Elective Direct Current Cardioversion Research Articles

Elective direct current cardioversion of atrial fibrillation - silent brain infarction and health related quality of life.

Atrial fibrillation (AF) increases the risk for stroke, dementia and impaired health related quality of life (HRQL). Elective direct current cardioversion (ECV) is often used to restore sinus rhythm, but is associated with thromboembolism. While larger strokes usually produce symptoms, subclinical ones may go unrecognized and may cause cognitive and functional decline over time. In the current study, we sought to evaluate the effects of ECV on silent brain infarctions and HRQL in patients with AF. Patients with AF (n=46) underwent brain magnetic resonance imaging (MRI) and HRQL assessment using the EuroQL-5D5L questionnaire before and after ECV. Implantable loop recorders (ILR) were used to observe the rate of early AF recurrences within the first thirty days. All patients were treated with anticoagulants according to guidelines. The primary endpoint was silent brain infarction assessed by brain MRI within the first two weeks after ECV. Secondary endpoints were the change in HRQL and its association with AF recurrence at follow-up and by ILR recordings. New silent brain infarction after ECV was detected in one patient. At follow-up visit after 19.1 days AF recurrence was detected by 12-lead ECG in 13 patients (28.3 %), whereas 27 patients (58.7 %) had AF recurrence recorded by ILR within the first thirty days after ECV. European Heart Rhythm Association (EHRA) symptom score and the EuroQL-5d5L score were improved after ECV. Silent brain infarctions may occur after ECV despite anticoagulation treatment. Early AF recurrence is frequent. ECV positively affects HRQL mainly in those patients with sustained sinus rhythm at follow-up.

Clinical and instrumental factors associated with sinus rhythm maintenance following direct current cardioversion of late persistent non-valvular atrial fibrillation at 6-months follow-up

Abstract Purpose To study the clinical and instrumental factors, associated with sinus rhythm (SR) maintenance following direct current cardioversion (DCCV) in patients with late persistent non-valvular atrial fibrillation (AF) at 6-months follow-up. Methods The cohort single-center study analyzed clinical and instrumental data from 59 late persistent AF patients (with duration of its episode ≥90 days [up to 12 months]), who underwent an elective DCCV. At 6-months follow-up, 32 (54 %%) patients succeeded to maintain SR, in contrast to 27 (46 %) patients with a failure to its maintenance. Results The univariate logistic regression analysis revealed, that the absence of heart failure (HF) stage C (i.e., the presence of its stage B), the higher left ventricular ejection fraction (LVEF) (by transthoracic echocardiography [TTE]), left atrial appendage flow velocity (LAAFV) >40 cm/s and the freedom from left atrial spontaneous echo contrast (LASEC) (by transesophageal echocardiography), ‒ all were associated with the higher chance to maintain SR at 6-months follow-up (Figure). At the same time, the higher baseline left atrial dimension (LAD) and more advanced pulmonary hypertension (PH) (by TTE) were associated with the failure of its maintenance to be more probable (Figure). At multivariate analysis, the following predictors of SR maintenance after DCCV at 6-months follow-up were identified: higher LVEF (OR 1,07 (95 % CI 1,01-1,13); р=0,021); LAAFV >40 cm/s (OR 4,33 (95 % CI 1,06-17,78); р=0,042), and less advanced PH (OR 0,24 (95% CI 0,06-0,93); р=0,038). Conclusion Better LV systolic function, LAAFV >40 cm/s and less advanced PH were the predictors of SR maintenance following DCCV in patients with late persistent (with duration of its episode ≥90 days) non-valvular AF at 6-months follow-up.

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.

A genetic polymorphism on chromosome 4q25 (rs17570669_T) may predict atrial fibrillation recurrence after successful electrical cardioversion

