Elective Electrical Cardioversion Research Articles

Prediction of the success of electrical cardioversion in patients with atrial fibrillation using parameters obtained by spectral and vectorcardiographic analysis of the ECG

Abstract Introduction Electrical cardioversion (ECV) still presents a treatment option for atrial fibrillation (AF). Despite the great success rate in the acute setting, its long-term success rate is low. The aim of the study was to find predictors of SR maintenance after ECV using spectral and vectorcardiographic (VCG) analysis of the ECG curve. Methods Consecutive patients with AF referred for elective ECV were prospectively enrolled. The digital ECG recording obtained before the ECV was analyzed using spectral and VCG analysis. All patients had Holter monitoring and clinical follow-up three months after cardioversion to assess SR maintenance. Atrial fibrillation activity was analyzed by spectral analysis, determining the dominant frequency (DF), RI (regularity index) and OI (organization index). QRS complexes were analyzed by vectorcardiography and dXmean, dYmean and dZmean (derivation of VCG signals) parameters were determined. Using logistic regression (LR) with backward parameter reduction, separate and combined predictive models of SR maintenance were calculated based on both the analysis from the VCG data and the spectral analysis data. Additional models with a forward selection of clinical variables were also calculated. The efficiency of the models was evaluated on a separate test subset of the data (N=32). Results A total of 80 patients were enrolled (age 70+10 years, 48 (64%) men, CHADSVASc 3.17+1.5, BMI 29.75kg/m2). At the 3-month follow-up, AF recurrence was present in 36 patients (45%). Using only vectorcardiographic parameters, dXmean (OR 3.07, 95 %CI 1.14- 8.63), p=0.001) and dYmean (OR 0.26, 95% CI 0.09-0.72), p <0.001) best predicted the SR maintenance (AUC of 0.72). Using only spectral analysis parameters, the best predictor was DF (OR 3.07, 95%CI 1.14-8.63), p=0.012) with AUC of 0.66. By combining the results of spectral analysis and vectorcardiography, an AUC of 0.78 was achieved. Among the clinical parameters, the most significant predictors were insufficiently controlled arterial hypertension and previous history of stroke. Conclusion Digital analysis of ECG curves using deeper mathematical models provides a better predictive model than classical clinical and echocardiographic models. The combination of spectral analysis of fibrillation atrial activity and vectorocardiographic analysis of QRS complexes revealed more accurate predictive information compared to both analyses alone.

A Quantitative Assessment of Cerebral Hemodynamic Perturbations Associated with Long R-R Intervals in Atrial Fibrillation: A Pilot-Case-Based Experience.

Background and Objectives: Atrial fibrillation (AF) results in systemic hemodynamic perturbations which impact cerebral circulation, possibly contributing to the development of dementia. However, evidence documenting effects in cerebral perfusion is scarce. The aim of this study is to provide a quantitative characterization of the magnitude and time course of the cerebral hemodynamic response to the short hypotensive events associated with long R-R intervals, as detected by near-infrared spectroscopy (NIRS). Materials and Methods: Cerebral NIRS signals and arterial blood pressure were continuously recorded along with an electrocardiogram in twelve patients with AF undergoing elective electrical cardioversion (ECV). The top 0.5-2.5% longest R-R intervals during AF were identified in each patient and used as triggers to carry out the triggered averaging of hemodynamic signals. The average curves were then characterized in terms of the latency, magnitude, and duration of the observed effects, and the possible occurrence of an overshoot was also investigated. Results: The triggered averages revealed that long R-R intervals produced a significant drop in diastolic blood pressure (-13.7 ± 6.1 mmHg) associated with an immediate drop in cerebral blood volume (THI: -0.92 ± 0.46%, lasting 1.9 ± 0.8 s), followed by a longer-lasting decrease in cerebral oxygenation (TOI: -0.79 ± 0.37%, lasting 5.2 ± 0.9 s, p < 0.01). The recovery of the TOI was generally followed by an overshoot (+1.06 ± 0.12%). These effects were progressively attenuated in response to R-R intervals of a shorter duration. Conclusions: Long R-R intervals cause a detectable and consistent cerebral hemodynamic response which concerns both cerebral blood volume and oxygenation and outlasts the duration of the systemic perturbation. These effects are compatible with the activation of dynamic autoregulatory mechanisms in response to the hypotensive stimulus.

