFpEF and HFrEF, and increased in prevalence over the study period. A very low proportion of the cohort underwent either direct-current cardioversion or catheter-ablation. Compared to those without AF, those with AF experienced higher in-hospital mortality regardless of heart failure subtype. In multivariable regression analysis, AF was associated with in-hospital mortality in HFpEF (OR 1.10, CI [1.08–1.11]), but not in HFrEF (OR 0.93 [0.92–0.94], p-for-interaction < 0.001). ConclusionsOur study revealed that the prevalence and adverse impact of AF on those with HFpEF is substantial, providing a rationale to rigorously investigate strategies, such as rhythm-control, to improve outcomes for this particularly vulnerable subpopulation.

Advances in Clinical Cardiology 2017: A Summary of Key Clinical Trials.

Numerous important cardiology clinical trials have been published or presented at major international meetings during 2017. This paper aims to summarize these trials and place them in clinical context. The authors reviewed clinical trials presented at major cardiology conferences during 2017 including the American College of Cardiology, European Association for Percutaneous Cardiovascular Interventions, European Society of Cardiology, European Association for the Study of Diabetes, Transcatheter Cardiovascular Therapeutics, and the American Heart Association. Selection criteria were trials with a broad relevance to the cardiology community and those with potential to change current practice. A total of 75 key cardiology clinical trials were identified for inclusion. New interventional and structural cardiology data include left main bifurcation treatment strategy, multivessel disease management in cardiogenic shock, drug-eluting balloons for in-stent restenosis, instantaneous wave-free physiological assessment, new-generation stents (COMBO, Orsiro), transcatheter aortic valve implantation, and closure devices. New preventative cardiology data include trials of liraglutide, empagliflozin, PCSK9 inhibitors (evolocumab and bococizumab), inclisiran, and anacetrapib. Antiplatelet data include the role of uninterrupted aspirin therapy during non-cardiac surgery and dual antiplatelet therapy following coronary artery bypass grafting. New data are also included from fields of heart failure (levosimendan, spironolactone), atrial fibrillation (apixaban in DC cardioversion), cardiac devices (closed loop stimulation pacing for neuromediated syncope), and electrophysiology (catheter ablation for atrial fibrillation). This paper presents a summary of key clinical cardiology trials during the past year and should be of practical value to both clinicians and cardiology researchers.

Lipidomic profiling reveals free fatty acid alterations in plasma from patients with atrial fibrillation.

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and its incidence is increasing worldwide. One method used to restore sinus rhythm is direct current cardioversion (DCCV). Despite the high success rate of DCCV, AF typically recurs within the first 2 weeks. However, our understanding of the pathophysiology of AF recurrence, incidence, and progression are highly limited. Lipidomic profiling was applied to identify altered lipids in plasma from patients with AF using ultra-performance liquid chromatography/quadrupole time-of-flight mass spectrometry coupled with multivariate statistical analysis. Partial least-squares discriminant analysis revealed a clear separation between AF patients and healthy controls. The levels of several lipid species, including fatty acids and phospholipids, were different between AF patients and healthy controls, indicating that oxidative stress and inflammation are associated with the pathogenesis of AF. Similar patterns were also detected between recurrent and non-recurrent AF patients. These results suggest that the elevated saturated fatty acid and reduced polyunsaturated fatty acid levels in AF patients may be associated with enhanced inflammation and that free fatty acid levels may play a crucial role in the development and progression of AF.

Risks and outcomes of direct current cardioversion in children and young adults with congenital heart disease.

Evaluate the efficacy, outcomes, and complications associated with direct current cardioversion (DCCV) in the treatment of arrhythmias in pediatric and adult congenital heart disease (CHD) populations and identify patient and procedural characteristics associated with adverse events. Pediatric and adult patients with CHD are at risk of atrial arrhythmias. DCCV is effective but is associated with potential complications. In this single-center retrospective series, patients who underwent DCCV between January 2010 and May 2015 were identified and categorized as pediatric (<18 years) or adult (>18 years). Records were reviewed for demographic, arrhythmic, and CHD-specific characteristics; acute efficacy; and 3-month arrhythmia recurrence. Complications were categorized as life-threatening (LT) or non-life-threatening (NLT). Univariate followed by multiple variable and logistic regression (LR) analyses were used to identify characteristics associated with complications. We identified 104 patients with 152 discrete DCCV events with median age 17.4 years (0.15-62.2). DCCV efficacy was 89% with 3-month recurrence of 46%. There were 52 complications among 24 patients, median age 17.7 years (0.15-49). Risks associated with NLT complications are as follows: moderate-severe systolic dysfunction (8/152 encounters, P=<0.01) and more than one shock per DCCV encounter (P=<0.01). Six of eight encounters with moderate-severe systolic dysfunction were<18 years (P=0.1). Risks for LT complications included age>18 years and associated NLT complication. Adults had more frequent arrhythmia recurrence within 3 months than children (P=<0.01). DCCV is effective for arrhythmias but is associated with frequent recurrence, particularly in adult patients. Complications associated with DCCV may be greater than previously reported. Additional support and precautions should be in place for those at greatest risk.