Abstract Background Direct current electrical cardioversion (DCCV), is an effective treatment method in patients with symptomatic persistent atrial fibrillation (AF). However, AF recurrence may occur following successful DCCV in nearly half of the patients. There is not enough data investigating the association between single nucleotide polymorphisms (SNP) and AF recurrence after DCCV. Purpose We aimed to investigate whether 11 SNPs previously associated with AF (rs2200733, rs10033464, rs6838973, rs3853445 and rs17570669 SNPs in PITX2 gene; rs2106261 SNP in ZFHX3 gene; rs751141 SNP on chromosome 8q21; rs3807989 SNP in CAV1 gene; rs10570248 SNP in TBX5 gene; rs1800469 SNP in TGF-1 gene; and rs6795970 SNP in SCN10A gene) were predictive for recurrence after successful DCCV in patients with persistent AF in Turkish society. Methods We included 75 patients with sinus rhythm after direct current electrical cardioversion (DCCV). Baseline clinical features and 11 AF-related SNPs were compared between patients with and without AF recurrence during the follow-up. The association between SNPs and AF recurrence was evaluated with the additive model (wild type vs heterozygous variant vs homozygous variant), the dominant model (wild type/heterozygous vs homozygous variant), and the recessive model (wild type vs heterozygous variant/homozygous variant). Results The mean age of the patients was 61.9 ± 11.5 years. At a mean follow-up of 17.0 (11.0-25.0) months, 38 patients (50.7%) developed AF recurrence. The frequency of the female gender was higher (55.3% vs. 32.4%), AF duration before DCCV was longer [9.2 (5.5-11.6) vs 5.0 (2.7-11.0) months], and left atrial volume index before DCCV was higher (43.6 ± 8.8 ml/m2 vs. 38.2 ± 12.9 ml/m2) in patients who developed AF recurrence than those without it (p=0.046, 0.029 and 0.036, respectively) (Figure 1a). In the additive model, a SNP at the PITX2 gene (rs17570669_T: OR 9.00, 95% CI 1.28-63.02, p=0.027) and a SNP at the ZFHX3 gene (rs2106261_T: OR 8.96, 95% CI 1.03-77.66, p=0.047) were significantly associated with AF recurrence. Female gender (HR: 1.99, 95% CI: 1.05-3.79, p=0.035) and the rs17570669_T SNP (HR: 4.16, 95% CI: 1.22-14.11, p=0.022) were predictors for AF recurrence in univariate analysis. A multivariate Cox regression analysis showed that the rs17570669_T SNP was an independent predictor of AF recurrence following successful DCCV in the additive model (HR: 3.59, 95% CI: 1.05-12.21, p=0.04) (Figure 1b). A Kaplan-Meier curve showed that AF-free survival was significantly lower in patients who had rs17570669_T SNP in the additive model (Figure 2). Conclusion A SNP at the PITX2 locus (rs17570669_T) may predict AF recurrence after successful DCCV in patients with persistent AF in Turkish society. Such individuals may be closely monitored for the development of AF recurrence after DCCV. In addition, reversible risk factors associated with AF recurrence may be more tightly controlled in such patients.Baseline features and Cox analysisKaplan-Meier curve

Предиктори утримання синусового ритму в пацієнтів із пізньою персистентною фібриляцією передсердь після електричної кардіоверсії під час 6-місячного проспективного спостереження

The aim – to study the predictors of sinus rhythm (SR) maintenance in patients with persistent atrial fibrillation (AF) and duration of AF episode ≥90 days at 6-months follow-up after elective direct current (DC) cardioversion.Materials and methods. The cohort single-center study analyzed clinical and instrumental data from 59 persistent AF patients with duration of its episode ≥90 days (up to 12 months), who underwent an elective DC cardioversion. At 6-months follow-up, patients were subdivided into the groups depending on SR maintenance: 32 (54 %) patients with a maintained SR (G1), and 27 (46 %) patients with a failure to maintain SR (G2).Results. G2, as compared to G1, demonstrated more advanced heart failure (stage C occurred in 74 % and 44 %, respectively [p=0,019]). According to transthoracic echocardiography (TTE) data, G1, as opposed to G2, was characterized by better baseline structure parameters of left heart chambers, particularly the diameter of left atrium (LA), end-diastolic and end-systolic volumes left ventricular (LV) volumes, higher LV systolic function (by LV ejection fraction [EF]), and the majority of the cases without or with mild pulmonary hypertension (PH). Transesophageal echocardiography data suggested the cases of LA spontaneous (echo) contrast and LA appendage flow velocity (LAAFV) ≤ 40 cm/s to be more frequent in G2, in contrast to G1. We revealed the following predictors of SR maintenance after DC cardioversion at 6-months follow-up: higher LV EF (OR 1,07 (95 % CI 1,01–1,13); р=0,021); LAAFV > 40 cm/s (OR 4,33 (95 % CI 1,06–17,78); р=0,042), and less advanced PH (OR 0,24 (95 % CI 0,06–0,93); р=0,038). TTE data from G1 at 6-months follow-up after DC cardioversion suggested the reverse remodeling of both atria (the decrease of LA diameter, LA and right atrium volumes and their indexes). Additionally, G2 demonstrated a worsening in LV systolic function (the rise of LV end-systolic volume and decrease of LV EF), as opposed to G1. Moreover, at 6-months follow-up, G2 patients presented with more advanced severity of PH, as well as mitral and tricuspid regurgitation, in contrast to G1.Conclusions. Better LV systolic function, LAAFV > 40 cm/s and less advanced PH were the predictors of SR maintenance in patients with persistent AF and duration of its episode ≥ 90 days at 6-months follow-up after elective DC cardioversion. The SR maintenance at 6-months follow-up associated with the reverse remodeling of let heart chambers and right atrium. On the contrary, a failure to maintain SR associated with the decrease of LV systolic function, and more advanced PH, mitral and tricuspid regurgitation.