Predictors of Transthoracic Impedance in Patients Who Underwent Elective Electrical Cardioversion

Successful synchronized direct current cardioversion (DCCV) requires adequate current delivery to the heart. However, adequate current for successful DCCV is not yet established. Trans-myocardial current depends on two factors: input energy and transthoracic impedance (TTI). While factors affecting TTI have been studied in animal models, factors affecting TTI in humans have not been well established. Here we explored the potential factors that affect TTI in humans. Retrospective review of patients undergoing DCCV at a large quaternary medical center between October 2019 and August 2021 was conducted. Pertinent clinical information, including demographics, echocardiography findings, laboratory findings and body characteristics were collected. Cardioversion details including joules delivered and TTI were recorded by the defibrillator for each patient's first shock. Predictors of thoracic impedance were assessed using regression analysis. A total of 220 patients (29% female) were included in the analysis. 143 (65%) of the patients underwent DCCV for atrial fibrillation, 77 (35%) underwent DCCV for atrial flutter. Mean impedance in our population was 73 ± 18 ohms. In a regression model with high impedance defined as the upper quartile of our cohort, BMI, female sex, obstructive sleep apnea and chronic kidney disease (All p values <0.05) were significantly associated with high impedance. According to an ROC analysis, BMI has a high predictive value for high impedance, with an AUC of 0.76. In conclusion, our study reveals that elevated BMI, female sex, sleep apnea and chronic kidney disease were predictors of higher TTI. These factors may help in determining the appropriate initial shocking energy in patients undergoing DCCV for atrial fibrillation and flutter.

Usefulness of risk scores and predictors of atrial fibrillation recurrence after elective electrical cardioversion.

Electrical cardioversion (ECV) is a frequently used procedure for restoring sinus rhythm in atrial fibrillation (AF); however, the rate of recurrence is high. The identification of patients at high risk of recurrence could influence the decision-making process. The present study evaluates the predictive value of risk scores in atrial fibrillation recurrence after elective electrical cardioversion. Unicentric, observational, and prospective study of adult patients who have undergone an elective ECV as rhythm control strategy between July 2017 and September 2022. From the 283 analyzed patients (mean age 63.95 ± 10.76212, 74.9% male); 99 had paroxysmal AF (35%) and 159 (59%) presented AF recurrence during a follow-up of 6 months. In patients with post-ECV AF recurrence, the period of time from diagnosis until the performance of the procedure was longer (393 ± 891 vs. 195 ± 527, p = .02). No paroxysmal AF (71.3% vs. 57.8%, p = .02) and LA dilatation with >40 mL/m2 (35.9% vs. 23.3%, p = .02) volumes were more frequent within these patients. AF recurrence was more frequent in patients who had previous ECV (HR = 1.32; 95% CI: 1.12-2.35; p = .01) and more than 1 shock to recover sinus rhythm (HR = 1.62; 95% CI: 1.07-1.63; p = .01). The SLAC, ALARMEc, ATLAS, and CAAP-AF scores were statistically significant, although with a moderate predictive capacity for post-ECV recurrence. Risk scores analyzed showed a modest value predicting AF recurrence after ECV. Previous ECV, and greater difficulty in restoring SR were independent predictors of recurrence.

Metabolomics and frailty: a "from bench to bedside" approach to atrial fibrillation in older patients

Abstract Background Atrial fibrillation (AF) is the most common sustained arrhythmia diagnosed at an advanced age. The most important complications of AF are stroke, heart failure and dementia. The pathophysiology of the arrhythmia is complex and multifaceted and several aspects are still not completely understood. Purpose Our project aimed at exploring the molecular characteristics of AF in older patients using an untargeted metabolomics approach, an analytical technique that provides an insight of the global metabolic profile at an individual level. As secondary endpoints, we evaluated the association between metabolomics and acylcarnitines, which are mediators of myocyte electrical instability, and difference in metabolomics profile between healthy controls (C) and AF patients (AF-P). Method We evaluated 50 consecutive older AF-P with persistent AF, waiting to be treated with elective electrical cardioversion of the arrhythmia, and 22 healthy controls (C). In all patients, the cardiological evaluation was integrated with tools of the Geriatric Multidimensional Assessment (GMA) to describe neurocognitive function (Mini-Mental State Examination, MMSE), depressive symptoms (15-item Geriatric Depression Scale, GDS), and physical performance (Short Physical Performance Battery, SPPB). Interleukin-6 (IL-6), a marker of low-grade inflammation, was measured with ELISA assays. Metabolomics analysis and acylcarnitine measurements were carried out using gas chromatography coupled with mass spectrometry (GC-MS). Results AF-P and C did not differ by age (76 ± 6 vs. 70 ± 14 years, p = 0.055); patients had a lower proportion of women (AF-P: 32% vs. C: 64%, p = 0.012). Cluster analysis applied to metabolomic data in all population identified two subset of subjects, characterized by a different body mass index (BMI; 23.57 vs. 32.53 Kg/m², p = 0.046). When studying only the AF-P group, the simultaneous presence of a higher CHA2DS2-VASc score (4.17 ± 1.32 vs. 2.88 ± 1.83, p = 0.007), a lower physical function (SPPB; 8.97± 2.22 vs. 10.75 ± 1.13, p = 0.009), and higher IL-6 levels (4.42 vs. 2.39 pg/mL, p = 0.002) described the cluster with a worse clinical phenotype and a specific metabolomics pattern. Furthermore, an association between IL-6 and medium- long-chain acylcarnitines emerged (acylcarnitine 12:1, β = 31.7 ± 9.4, R = 0.446, p = 0.001). Conclusions Present analysis demonstrated that a specific metabolomics profile was characteristic of older AF patients with a frail phenotype, identified by higher CHA2DS2-VASc score and IL-6 concentration, and lower physical performance. Future studies are needed to reveal the single molecular pathways responsible of these behaviour, potentially useful to guide a targeted therapy. Last, inflammation per se could contribute to electrical instability in AF, while body mass index, a surrogate measure of undernutrition, could identify different metabolic pathways in controls and in patients with the arrhythmia.Metabolomics by clinical phenotypes

