External Cardioversion Research Articles

A randomised controlled trial of the effect of biphasic or monophasic waveform on the incidence and severity of cutaneous burns following external direct current cardioversion

Cutaneous burns are a common cause of morbidity following direct current (DC) cardioversion. We designed a prospective randomised double-blinded controlled study to determine the effect of biphasic or monophasic waveform on the pain and inflammation occurring after elective cardioversion. One hundred and thirty nine patients undergoing elective DC cardioversion were randomised to receive monophasic (HP Codemaster XL; 100, 200, 300, 360, and 360 J) or biphasic (Welch Allyn-MRL PIC defibrillator; 70, 100, 150, 200, and 300 J) waveforms. Two hours after DC cardioversion, skin temperature, erythema index and sensory threshold to light and sharp touch was measured at the centre and edge of paddle sites. Visual analogue pain score (VAS) was recorded at 2 and 24 h. There was significantly less pain following biphasic cardioversion as assessed by VAS at both 2 h (p < 0.001; 95% confidence intervals of difference of medians (CI) 0.2-0.8 cm) and 24 h (p = 0.004; 95% CI 0.0-0.4 cm). There was significantly less erythema in patients receiving biphasic cardioversion at the edge of the sternal site (p = 0.046; 95% CI 0.41-4.5). There was no difference in any other variable at any site between biphasic and monophasic cardioversion. The use of a biphasic waveform for DC cardioversion reduces the inflammation and pain of burns as measured by erythema index and visual analogue scale.

A Single Pulmonary Vein as Electrophysiological Substrate of Paroxysmal Atrial Fibrillation

It has been demonstrated that pulmonary veins (PVs) play an important role in initiation and maintenance of paroxysmal atrial fibrillation (AF). However, it is not clearly known whether a single PV acts as electrophysiological substrate for paroxysmal AF. This study included five patients with paroxysmal AF. All patients underwent complete PV isolation with continuous circular lesions (CCLs) around the ipsilateral PVs guided by a three-dimensional mapping system. Irrigated radiofrequency (RF) delivery was performed during AF on the right-sided CCLs in two patients and on the left-sided CCLs in three patients. The incomplete CCLs resulted in a change from AF to atrial tachycardia (AT), which presented with an identical atrial activation sequence and P wave morphology. Complete CCLs resulted in AF termination with persistent PV tachyarrhythmias within the isolated PV in all five patients. PV tachyarrhythmia within the isolated PV was PV fibrillation from the left common PV (LCPV) in two patients, PV tachycardia from the right superior PV (RSPV) in two patients, and from the left superior PV in one patient. All sustained PV tachyarrhythmias persisted for more than 30 minutes, needed external cardioversion for termination in four patients and a focal ablation in one patient. After the initial procedure, an AT from the RSPV occurred in a patient with PV fibrillation within the LCPV, and was successfully ablated. In patients with paroxysmal AF, sustained PV tachyarrhythmias from a single PV can perpetuate AF. Complete isolation of all PV may provide good clinical outcome during long-term follow-up.

Anesthetic management of an AAI pacemaker patient with paroxysmal atrial fibrillation during colorectal surgery

Perioperative management of patients with cardiac pacemakers may be challenging because of the increasing sophistication of these devices. We report a case of a patient with paroxysmal atrial fibrillation (PAF) and with a permanent AAIR (bipolar atrial-inhibited adaptive rate) pacemaker who suffered life-threatening episodes of arrhythmias during operation. The first episode was vagally induced PAF during bowel manipulation; the second, induced by the increased pacing threshold from the external electric cardioversion and hyperkalemia. Transcutaneous pacing provided cardiac pacing and stabilized the patient during the second episode. Thorough preoperative evaluation and prophylactic placement of temporary pacing or at least transcutaneous pacing are important for the avoidance and minimization of intraoperative complications in patients with sick sinus syndrome and with an AAI (atrial inhibited) pacemaker.

Tissue Doppler Imaging Analysis at Pre‐Cardioversion Time Predicts Recurrent Atrial Fibrillation: A 12‐Month Follow‐Up Study

Tissue Doppler imaging (TDI) has been extensively used in several clinical settings. We aimed to investigate whether TDI can predict recurrent atrial fibrillation (AF). Seventy-four consecutive patients (aged 62.6 +/- 11.7 years) with AF (>48 hours and <6 months of duration) who underwent successful external electrical direct current cardioversion and 20 healthy individuals were enrolled. Conventional echocardiography and TDI were prospectively performed before cardioversion. Based on a cutoff point of 5.43 cm/sec for the negative systolic wave velocity (NSWV), derived by the normal controls (mean + 2 SD), patients were divided into Group I (36 patients) with a NSWV >5.43 cm/sec and Group II (38 patients) with NSWV <or=5.43 cm/sec. In Group I, 27.8% of patients were in sinus rhythm at 6 months, but had episodes of asymptomatic paroxysmal AF lasting >48 hours; all patients were in AF at 12 months. In Group II, all patients were in sinus rhythm at 12 months. However, those patients presenting with a NSWV less but near to 5 cm/sec had frequent episodes of asymptomatic paroxysmal AF lasting for <48 hours. One year after successful direct current cardioversion, TDI analysis at pre-cardioversion time may be a useful marker to identify a subgroup of patients with increased risk for AF recurrence.