Relation between 25-Hydroxy Vitamin D Deficiency and Success of Cardioversion for Lone Atrial Fibrillation (AF)

Abstract Aim and objectives The aim of this study was to assess the relationship between vitamin D deficiency and extent of success of cardioversion in patients with lone atrial fibrillation (AF). Patients and Methods This observational cross-sectional study included 50 patients (18-60 years old) who presented to the cardiology department of Ain Shams university hospitals with lone atrial fibrillation with structurally normal heart for cardioversion after fulfilling the inclusion criteria, considering that failure of cardioversion was defined as failure of restoration to normal sinus rhythm after applying the cardioversion protocol that is being used in our cardiology department in Ain Shams University hospitals. Serum vitamin D level on admission was sampled for all patients before cardioversion, and cardioversion was assessed after then whether success or failure. Cardioversion success was restoration of normal sinus rhythm and that the patient was discharged in sinus rhythm. Cardioversion protocol that was being used was applied as Loading dose of Intravenous (IV) Amiodarone of 300 mg diluted in 250 ml 5% dextrose over 30-60 minutes, then follow up dose of 900 mg IV over 24 hours diluted in 500-1000 ml of normal saline, then if failed, application of biphasic synchronized direct current electrical cardioversion at 200 joules at anteriorlateral electrode positions. Results The success rate of cardioversion was 80% (40 out of 50) in all the patients presented, and the failure rate was 20% (10 out of 50). In the success group, majority of patients 23 (57.5%) had sufficient Vitamin D levels (≥30 ng/ml), 15 patients (37.5%) had insufficient vitamin D levels (21-29 ng/ml) and 2 patients (5%) had deficient vitamin D levels (≤20 ng/ml). Meanwhile, in the failure group, the majority of patients 8 (80%) had deficient vitamin D levels (≤20 ng/ml), 1 patient (10%) had insufficient vitamin D level (21-29 ng/ml), and 1 patient (10%) had sufficient vitamin D level (≥30 ng/ml).This difference was statistically significant with a P value of < 0.01. Vitamin D level measured (25-OH vitamin D) had values of mean ± SD of 29.41 ± 4.89 ng/ml in the success group vs 19.22 ± 4.68 ng/ml in the failure group, which was statistically significant with a P value of <0.01. A-P (antero-posterior) LAD (left atrial diameter) measured in parasternal long axis view during routine pre-cardioversion work-up study by echocardiography that has been done, had values of mean ± SD of 37.60 ± 3.20 mm in the success group vs 37.80 ± 2.86 mm in the failure group, which was statistically non- significant with a P value of 0.858. There was not a statistically significant difference between the 2 groups regarding age, sex, BMI, smoking, duration of AF(duration of onset of symptoms), number of previous trials of cardioversion, previous antiarrythmic drugs that have been administered and heart rate at time of cardioversion. Conclusion Failure rate of cardioversion was found to be higher in patients with vitamin D deficiency in comparison to patients with sufficient and insufficient vitamin D levels. Abbreviations AF: Atrial Fibrillation; A-P: Antero-posterior; BMI: Body mass index; LAD: Left atrial diameter; SD: Standard deviation

Biomarkers of Atrial Fibrillation Recurrence in Patients with Paroxysmal or Persistent Atrial Fibrillation Following External Direct Current Electrical Cardioversion.

Atrial fibrillation (AF) is associated with atrial remodeling, cardiac dysfunction, and poor clinical outcomes. External direct current electrical cardioversion is a well-developed urgent treatment strategy for patients presenting with recent-onset AF. However, there is a lack of accurate predictive serum biomarkers to identify the risks of AF relapse after electrical cardioversion. We reviewed the currently available data and interpreted the findings of several studies revealing biomarkers for crucial elements in the pathogenesis of AF and affecting cardiac remodeling, fibrosis, inflammation, endothelial dysfunction, oxidative stress, adipose tissue dysfunction, myopathy, and mitochondrial dysfunction. Although there is ample strong evidence that elevated levels of numerous biomarkers (such as natriuretic peptides, C-reactive protein, galectin-3, soluble suppressor tumorigenicity-2, fibroblast growth factor-23, turn-over collagen biomarkers, growth differential factor-15) are associated with AF occurrence, the data obtained in clinical studies seem to be controversial in terms of their predictive ability for post-cardioversion outcomes. Novel circulating biomarkers are needed to elucidate the modality of this approach compared with conventional predictive tools. Conclusions: Biomarker-based strategies for predicting events after AF treatment require extensive investigation in the future, especially in the presence of different gender and variable comorbidity profiles. Perhaps, a multiple biomarker approach exerts more utilization for patients with different forms of AF than single biomarker use.

Absence of significant myocardial injury following elective direct current cardioversion for atrial fibrillation.