Is there a reduced confidence towards direct oral anticoagulants compared to vitamin K antagonists in patients scheduled for an elective electrical cardioversion? The results of the BLITZ-AF study

ObjectiveTo study the confidence of cardiologists in performing an electrical cardioversion in patients on oral anticoagulation (OA) with or without transoesophageal echocardiography (TOE). MethodsData about atrial fibrillation (AF) patients admitted to cardiology wards for elective cardioversion (ECV) were extrapolated from the BLITZ-AF study. Percentage of vitamin K antagonists (VKAs), direct oral anticoagulants (DOAC) and heparin prescription were analysed in relation to the use of TOE before ECV. ResultsOverall rate of TOE was 33.7% (240/713); it was used before ECV in 124/313 (39.6%) of DOACs patients and in 96/372 (25.8%) of the patients on VKAs, showing a significant reduced resort to TOE in VKAs patients (p = 0.0001). Among non-valvular patients TOE was more frequently performed in males, at younger ages and in patients on heparin when compared to patients treated with OA. TOE was also more frequently performed in tertiary hospitals and in hospitals with cardiology wards and electrophysiology labs, when compared to hospital provided only with cardiology wards. At multivariable analysis there was a significant less recourse to TOE in patients on VKAs (OR 0.47; 95% CI: 0.33–0.67) and higher recourse in the heparin group (OR: 3.85; 95% CI:1.59–9.28) with respect to patients on DOACs; a higher recourse to TOE was observed also in tertiary hospitals (OR 4.25; 95% CI 2.69–6.69) and in hospitals with cardiology wards and electrophysiology (EP) labs (OR 1.87; 95% CI 1.23–2.82). Conclusionour study shows the reluctance in cardioverting patients on DOACs respect to VKAs without a previous TOE, despite adequate anticoagulant treatment.

Incremental Value of Right Atrial Strain Analysis to Predict Atrial Fibrillation Recurrence After Electrical Cardioversion

Although the assessment of left atrial (LA) mechanics has been reported to refine atrial fibrillation (AF) risk prediction, it doesn't completely predict AF recurrence. The potential added role of right atrial (RA) function in this setting is unknown. Accordingly, this study sought to evaluate the added value of RA longitudinal reservoir strain (RASr) for the prediction of AF recurrence after electrical cardioversion (ECV). We retrospectively studied 132 consecutive patients with persistent AF who underwent elective ECV. Complete two-dimensional and speckle-tracking echocardiography analyses of LA and RA size and function were obtained in all patients before ECV. The end point was AF recurrence. During a 12-month follow-up, 63 patients (48%) showed AF recurrence. Both LASr and RASr were significantly lower in patients experiencing AF recurrence than in patients with persistent sinus rhythm (LASr, 10%±6% vs 13%±7%; RASr, 14%±10% vs 20%±9%, respectively; P<.001 for both). Right atrial longitudinal reservoir strain (area under the curve=0.77; 95% CI, 0.69-0.84; P<.0001) was more strongly associated with the recurrence of AF after ECV than LASr (area under the curve=0.69; 95% CI, 0.60-0.77; P<.0001). Kaplan-Meier curves showed that patients with both LASr ≤ 10% and RASr ≤ 15% had a significantly increased risk for AF recurrence (log-rank, P<.001). However, at multivariable Cox regression, RASr (hazard ratio, 3.26; 95% CI, 1.73-6.13; P<.001) was the only parameter independently associated with AF recurrence. Right atrial longitudinal reservoir strain was more strongly associated with the occurrence of AF relapse after ECV than LASr, and LA and RA volumes. Right atrial longitudinal reservoir strain was independently and more strongly associated than LASr with AF recurrence after elective ECV. This study highlights the importance of assessing the functional remodeling of both the RA and LA in patients with persistent AF.