Determinants of Thoracic Electrical Impedance in External Electrical Cardioversion of Atrial Fibrillation

The success of external cardioversion (ECV) of atrial fibrillation depends on generating sufficient transmyocardial current for defibrillation with minimal myocardial injury. Thoracic electrical impedance plays an important role in the relation between the delivered energy and transmyocardial current. This study assessed the determinants of thoracic electrical impedance in ECV of atrial fibrillation. ECV of atrial fibrillation was performed in 80 consecutive patients (mean age 73 +/- 9 years; men 69%; body mass index 26.0 +/- 3.6 kg/m(2)) within 12 months, using biphasic shocks (Multipulse Biowave) delivered through adhesive pads in an anteroposterior position. Thoracic electrical impedance was measured using the first shock. The mean thoracic electrical impedance was 57.7 +/- 12.3 Omega (energy 71 +/- 43 J, current intensity 33 +/- 12 A). Sinus rhythm was immediately restored in 75 patients (94%). Thoracic electrical impedance was greater (60.9 +/- 11.8 vs 51.7 +/- 11.0 Omega, p = 0.001) in patients requiring >1 shock (65%). At multivariate linear regression analysis (R = 0.761, p <0.001), female gender (+9.7 +/- 2.0 Omega, p <0.001), body mass index (+1.5 +/- 0.3 for a 1 kg/m(2) increase, p <0.001), hemoglobin concentration (+1.9 +/- 0.6 for a 1 g/dl increase, p = 0.004), and the presence of chronic heart failure (-5.3 +/- 2.0 Omega, p = 0.009) were independent predictors of thoracic electrical impedance. In conclusion, to increase ECV efficacy and minimize complications, the delivered energy should be adjusted in accordance with the clinical variables that independently affect thoracic electrical impedance and, hence, transmyocardial current.

Supraventricular ectopy and recurrence of atrial fibrillation after electrical cardioversion

Paroxysmal atrial fibrillation (AF) is usually preceded by a premature atrial complex (PAC). We hypothesized that patients with a high frequency of atrial ectopic activity after restoration of sinus rhythm following direct current cardioversion would be more likely to experience recurrence of AF. Forty-four patients with documented persistent AF were studied. A 24 h Holter recording was performed from the day of external direct current cardioversion. Patients were reviewed at 1 week, 1 month, and 6 months. After 6 months, 59% of patients had experienced a recurrence of AF. Neither the frequency of PACs nor the frequency or duration of supraventricular tachycardia (SVT) episodes predicted AF recurrence (P=0.60, 0.30, and 0.42, respectively). There was a trend towards maximum rate of SVT predicting recurrence of AF (P=0.08). Frequency of supraventricular ectopy or the number and length of SVT runs in the 24 h after restoration of sinus rhythm are not strong predictors of recurrence of AF after electrical cardioversion. A larger study would be required to detect a small predictive effect.

A simple point score system for predicting the efficacy of external rectilinear biphasic cardioversion for persistent atrial fibrillation

To develop a simple point score system that can accurately predict the optimal energy of initial rectilinear biphasic (RLB) waveform shock for cardioversion (DC) of persistent atrial fibrillation (AF). Data from 302 consecutive patients with AF who underwent a step-up protocol of sequential shocks of 50 J-from 1 up to 2 J/kg-200 J of RLB waveform DC were prospectively examined. Using a logistic regression model, three variables independently predicted the need for 2 J/kg shocks: AF duration > 7 months, previous DC, and increased left atrial (LA) diameter > 4.5 cm. A simplified point score system (REBICAF score) that spans from 0 to 4 was developed. The score gives two points for AF duration > 7 months and one point for previous DC or LA diameter > 4.5 cm. The area under the receiver operator curve (ROC) of the proposed score for predicting the need for 2 J/kg shock was 0.84. There was a progressive increase in the need for 1 J/kg, 2 J/kg, and 200 J as the point score increased (P < 0.001, chi2 test for trend). More than 90% cumulative success rate was achieved in the low- (0-1), intermediate- (2), and high-REBICAF (3-4) score subgroups with 1 J/kg, 2 J/kg, and 200 J RLB shocks, respectively. A simple point score system is useful in prediction of successful initial RLB energy for DC of AF.

Does P-Wave Dispersion Predict the Atrial Fibrillation Occurrence After Direct-Current Shock Therapy?