Direct current (DC) cardioversion is used to terminate cardiac arrhythmias. Current guidelines list cardioversion as a cause of myocardial injury. This study determined whether external DC cardioversion results in myocardial injury measured by serial changes in high-sensitivity cardiac troponin T (hs-cTnT) and high-sensitivity cardiac troponin I (hs-cTnI). This was a prospective study of patients undergoing elective external DC cardioversion for atrial fibrillation. hs-cTnT and hs-cTnI were measured precardioversion and at least 6 hours postcardioversion. Myocardial injury was present when there were significant changes in both hs-cTnT and hs-cTnI. Ninety-eight subjects were analyzed. Median cumulative energy delivered was 121.9 (interquartile range [IQR] 102.2-302.7) J. Multiple cases 23 (23.5%) required 300 J or more. Maximum cumulative energy delivered was 2455.1 J. There were small significant changes in both hs-cTnT (median precardioversion 12 [IQR7-19) ng/L], median postcardioversion 13 [IQR 8-21] ng/L; P < .001) and hs-cTnI (median precardioversion 5 [IQR 3-10) ng/L], median postcardioversion 7 [IQR 3.6-11) ng/L; P < .001). Results were similar in patients with high-energy shocks and did not vary based on precardioversion values. Only 2 (2%) cases met criteria for myocardial injury. DC cardioversion resulted in a small but statistically significant changes in hs-cTnT and hs-cTnI in 2% of patients studied irrespective of shock energy. Patients with marked troponin elevations after elective cardioversion should be assessed for other causes of myocardial injury. It should not be assumed the myocardial injury was from the cardioversion.

Genetic Polymorphism on Chromosome 4q25 (rs17570669) May Predict Recurrence After Successful Electrical Cardioversion in Patients with Persistent Atrial Fibrillation.

Direct current electrical cardioversion (DCCV) is an effective rhythm-control option for patients with atrial fibrillation (AF). Despite initial success, a high recurrence rate remains a significant challenge. There is limited data on the genetic predictors of AF recurrence following successful DCCV. In this study, we aimed to evaluate whether 11 single nucleotide polymorphisms (SNPs) previously associated with AF are also linked to recurrence after DCCV in the Turkish population. Seventy-five patients with persistent AF, who achieved stable sinus rhythm following DCCV, were included in the study. The patients were prospectively monitored for the onset of AF recurrence. Clinical characteristics and SNPs were analyzed and compared between patients who experienced recurrence and those who did not. The average age of the patients was 61.9 ± 11.5, and 33 (44%) were female. Over an average follow-up period of 17.0 (11.0-25.0) months, AF recurrence was observed in 38 patients (50.7%). A SNP in the PITX2 gene (rs17570669) (OR: 9.00, 95% Confidence Interval (CI): 1.28-63.02) and another in the ZFHX3 gene (rs2106261) (OR: 8.96, 95% CI: 1.03-77.66) were notably associated with AF recurrence in the additive model (P = 0.027 and 0.047, respectively). Multivariate Cox regression analysis revealed that the rs17570669 SNP was the sole independent predictor of AF recurrence (Hazard Ratio (HR): 3.59, 95% CI: 1.05-12.21, P = 0.040). The SNP in the paired-like homeodomain 2 (PITX2) gene (rs17570669) emerges as an independent predictor for AF recurrence after successful electrical cardioversion.

Predictors of sinus rhythm restoration in patients with long-term episodes of persistent atrial fibrillation

The aim – to compare clinical, laboratory and instrumental characteristics of patients with persistent atrial fibrillation (AF) and duration of AF episode ≥ 90 days, undergoing direct current (DC) cardioversion, in groups with or without further sinus rhythm (SR) restoration, for the purpose of determining the predictors of SR restoration.Materials and methods. The cohort single-center study analyzed clinical, laboratory and instrumental data from 115 persistent AF patients with duration of its episode ≥ 90 days, who underwent an elective direct current cardioversion. Patients were subdivided into the groups depending on SR restoration effectiveness: 59 (51.3 %) and 56 (48.7 %) patients with restored and non-restored SR, respectively.Results and discussion. The group of patients with non-effective DC cardioversion was characterized more severe heart failure (HF) and more frequent percutaneous coronary intervention (PCI) cases, as opposed to the group with restored SR. The studied groups differed significantly by the certain echo parameters, characterizing the structure and function of left heart chambers. The transthoracic echocardiography (TTE) revealed a higher left ventricular (LV) dilatation and more frequent pulmonary hypertension (PH) cases in non-restored SR group. According to transesophageal echocardiography (TEE) data, both groups demonstrated the deterioration of left atrial (LA) function, namely the decrease of LA appendage flow velocity ≤ 40 cm/s in more than 60 % of patients. Additionally, the LA spontaneous echo contrast (SEC) was visualized in vast majority of non-restored SR patients (94.6 %). At the same time, only 2 (3.6 %) patients with non-effective DC cardioversion were free from SEC, as compared to 44 (74.6 %) restored SR patients (р &lt; 0.001). The multivariable logistic regression analysis revealed SEC as an independent predictor of SR restoration.Conclusions. Persistent AF patients with duration of its episode ≤ 90 days and non-effective elective DC cardioversion demonstrated higher stage of HF, more frequent demand for PCI, the higher LV dilatation, and presence of PH (TTE) and LA SEC (TEE). Among other associated factors, the freedom from LA SEC appeared to be the only independent predictor of SR restoration in such patients.