Predictors of success of elective electrical cardioversion in patients with atrial fibrillation and atrial flutter

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Electrical cardioversion is an effective therapy for the restoration of sinus rhythm. The success of cardioversion has been related to different clinical and echocardiographic variables, although the available evidence is scarce and heterogeneous. Methods Ambispective, observational, single-center registry that consecutively included 271 patients scheduled for elective electrical cardioversion (ECV) on the inpatient ward for atrial fibrilation (AF) or flutter fibrilation (AFL) &amp;gt;48 hours of onset during the years 2018-2021. All patients scheduled for CVE that were ultimately discontinued on the day of the procedure were excluded, finally analyzing 244 patients. Results The baseline characteristics are shown in Picture 1. No statistically significant differences were observed in the main comorbidities, cardiovascular risk factors, CHAD2S2-VASc scale, the position of the paddles, or days to ECV between patients with successful ECV and those with a failed procedure. Neither were they observed in terms of pharmacological treatment, including the presence of previous antiarrhythmic treatment as part of a facilitated ECV strategy (Picture 2). Moderately-severely depressed systolic function and the presence of moderate-severe mitral regurgitation were associated with a higher rate of cardioversion failure (3% vs 2.6% p= 0.002; 3.3% vs 1.3% p=0.001), higher number of biphasic electric shocks (1.3 vs 1.6 p&amp;lt;0.001; 1.2 vs 1.6 p&amp;lt;0.001) and higher total voltage received (245J vs 310J p=0.32; 229J vs 325J p&amp;lt;0.001). Moderate-severe tricuspid regurgitation was also associated with lower cardioversion success rate (96.7% vs 85% p=0.02) although no differences were seen with respect to the number of shocks or energy received. On the other hand, severe left atrial dilatation, although it had a neutral impact on the success of ECV, was associated with greater immediate recurrence (&amp;lt;5 minutes after ECV) (4.2% vs 50% p&amp;lt;0.001). Conclusion Patients with moderate-severe systolic dysfunction and significant mitral and tricuspid regurgitation have a lower success rate of ECV. Previous antiarrhythmic therapy presents a neutral effect on sinus rhythm restoration and immediate recurrence.

Prevalence of left atrial thrombus in anticoagulated patients undergoing elective electrical cardioversion

Abstract Funding Acknowledgements Type of funding sources: None. Introduction and objectives The prevalence of left atrial (LA) thrombus in patients with atrial fibrillation (AF) or atrial flutter (AFL) on guideline-directed anticoagulation is nor well known, moreover, evidence on the presence of left atrial thrombus with different anticoagulation therapies provides heterogeneous results. Methods Ambispective, observational, single-center study that consecutively included 271 patients undergoing elective electrical cardioversion (ECV) for AF or AFL &amp;gt;48 hours of onset. A transoesophageal echocardiogram (TOE) was performed in all patients within 24 hours prior to ECV. Patients with &amp;lt;3 weeks of anticoagulation and those in sinus rhythm on admission were excluded, and the clinical characteristics and presence of atrial thrombus were analyzed in 172 patients. Results The main baseline characteristics are shown in Picture 1. A total of 66.5% of the patients were receiving treatment with direct oral anticoagulants (NOAC) dabigatran (15.9%); rivaroxaban (28.3%); apixaban (31.2%) and edoxaban (23.9%). The remaining 33.5% were anticoagulated with vitamin K antagonists (VKA). Eight thrombi were detected in the left atrial appendage (prevalence 4.7%), and on 2 occasions the presence of thrombus could not be ruled out, and CVE was also suspended. No statistically significant differences were observed between the prevalence of thrombus and the type of anticoagulant (NOAC vs VKA 4.5% vs 4.9%; p= 0.56) or between the different NOACs (p=0.61). Of the 8 patients with left atrial thrombus, anticoagulant treatment was modified in 3 of them. Control TOE was performed (median until new TOE 64 days), and resolution was verified in 3 cases (all under treatment with NOAC), of which 2 patients had maintained their previous anticoagulant treatment. Conclusions Anticoagulated patients scheduled for elective ECV present a prevalence of left atrial thrombus close to 5%. No differences were observed with respect to the anticoagulation treatment received.