Should We Always Perform TEE Before Direct Current Cardioversion?

Spontaneous or intended conversion of atrial fibrillation (AF) to sinus rhythm is associated with a short-term increase from baseline risk of clinical thromboembolism. Guidelines suggest performing cardioversion without prior execution of trans esophageal echo (TEE) if the patient has completed a month of anticoagulation with warfarin (in the therapeutic international normalized ratio range) or non-vitamin K antagonist oral anticoagulants (NOACs).

Handheld Ultrasound as a Novel Predictive Tool in Atrial Fibrillation: Prediction of Outcomes Following Electrical Cardioversion.

BackgroundAtrial fibrillation (AF) recurrence after successful direct current cardioversion (CV) is common, and clinical predictors may be useful. We evaluated the risk of early AF recurrence according to inferior vena cava (IVC) measurements by handheld ultrasound (HHU) at the time of CV.ObjectiveAssess HHU and objectively obtained measurements acquired at the point of care as potential clinical predictors of future clinical outcomes in patients with AF undergoing CV.MethodsMaximum IVC diameter (IVCd) and collapsibility with inspiration were measured by the Vscan HHU (General Electric Healthcare Division) in 128 patients immediately before and after successful CV for AF. Patients were followed by chart review for recurrence of AF.ResultsMean IVCd was 2.16 cm in AF pre-CV and 2.01 cm in sinus rhythm post-CV (P<.001). AF recurred within 30 days of CV in 34 of 128 patients (26.6%). Among patients with IVCd <2.1 cm pre-CV and decrease in IVCd post-CV, AF recurrence was 12.1%, compared to 31.6% in patients not meeting these parameters (odds ratio [OR] 0.299, P=.04). This association persisted after adjustment for age, ejection fraction <50%, left atrial enlargement, and amiodarone use (adjusted OR 0.185, P=.01). Among patients with IVCd post-CV <1.7 cm, AF recurrence was 13.5%, compared to 31.9% in patients not meeting this parameter (OR 0.185, P=.01). IVC parameters did not predict AF recurrence at 180 or 365 days.ConclusionsThe presence of a normal IVCd pre-CV that becomes smaller post-CV and the presence of a small IVCd post-CV were each independently associated with reduced likelihood of early, but not late, AF recurrence. HHU assessment of IVCd at the time of CV may be useful to identify patients at low risk of early recurrence of AF after CV.

Cost-effectiveness of digoxin, pacing, and direct current cardioversion for conversion of atrial flutter in neonates.

The cost analysis for cardioversion of atrial flutter found the most efficient method to be direct current cardioversion at a cost of $10 304, pacing was next at $11 086, and the least cost-effective was digoxin at $14 374. The majority of additional cost, regardless of method, was from additional neonatal ICU day either owing to digoxin loading or failure to covert. Direct current cardioversion remains the most cost-effective strategy by sensitivity analyses performed on pacing conversion rate and the cost of the neonatal ICU/day. Direct current cardioversion remains cost-effective until the assumed conversion rate is below 64.6%. The most cost-efficient method of cardioverting a neonate with atrial flutter is direct current cardioversion. It has the highest success rates based on the meta-analysis, shorter length of stay in the neonatal ICU owing to its success, and results in cost-savings ranging from $800 to $4000 when compared with alternative approaches.

STRESS CARDIOMYOPATHY INDUCED BY ELECTRICAL CARDIOVERSION: SHOULD WE CHANGE OUR CURRENT CLINICAL PRACTICE?

Direct current cardioversion (DCCV) for atrial fibrillation (AF) is a low risk outpatient procedure commonly with same day discharge. Atrial stunning post DCCV is a known phenomenon, but significant left ventricular (LV) dysfunction mimicking stress cardiomyopathy (SCM) is uncommon. An 87 years old

LEFT ATRIAL APPENDAGE “SMOKE” AND STROKE RISK FOLLOWING CARDIOVERSION

Direct current cardioversion (DCCV) is proven to restore sinus rhythm in patients with atrial fibrillation. Thrombus seen on transesophageal echocardiogram (TEE) however precludes the procedure. Though not indicative of a thrombus, spontaneous echo contrast (SEC) on TEE has been independently

ELECTRIC SHOCK AND CARDIOGENIC SHOCK: A CASE OF DC CARDIOVERSION RESULTING IN STRESS CARDIOMYOPATHY

Direct current cardioversion is a common therapy for atrial fibrillation and is generally a safe and effective procedure. Complications are rare and can include brady-arrhythmias and even cardiogenic shock. A 77 year old woman with paroxysmal atrial fibrillation for 13 years, who had failed medical