Abstract 15091: Cardiac Ct-Guided Exclusion of Left Atrial Appendage Thrombus Prior to Electrical Cardioversion for Atrial Fibrillation

Introduction: Transesophageal echo (TEE) is routinely used to exclude left atrial appendage (LAA) thrombus prior to direct current cardioversion (DCCV) for atrial fibrillation (AF). However, the COVID-19 pandemic accelerated the use of non-invasive modalities such as cardiac computed tomography (CCT) to avoid aerosolizing viral particles during intubation, such as with introduction of a TEE probe. CCT is not routinely used as a clinical strategy to exclude LAA thrombus prior to DCCV. Therefore, we sought to determine the feasibility of CCT-guided DCCV.Hypothesis: CCT-guided elective cardioversion for atrial arrhythmias is a feasible modality to rule out left atrial appendage thrombus. Methods: We identified patients at Abbott Northwestern Hospital who underwent CCT in lieu of or in addition to TEE within 24 hours of elective DCCV for AF or atrial flutter from March 2020 to February 2022. Thirty-day outcomes were collected including cerebrovascular accident (CVA), myocardial infarction, cardiovascular death, re-hospitalization, arrhythmia recurrence, and overall mortality. Delayed imaging, 90 seconds after arterial phase, was obtained to exclude LAA thrombus. Results: Thirty-two patients were included in our analysis, 10 (31%) were female. Ten (31%) presented with new-onset of AF. CCT did not identify LAA thrombus in any patient. Post-DCCV, the mean time to arrhythmia recurrence was 16.5 days (SD: 9.3). At 30 days, 11 (34%) had been re-hospitalized but mostly for elective procedures. There was no CVA or mortality reported at the 30-day follow-up. Conclusion: CCT-guided elective cardioversion for atrial arrhythmias was evaluated for feasibility in a small pilot. In patients who had no LAA thrombus on CCT and subsequently underwent cardioversion, there were no CCT-related complications, CVA, or deaths at 30 days. Many patients benefit from early DCCV rather than waiting with uninterrupted anticoagulation. CCT guidance is a feasible alternative to TEE but needs further prospective comparison to TEE and uninterrupted anticoagulation in this clinical setting.

Anterior-Posterior versus anterior-lateral electrodes position for electrical cardioversion of atrial fibrillation: A meta-analysis of randomized controlled trials.

BackgroundThe optimal electrodes position for elective direct current (DC) cardioversion of patients with atrial fibrillation (AF) remains uncertain.MethodsAn electronic search of MEDLINE, EMBASE and COCHRANE databases was performed through March 2022 for randomized trials that examined the outcomes of anterior-posterior (AP) versus anterior-lateral (AL) electrodes position during cardioversion of (AF). The main outcome was the success rate of cardioversion. Data were pooled using random effects model.ResultsThe final analysis included 10 RCTs with a total of 1677 patients. There was no difference in the rate of successful cardioversion between the AP versus AL groups (86.6 vs 87.9 %; RR 1.00; 95 % Confidence Interval (CI) 0.95 to 1.06). Subgroup analysis by the shock waveform showed no significant interaction between monophasic and biphasic waveforms (Pintercation = 0.23). meta-regression analyses showed no effect modification of primary outcome according to body mass index (p = 0.15), left atrial diameter (p = 0.64), valvular heart disease (p = 0.34), lone AF (p = 0.58), or the duration of AF (p = 0.70). There was no significant difference between the AP and AL electrode position groups in successful cardioversion at low energy (RR 0.94; 95 % CI 0.74 to 1.19), the number of the delivered shocks (standardized mean difference [SMD] −0.03; 95 % CI −0.32 to 0.26) or the mean energy of the delivered shocks (SMD −0.11 and 95 % CI −0.30 to 0.07). There was lower transthoracic impedance with AP versus AL electrode position (SMD −0.28; 95 %CI −0.47 to −0.10).ConclusionMeta-analysis of randomized data showed no difference between AP and AL electrode positions in the success rate of DC cardioversion of AF. Either AP or AL electrode positions should be acceptable approaches for elective DC cardioversion of patients with AF.

Comparison of Bolus Dosing of Methohexital and Propofol in Elective DirectCurrent Cardioversion.