Atrial fibrillation detection using the ECG signal in the left in ear region: validation study on patients electively admitted for DC cardioversion

Abstract Funding Acknowledgements Type of funding sources: None. Early detection of atrial fibrillation is a major opportunity for mobile health, as portable devices nowadays available can detect multiple-lead electrocardiogram (ECG). The study aims to validate the in-ear region as a new anatomical site for ECG signal detection in patients (pts) affected by atrial fibrillation (AF). Methods We performed the ECG using KardiaMobile 6L device on 40 patients affected by AF and admitted to our hospital for elective electrical cardioversion. All the digital ECGs were detected in a modified modality or using the left in-ear region instead of the right hand. All the recorded ECGs were analyzed by the device and the results checked by two cardiologists. Results We successfully collected all 40 modified digital ECGs performed on the group of 40 pts: age 69.4 ± 9.4 years; male 28 (70)%; medium HR 95±25.4bpm; 26 (65%) affected by hypertension; 2 (5%) affected by diabetes mellitus; 37 (92,5%) in NOACs. In all cases, the KardiaMobile 6L automatic diagnosis of the ECG detected by this modified modality was correct in 100% of cases. Conclusion The in-ear region could be a reliable novel anatomical site for ECG signal detection in patients affected by atrial fibrillation. These data could support the development of new portable mobile ECG devices using the left in ear region and so leaving at least one hand free.

Beat-to-beat finger photoplethysmography in atrial fibrillation patients undergoing electrical cardioversion

Atrial fibrillation (AF)-induced peripheral microcirculatory alterations have poorly been investigated. The present study aims to expand current knowledge through a beat-to-beat analysis of non-invasive finger photoplethysmography (PPG) in AF patients restoring sinus rhythm by electrical cardioversion (ECV). Continuous non-invasive arterial blood pressure and left middle finger PPG pulse oximetry waveform (POW) signals were continuously recorded before and after elective ECV of consecutive AF or atrial flutter (AFL) patients. The main metrics (mean, standard deviation, coefficient of variation), as well as a beat-to-beat analysis of the pulse pressure (PP) and POW beat-averaged value (aPOW), were computed to compare pre- and post-ECV phases. 53 patients (mean age 69 ± 8 years, 79% males) were enrolled; cardioversion was successful in restoring SR in 51 (96%) and signal post-processing was feasible in 46 (87%) patients. In front of a non-significant difference in mean PP (pre-ECV: 51.96 ± 13.25, post-ECV: 49.58 ± 10.41 mmHg; p = 0.45), mean aPOW significantly increased after SR restoration (pre-ECV: 0.39 ± 0.09, post-ECV: 0.44 ± 0.06 a.u.; p < 0.001). Moreover, at beat-to-beat analysis linear regression yielded significantly different slope (m) for the PP (RR) relationship compared to aPOW(RR) [PP(RR): 0.43 ± 0.18; aPOW(RR): 1.06 ± 0.17; p < 0.001]. Long (> 95th percentile) and short (< 5th percentile) RR intervals were significantly more irregular in the pre-ECV phases for both PP and aPOW; however, aPOW signal suffered more fluctuations compared to PP (p < 0.001 in both phases). Present findings suggest that AF-related hemodynamic alterations are more manifest at the peripheral (aPOW) rather than at the upstream macrocirculatory level (PP). Restoring sinus rhythm increases mean peripheral microvascular perfusion and decreases variability of the microvascular hemodynamic signals. Future dedicated studies are required to determine if AF-induced peripheral microvascular alterations might relate to long-term prognostic effects.

Association of Electrical Cardioversion with Brain Perfusion and Cognitive Function in Patients with Atrial Fibrillation.

The association of atrial fibrillation (AF) and brain perfusion (BP) has not been well-defined. This study aimed to determine the association of persistent AF with BP and cognition, in comparison to control subjects and with regards to electrical cardioversion (ECV). This study compared 25 patients with persistent AF undergoing elective ECV with 16 age/sex-matched controls. We measured regional BP by using the magnetic resonance (MRI) arterial spin labelling technique. Cognitive function was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) cognitive function index. Measurements were performed at baseline and 6 weeks after ECV. There was no significant difference in BP between AF patients and control subjects (p > 0.05). Following the ECV, there was a significant improvement in BP in 15 patients who maintained sinus rhythm, while there was no significant change in the recurrence group (297 ± 24 before vs. 328 ± 37 after ECV, p = 0.008, and 297 ± 22 before vs. 307 ± 24 after ECV, p = 0.45, respectively). There was no difference in the cognitive assessment between AF patients and control subjects, as well as before and after ECV within the AF group (52.2 ± 9.6 vs. 51.2 ± 6.2, p = 0.71 and 53 ± 10 vs. 54 ± 9, p = 0.46, respectively). This study did not show difference in BP between persistent AF patients and matched control subjects. Restoration of sinus rhythm was associated with significantly improved BP. There was no association of ECV and changes in cognitive function.