Background Methohexital and propofol can both be used as sedation for direct current cardioversion (DCCV). However, there are limited data comparing these medications in this setting. We hypothesized that patients receiving methohexital for elective DCCV would be sedated more quickly, recover from sedation faster, and experience less adverse effects. Methods and Results This was a prospective, blinded randomized controlled trial conducted at a single academic medical center. Eligible participants were randomly assigned to receive either methohexital (0.5 mg/kg) or propofol (0.8 mg/kg) as a bolus for elective DCCV. The times from bolus of the medication to achieving a Ramsay Sedation Scale score of 5 to 6, first shock, eyes opening on command, and when the patient could state their age and name were obtained. The need for additional medication dosing, airway intervention, vital signs, and medication side effects were also recorded. Seventy patients who were randomized to receive methohexital (n=37) or propofol (n=33) were included for analysis. The average doses of methohexital and propofol were 0.51 mg/kg and 0.84 mg/kg, respectively. There were no significant differences between methohexital and propofol in the time from end of injection to loss of conscious (1.4±1.8 versus 1.1±0.5 minutes; P=0.33) or the time to first shock (1.7±1.9 versus 1.4±0.5 minutes; P=0.31). Time intervals were significantly lower for methohexital compared with propofol in the time to eyes opening on command (5.1±2.5 versus 7.8±3.7 minutes; P=0.0005) as well as at the time to the ability to answer simple questions of age and name (6.0±2.6 versus 8.6±4.0 minutes; P=0.001). The methohexital group experienced less hypotension (8.1% versus 42.4%; P<0.001) and less hypoxemia (0.0% versus 15.2%; P=0.005), had lower need for jaw thrust/chin lift (16.2% versus 42.4%; P=0.015), and had less pain on injection compared with propofol using the visual analog scale (7.2±9.7 versus 22.4±28.1; P=0.003). Conclusions In this model of fixed bolus dosing, methohexital was associated with faster recovery, more stable hemodynamics, and less hypoxemia after elective DCCV compared with propofol. It can be considered as a preferred agent for sedation for DCCV. Registration URL: https://www.clinicaltrials.gov/ct; Unique identifier: NCT04187196.

The Practice of Deep Sedation in Electrophysiology and Cardiac Pacing Laboratories: Results of an Italian Survey Promoted by the AIAC (Italian Association of Arrhythmology and Cardiac Pacing).

The aim of this survey, which was open to all Italian cardiologists involved in arrhythmia, was to assess common practice regarding sedation and analgesia in interventional electrophysiology procedures in Italy. The survey consisted of 28 questions regarding the approach to sedation used for elective direct-current cardioversion (DCC), subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation, atrial fibrillation (AF) ablation, ventricular tachycardia (VT) ablation, and transvenous lead extraction procedures. A total of 105 cardiologists from 92 Italian centres took part in the survey. The rate of centres where DCC, S-ICD implantation, AF ablation, VT ablation and lead extraction procedures were performed without anaesthesiologic assistance was 60.9%, 23.6%, 51.2%, 37.3%, and 66.7%, respectively. When these procedures were performed without anaesthesiologic assistance, the drugs (in addition to local anaesthetics) commonly administered were benzodiazepines (from 64.3% to 79.6%), opioids (from 74.4% to 88.1%), and general anaesthetics (from 7.1% to 30.4%). Twenty-three (21.9%) of the 105 cardiologists declared that they routinely administered propofol, without the supervision of an anaesthesiologist, in at least one of the above-mentioned procedures. In current Italian clinical practice, there is a lack of uniformity in the sedation/analgesia approach used in interventional electrophysiology procedures.

Cardioversion of recent-onset atrial fibrillation using intravenous antiarrhythmics: A European perspective.

Pharmacological cardioversion using intravenous antiarrhythmic agents is commonly indicated in symptomatic patients with recent-onset atrial fibrillation (AF). Except in hemodynamically unstable patients who require emergency direct current electrical cardioversion, for the majority of hemodynamically stable patients, pharmacological cardioversion represents a valid option and requires the clinician to be familiar with the properties and use of antiarrhythmic agents. The main characteristics of selected intravenous antiarrhythmic agents for conversion of recent-onset AF, the reported success rates, and possible adverse events are discussed. Among intravenous antiarrhythmics, flecainide, propafenone, amiodarone, sotalol, dofetilide, ibutilide, and vernakalant are commonly used. Antazoline, an old antihistaminic agent with antiarrhythmic properties was also reported to give encouraging results in Poland. Intravenous flecainide and propafenone are the only Class I agents still recommended by recent guidelines. Intravenous new Class III agents as dofetilide and ibutilide have high and rapid efficacy in converting AF to sinus rhythm but require strict surveillance with electrocardiogram (ECG) monitoring during and after intravenous administration because of the potential risk of QT prolongation and Torsades de Pointes, which can be prevented and properly managed. Vernakalant, a partial atrial selective was shown to have a high success rate and to be safe in real-life use.