Safety and efficacy of a nurse-led elective cardioversion with etomidate for atrial arrhythmia in a tertiary hospital

Management of cardiac arrhythmias often requires direct current cardioversion (DCC) to restore sinus rhythm. This intervention varies greatly between countries and hospitals, mostly regarding the organization of an elective DCC, and the choice of the sedation. The aim of this study is to assess the safety and efficacy of an elective DCC performed in a cardiology day hospital, led by trained nurses, and using intravenous Etomidate as sedation. We performed a retrospective cohort study at a single tertiary hospital in Belgium. Data were collected from January 2017 to October 2020. A total of 788 electrical cardioversions were performed on 574 patients from 2017 to 2020. Age was 70.9 ± 10 years. Restoration of sinus rhythm was obtained in 89.5% of the patients. One (0.1%) patient experienced ischemic stroke within 24 h, despite adequate anticoagulation. There were 4 (0.5%) cases of transient sinus arrest requiring atropine. Three patients (0.4%) experienced respiratory depression, requiring bag-mask ventilation but not oro-tracheal intubation. There were no cases of hypotension. No periprocedural death was reported. In conclusion, an elective electrical cardioversion performed and led by trained nurses, using Etomidate as sedation, appears to be both safe and effective.

Late recurrence of atrial fibrillation and flutter in patients referred for elective electrical cardioversion.

Aim The primary aim was to ascertain long-term rates of atrial fibrillation (AF) recurrence in this all-comer patient population undergoing elective electrical cardioversion (DCR). Secondary aims included procedural DCR success, clinical predictors of long-term maintenance of sinus rhythm (SR) and AF related hospitalizations.Material and Methods A retrospective cohort study was conducted. Consecutive patients (n=316) undergoing elective DCR were included.Results Successful immediate reversion to SR was attained in 266 (84 %) of patients. 224 (84 %) patients were followed up for a median period of 3.5 years (IQR 2.7-4.3). Most patients (150 [67 %]) had recurrence of AF / flutter at a median time of 240 days. Clinical predictors of AF recurrence included a history of AF (HR 0.63, p=0.038) and a dilated left atrium (HR 4.13, p=0.048). Maintenance of SR was associated with fewer unplanned hospitalizations for AF (HR 3.25, p&lt;0.01).Conclusion There was high procedural success post DCR. However, long-term rates of AF recurrence were high, and AF recurrences were associated with increased hospitalizations. These findings underscore the importance of clinical vigilance and multi-modal management as part of a comprehensive and effective rhythm control strategy.

Electrical Cardioversion in a Patient with Persistent Atrial Fibrillation- A Case Report and Literature Review

Atrial fibrillation is the most common sustained cardiac arrhythmia in adults with an estimated prevalence of between 2-4% of the general population with a significant effect on morbidity and mortality. It is an important contributor to stroke, myocardial infarction, thromboembolism, and heart failure. Management of atrial fibrillation involves rate control, rhythm control, and anticoagulation therapy. We present the case of a 30-year-old male who presented with complaints of persistent palpitations and intermittent lightheadedness for over 6 months. No risk factors were readily identifiable and the transthoracic echocardiogram was essentially normal. He was started on anticoagulation. Flecainide initiated after 4 weeks of anticoagulation and continued for 4 months with anticoagulants and the beta-blocker. There was an improvement in the heart rate but the sensation of palpitations continued. The patient underwent elective electrical cardioversion with 100J of direct current and his rhythm was successfully converted to a sinus rhythm, which was confirmed by a 12-lead ECG. Electrical cardioversion terminates AF in over 90% of cases.

Speckle tracking-derived left atrial strain rate – undervalued and useful predictor of adverse events

Abstract Background Strain rate reflects the rate of change of the distance between two points of the myocardium occurring in the cardiac cycle. It is a time-dependent parameter requiring higher temporal resolution than standard strain assessment. Because of this limitation, speckle tracking-derived left atrial (LA) strain rate analysis is of less interest in the literature. Purpose To analyze the prognostic value of LA strain rate during 2-years follow-up in patients with atrial fibrillation (AF). Methods The prospective study involved 80 patients with nonvalvular AF scheduled for elective electrical cardioversion (mean age 63.5±13 years, 60% male). All patients underwent echo before cardioversion and 24 hours after conversion to sinus rhythm. We analyzed standard echocardiographic parameters. Using the speckle-tracking method, we assessed LA strain rate during ventricular systole LA-SSR, in the early stage of ventricular diastole LA-ESR, and during atrial active pump phase LA-ASR. The last one is possible to measure only in the sinus rhythm. The analysis included 4-chamber and 2-chamber views. The clinical endpoint was predefined as AF recurrence. Results Median time of the current AF episode was 2.1 (IQR 0.5–5) months. Standard echo measurements revealed a median left ventricular ejection fraction of 55% (IQR 46–58) and the median of LA volume indexed to body surface area 42 ml/m2 (IQR 33–51). The successful cardioversion rate was 90%. During follow-up, we noticed AF recurrence in 49 (68%) patients. The median time-to-event was 2 (IQR 1 to 6.9) months. Receiver operating characteristic curve analysis revealed that LA-SSR &amp;lt;−0.73 s–1 (AUC=0.745; p=0.0004) and LA-ESR &amp;gt;−1 s–1 (AUC=0.703; p=0.0015) assessed during AF as well as LA-ESR &amp;gt;−0.88 s–1 (AUC=0.644; p=0.04) and LA-ASR &amp;gt;−1 s–1 (AUC=0.837; p&amp;lt;0.0001) measured in sinus rhythm were the optimal cut-off values for predicting AF recurrence. The figure presents Kaplan-Meier survival analysis for AF recurrence. Conclusions Speckle tracking-derived LA strain rate predicts the recurrence of AF after successful electrical cardioversion. Funding Acknowledgement Type of funding sources: None.

Atrial fibrillation: a retrospective chart review of complications, morbidity and mortality at 30 days

Abstract Introduction Atrial fibrillation (AF) increasingly burdens medical health systems. Electrical cardioversion (ECV) forms an important rhythm control treatment for AF. Complications associated with this procedure include stroke and other arrhythmias. Currently, institutional sedation protocols state that patients have to be admitted if 24-hour supervision by family or friends cannot be provided. This implies increased costs, both financially and by occupying a hospital bed. We anticipate that this strategy of admitting patients will become a problem in the future due to the rapid increase of AF patient due to aging of the population. Purpose Our aim is to analyse the incidence, type and timing of complications, to determine whether additional supervision is justified. Methods This was a retrospective single-centre study, in a large tertiary care hospital in the Netherlands. The study was approved by the Ethical Commission, registered with the Netherlands Trial Register (NL9433). Patients were contacted, those who did not object to the reuse of care data were included. Data was extracted from the electronic patient file, entered into a research database, and analysed. This study includes all eligible elective ECV's performed under general anaesthesia, in 2019. We analysed at the number of documented complications within 2 hours (T1), between 2 and 24 hours (T2) and within 30 days of the ECV (T3). Results In total, 370 patients were approached, 7 patients refused consent and 363 unique patients with 564 ECV procedures were included. The majority were male (66%), mean age 65±12 years, BMI 28±6 kg/m2, 49% smoker (current or past), 19% had previously undergone a form of AF ablation, 115 (32%) patients underwent ≥2 ECV's (range 2–11), and 6 patients were admitted due to a social indication. In T1, 22 complications in 16 ECV's were documented, mostly unrelated to anaesthesia: asystole (3, &amp;gt;5 seconds asystole during/after procedure), hypotension (8), extreme bradycardia (8), chest-wall burn pain (1), and arrhythmias other than AF that developed after ECV (2). Nine complications in 7 ECVs (bradycardia, asystole and arrhythmias) were considered severe enough for admission, 5 patients were diagnosed with SSS/brady-tachy syndrome and were implanted with a pacemaker later. In T2, 11 complications were documented: bradycardia (1), skin pain (3), muscle pain (2), fatigue (4), fainting and palpitations (1). The latter patient developed bradycardia and recurrent AF, and was readmitted.In T3, 15 complications were documented of which 5 were severe (CVA, angina, heart failure, arrhythmias). Conclusion Based on this retrospective analysis of all eligible ECV's in a large tertiary hospital, performed in 2019, complications in T2 (1,8%) needed no further treatment. We therefore conclude that it seems safe to discharge patients to their homes without extra supervision after sedation ECV Funding Acknowledgement Type of funding sources: None.

Risk Factors of Early Atrial Fibrillation Recurrence Following Electrical Cardioversion When Left Ventricular Ejection Fraction Is Preserved.