Elective DC cardioversion: a comparison of the carbon footprint of the care pathways for warfarin and DOAC treated patients.

Editor – What is the impact of changing anticoagulation from warfarin to direct-acting oral anticoagulants (DOAC) on the carbon footprint (CF) of the elective direct current cardioversion (EDCCV) care pathway (supplementary material S1; Fig S1)? After Integrated Research Application System (230497), institutional approval (RHM-CR10347) and patient consent, we recruited all patients presenting for EDCCV under general anesthesia at University Hospital Southampton NHS Foundation Trust (UHS) between 2012–2017. Prospectively, data from 22 patients were analysed: mode of transport to their general practitioner and UHS, anaesthesia drugs, disposables, oxygen, waste generation and time spent …

Find me if you can: lessons learned using the novel cartofinder algorithm in a routine workflow for catheter ablation of atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background CARTOFINDER allows for a simultaneous and automated detection of repetitive focal and rotational activations during electroanatomical mapping using a multi-electrode catheter in patients with atrial fibrillation (AF). Aim This study aimed to validate the CARTOFINDER algorithm for the detection of potential drivers for AF under routine clinical conditions and to access the effects of PVI and additional substrate modification on regions of interests (ROI) from CARTOFINDER mapping. Methods Forty-four consecutive patients underwent AF ablation for persistent AF using a 3D-mapping system with the novel integrated CARTOFINDER module. All patients presented with persistent AF and mapping was performed using a multi-electrode catheter. The ablation workflow was divided into the following steps: 1. 3D reconstruction of the right (RA) and left atrium (LA). 2. Identification of the individual ROIs separated for focal and rotational activity in the RA and LA. 3. Ablation index guided pulmonary vein isolation (PVI). 4. Repeat mapping for ROIs in the RA and LA. 5. Direct current electrical cardioversion. 6. Confirmation of persistent PVI and bipolar ultra-high density mapping of the RA and LA followed by substrate modification if there was evidence for local bipolar low-voltage in the LA. Results Acute PVI was achieved in all patients (100%). In 28% of these patients additional LA substrate modification was performed. AF termination was observed in 4 patients. Mean procedure duration was 137 ± 30 min, mapping time for ROIs in the RA was 8 ± 5 min and 11 ± 5 for the LA, respectively. A mean number of 149 ± 82 ROIs were revealed from CARTOFINDER. In the LA, focal activity was predominantly observed inside the LA appendage (LAA) and in close relationship to the pulmonary vein ostia. The majority of rotational activities was found along the mitral valve annulus. In the RA, the majority of ROIs was found at the septum and in close relationship to the RA appendage. During re-mapping for ROIs after AF ablation we observed the elimination of ROIs close to the linear ablation set for PVI. In addition, rotational activity could not be re-identified at repeat mapping. Conclusions ROIs could be discriminated and visualized utilizing CARTOFINDER in all patients. These ROIs might potentially be an additional and individual ablation target beyond PVI in patients with persistent AF.

Effectiveness of a simple medication adjustment protocol for optimizing peri-cardioversion rate control: A derivation and validation cohort study.

BackgroundRate control medications are foundational in the management of persistent atrial fibrillation (AF). There are no guidelines for adjusting these medications prior to elective direct-current cardioversion (DCCV).ObjectiveTo derive and validate a preprocedural medication adjustment protocol that maintains peri-DCCV rate control and minimizes risk of postconversion bradycardia, pauses, need for pacing, and cardiopulmonary resuscitation (CPR).MethodsConsecutive patients with persistent AF awaiting elective DCCV across 2 hospitals were screened for inclusion into derivation, validation, and control cohorts. In the derivation cohort, each patient taking an atrioventricular (AV) nodal blocker had medications adjusted based on heart rate (HR) 2 days before DCCV, and the magnitude of dose adjustment was compared with peri-DCCV HR. The adjustment protocol that achieved the highest percentage of optimal peri-DCCV rate control was tested prospectively in the validation cohort and compared to a standard-of-care control group.ResultsThe optimal protocol from the derivation cohort (n = 71), based on the 2-day pre-DCCV HR, was to (1) CONTINUE AV nodal blocker for HR ≥ 100 beats per minute (bpm), (2) reduce dose by ONE increment when 80–99 bpm, (3) reduce dose by TWO increments when 60–79 bpm, and (4) HOLD when <60 bpm. In the prospective validation cohort (n = 106), this protocol improved peri-DCCV rate control (82% vs 62%, P < .001) compared to current standard of care (n = 107). There were no conversion pauses ≥5 seconds, need for pacing, or CPR post-DCCV.ConclusionThis simple preprocedural medication adjustment protocol provides an effective strategy of optimizing peri-DCCV rate control in patients with AF.

Outcomes of Direct Current Cardioversion (DCCV) for Atrial Fibrillation (AF) in a South Auckland Population

Elective direct current cardioversion (DCCV) is recommended in symptomatic patients with persistent atrial fibrillation (AF) as part of rhythm control therapy, but little is known about its efficacy in our population. Between 2017 to 2019, we identified and analysed 100 consecutive patients admitted for elective DCCV. We followed them retrospectively over one year to observe rhythm control, medication use and complications. The mean age was 64 yrs (41yrs to 83 yrs), 68% were male and one third identified as Māori (14%) or Pacific (19%). Risk factors: Previous DCCV, 18%, or ablation, 2%; mean BMI, 33 (16-62); smoking, 8%; hypertension, 46%; previous stroke, 3%; heart failure, 23%; cardiovascular disease, 16%; and type 2 diabetes, 26%. The mean CHADS2-VASc score was 2 (0-6). The majority (80%) had a left ventricular ejection fraction (LVEF) >40%. The most common anticoagulant was dabigatran 150mg BD (77%) and dabigatran 110mg BD (15%); also, rivaroxaban (2%) and warfarin (6%). The most common rate limiting therapy was beta blocker (84%); also, diltiazem (22%), amiodarone (33%) and digoxin (4%). At follow up review (mean 64 days, 7-421 days), 61% were in sinus rhythm (Māori/Pacific, 48% vs others, 67%) and after nearly 2 years of follow up, 74% had a further review with 42% in sinus rhythm (SR), 32% in AF/atrial flutter and 26% unknown. Over the study period, 5% of patients died (4% non-cardiac), and 8% had ablation. At 2 years of follow up over 1/3 of patients were in SR. Funded support around lifestyle change, to impact on obesity and hypertension rates, needs to be available.

The shocking lack of significant increases in high sensitivity troponin values after cardioversion

Abstract Background and introduction Cardioversion is commonly used to terminate cardiac arrhythmias. Some previous reports have suggested that cardioversion results in myocardial injury as evidenced by increased levels of cardiac troponin. However, many of these studies were done years ago with less sensitive troponin assays and monophasic waveform defibrillators. Purpose To determine if external direct current (DC) cardioversion with biphasic rectilinear waveform shocks results in myocardial injury as assessed by high sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI). Methods Patients scheduled for elective DC cardioversion for atrial fibrillation or atrial flutter were recruited. Plasma samples for measurement of hs-cTnT and hs-cTnI were obtained pre-cardioversion and as late as feasible but at least 6 hours post-cardioversion [median of 9 (7–11) hours]. Results A total of 96 patients were recruited. One patient was excluded because the pre-cardioversion sample was hemolysed. Median (25th–75th interquartile range) cumulative energy delivered was 121.6J (62.4–277.4J) and median highest energy individual shock was 121.0J (62.1–146.2J). A total of 39 (41.1%) patients received more than 1 shock, 23 (24.2%) patients received a cumulative energy of 300J or higher and 5 (5.3%) patients received a cumulative energy of 1,000J or more. The median pre-cardioversion hs-cTnT value was 11.48 (7.19–18.38) ng/L and the median hs-cTnI value was 5.1 (2.0–9.4) ng/L. Median post-cardioversion hs-cTnT value were 12.46 (7.98–20.28) ng/L and hs-cTnI value were 6.3 (3.5–10.0) ng/L. Wilcoxon-Signed ranks test showed a statistically significant change between the pre-and-post cardioversion hs-cTnT values (Z=−4.237, p&amp;lt;0.001) and hs-cTnI values (Z=−4.822, p&amp;lt;0.001). In only 5 (hs-cTnT) and 4 patients (hs-cTnI) was there an increase of &amp;gt;5 ng/L. There were 5 cases where the post-cardioversion values of both hs-cTnT and hs-cTnI were above the 50% reference change value. There was no relation between the change in hs-cTn values and sex, number of shocks, total energy delivered (even in those who received more than 1,000J), highest energy per shock, total current delivered, highest current delivered per shock or transthoracic impedance. Conclusion(s) There is a statistically significant but very small change in median hs-cTnT and hs-cTnI values (1 ng/L and 1.2 ng/L respectively) after DC cardioversion. The results were similar even in patients where high energy shocks were delivered and did not vary based on the pre cardioversion baseline value. Patients who have marked troponin elevations after cardioversion should be assessed for other causes of myocardial injury. It should not be assumed that they have myocardial injury from the cardioversion alone. Figure 1 Funding Acknowledgement Type of funding source: Other. Main funding source(s): Dr. Allan Jaffe has substantial research funds from both grants and private industry. Funds were used to pay for blood sample collection and analysis of high sensitivity cardiac troponin T at Mayo Clinic. Abbott Laboratories donated reagents for the high sensitivity cardiac troponin I analysis.