Background and objectives: To identify clinical, echocardiographic, and laboratory parameters that affect the early recurrence of atrial fibrillation (AF) after restoring sinus rhythm (SR) by electrical cardioversion (ECV), and to determine whether left atrial (LA) strain, as a noninvasive indicator reflecting fibrosis, is associated with laboratory indicators affecting the development of fibrosis, interleukin 6 (IL-6) or tumor necrosis factor α (TNF-α). Materials and Methods: The study included 92 persistent AF patients who underwent elective ECV. The effective maintenance of SR was evaluated after 40 ± 10 days of ECV. Echocardiography, inflammatory markers (high-sensitivity c-reactive protein (hs-CRP), IL-6, and TNF-α), and natriuretic peptides (N-terminal pro b-type natriuretic peptide (NT-proBNP) and N-terminal pro a-type natriuretic peptide (NT-proANP)) were assessed. Results: After a 40 ± 10 days observation period, 51 patients (55.4%) were in SR. Patients with AF recurrence had a significantly longer duration of AF (p = 0.008) and of arterial hypertension (p = 0.035), lower LA ejection fraction (p = 0.009), lower LA strain (p < 0.0001), higher left ventricular global longitudinal strain (p = 0.001), and a higher E/e‘ ratio (p < 0.0001). LA strain was an independent predictor of early AF recurrence (OR: 0.65; 95% Cl 0.5–0.9, p = 0.004). LA strain < 11.85% predicted AF recurrence with 70% sensitivity and 88% specificity (AUC 0.855, 95% CI 0.77–0.94, p < 0.0001). LA strain demonstrated the association with NT-proBNP (r = −0.489, p < 0.0001) and NT-proANP (r = −0.378, p = 0.002), as well as with hs-CRP (r = −0.243, p = 0.04). Conclusions: LA strain appeared to be the most accurate predictor of early AF recurrence after ECV in patients with persistent AF. LA strain inversely correlated with NT-proBNP and NT-proANP, but no significant association with any of the inflammatory markers was identified.

Pre-treatment with antiarrhythmic drugs for elective electrical cardioversion of atrial fibrillation: a systematic review and network meta-analysis.

Our objective was to compare the efficacy of pre-treatment with different classes of anti-arrhythmic drugs (AADs) in patients with atrial fibrillation (AF) undergoing electrical cardioversion. We performed a systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing different AADs in patients with AF undergoing electrical cardioversion. We grouped AADs into five network nodes: no treatment or rate control, Class Ia, Class Ic, Class III, and amiodarone. Outcomes were (i) acute restoration and (ii) maintenance of sinus rhythm. We searched MEDLINE and EMBASE from inception until June 2020. We used Python 3.8.3 and R 3.6.2 for data analysis. We evaluated the overall certainty of evidence with the GRADE framework. We included 28 RCTs. Compared with no treatment or rate control, Class III AADs [odds ratio (OR): 2.41; 95% credible interval (CrI): 1.37 to 4.62, high certainty] and amiodarone (OR: 2.58; 95% CrI: 1.54 to 4.37, high certainty) improved restoration of sinus rhythm. Amiodarone improved long-term maintenance of sinus rhythm when compared with no treatment or rate control (OR: 5.37; 95% CrI: 4.00-7.39, high certainty), Class Ic (OR: 1.89; 95% CrI: 1.05-3.45, moderate certainty) and Class III AADs (OR: 2.19; 95% CrI: 1.39-3.26, high certainty). Before electrical cardioversion of AF, treatment with Class III AADs or amiodarone improves the acute restoration of sinus rhythm. Amiodarone is most likely to improve the maintenance of sinus rhythm after electrical cardioversion, but Class Ic and Class III AADs are also effective.

Outcome Analysis in Elective Electrical Cardioversion of Atrial Fibrillation Patients: Development and Validation of a Machine Learning Prognostic Model.

Background: The integrated approach to electrical cardioversion (EC) in atrial fibrillation (AF) is complex; candidates can resolve spontaneously while waiting for EC, and post-cardioversion recurrence is high. Thus, it is especially interesting to avoid the programming of EC in patients who would restore sinus rhythm (SR) spontaneously or present early recurrence. We have analyzed the whole elective EC of the AF process using machine-learning (ML) in order to enable a more realistic and detailed simulation of the patient flow for decision making purposes. Methods: The dataset consisted of electronic health records (EHRs) from 429 consecutive AF patients referred for EC. For analysis of the patient outcome, we considered five pathways according to restoring and maintaining SR: (i) spontaneous SR restoration, (ii) pharmacologic-cardioversion, (iii) direct-current cardioversion, (iv) 6-month AF recurrence, and (v) 6-month rhythm control. We applied ML classifiers for predicting outcomes at each pathway and compared them with the CHA2DS2-VASc and HATCH scores. Results: With the exception of pathway (iii), all ML models achieved improvements in comparison with CHA2DS2-VASc or HATCH scores (p < 0.01). Compared to the most competitive score, the area under the ROC curve (AUC-ROC) was: 0.80 vs. 0.66 for predicting (i); 0.71 vs. 0.55 for (ii); 0.64 vs. 0.52 for (iv); and 0.66 vs. 0.51 for (v). For a threshold considered optimal, the empirical net reclassification index was: +7.8%, +47.2%, +28.2%, and +34.3% in favor of our ML models for predicting outcomes for pathways (i), (ii), (iv), and (v), respectively. As an example tool of generalizability of ML models, we deployed our algorithms in an open-source calculator, where the model would personalize predictions. Conclusions: An ML model improves the accuracy of restoring and maintaining SR predictions over current discriminators. The proposed approach enables a detailed simulation of the patient flow through personalized predictions.