Supraventricular tachycardia attacks, including atrial fibrillation (AF), occur after both external and internal cardioversions. These attacks of atrial fibrillation after direct-current (DC) shock may be related to hemodynamic impairment, thromboembolic events, or enhanced electrical instability of the ventricular and atrial myocardium, especially in predisposed patients. In this study, the authors aimed to show the importance of P-wave dispersion (PWD), which lead the atrium to fibrillate, in predicting post-DC shock AF after external cardioversion. Thus physicians may be able to choose the patients with high risk for AF occurrence and apply some other therapeutic modalities to those patients. The authors identified 18 patients in whom an AF attack was induced by urgent or elective cardioversion for a ventricular tachycardia attack and compared these patients with a control group composed of 40 patients without AF in regard to some clinical, echocardiographic, and electrocardiographic parameters. Left atrial diameters were greater (4.3+/-0.3 vs 3.5+/-0.5 cm, p = 0.001), left ventricular ejection fractions (LVEF) were lower (45.2+/-8.2 vs 54.9+/-7.5, p = 0.001), the energy needed for successful cardioversion was higher (166.6+/-59.4 vs 80.8+/-51.6 J, p = 0.001), and P max (135.2+/-7.4 vs 118.7+/-10.5 ms, p = 0.001) and PWD (53.8+/-12.2 vs 23.8+/-9.5 ms, p = 0.001) values were higher in patients with AF when compared to those without AF. Thus, the patients with higher PWD values had a greater risk for development of AF after a DC shock.

Recognition and treatment of unstable supraventricular tachycardia by pediatric residents in a simulation scenario

Background: Supraventricular tachycardia (SVT) is the most frequent form of symptomatic tachydysrhythmia in children. Therapy depends on the individual situation, but in severe hemodynamic compromise, it should be terminated immediately by external cardioversion. Despite this, no studies to date document whether pediatricians can differentiate “stable” from “unstable” SVT and make therapeutic decisions based on this discrimination. Purpose: 1) To establish time to recognition and successful cardioversion of simulated unstable SVT by pediatric housestaff and 2) to document delays to initiation of and mistakes made during cardioversion. Methods: Utilizing Laerdal’s® SimMan, ten different teams of pediatric residents were presented with an unresponsive patient who had narrow complex tachycardia with no P waves, low BP, and a weak pulse (i.e. unstable SVT). Events and time logs were downloaded from the simulator computer. Time to successful initiation of cardioversion was measured. Therapies instituted prior to cardioversion and mistakes made during cardioversion were recorded. Results: Ten scenarios were analyzed. Median time to successful cardioversion was 8.9 minutes (range 5.3 min to ∞). In 20% of scenarios, the patient was never cardioverted (1 due to lack of knowledge in defibrillator functionality and 1 due to lack of recognition for need to cardiovert). In 90% of scenarios, adenosine was given but 44% of those attempts demonstrated incorrect drug administration technique. Other maneuvers made prior to cardioversion were as follows: 70% gave fluid bolus, 60% attempted vagal maneuvers, 30% requested electrocardiogram, 30% requested an antiarrhythmic other than adenosine, 20% administered epinephrine, 20% requested a lab draw, and 10% requested cardiology consultation. In 20% of scenarios, the rhythm was misidentified (1 as ventricular tachycardia and 1 as sinus tachycardia). When cardioversion was performed, 25% failed to use gel with paddles, 37.5% failed to use synchronization, and 25% used an inappropriate energy dose. In 60% of scenarios, there was no oxygen administration. In 90% there was no formal assignment of Glasgow Coma Scale, and no assessment at all of mental status in 30%. In 60% there was no assessment of perfusion or capillary refill. Conclusions: The median time to successful cardioversion of 8.9 minutes is inconsistent with the American Heart Association recommendation for treatment of unstable SVT with “immediate cardioversion”. Many delays to cardioversion were secondary to lack of recognition of “unstable” SVT, due to failure to assess perfusion and mental status. Even with successful cardioversion, errors in technique and dosing were frequent. Mistakes and delays encountered during the SVT simulation identify targets for future educational interventions. When designing curriculum for pediatric housestaff, this data will be used to emphasize the importance of using definitive criteria to discriminate between “stable” versus “unstable” SVT, and to use this discrimination in therapeutic decision making. Conflict of Interest: Authors indicated they have nothing to disclose.

Four years experience of a nurse-led elective cardioversion service within a district general hospital setting

External direct current cardioversion is an effective method of restoring sinus rhythm (SR) in patients with persistent atrial arrhythmias. Increasing demand for hospital beds, together with a reduction in junior doctors' hours, has adversely affected cardioversion provision. A regular nurse-led cardioversion service conducted in a dedicated hospital day-unit was introduced to resolve these constraints. There are limited data on the safety or efficacy of such a service. All cardioversions between October 2000 and October 2004 were performed by an appropriately trained specialist nurse, under general anaesthesia. Patients attended a pre-assessment clinic. Energy requirements for initial and subsequent defibrillations were guided by a local protocol in accordance with the guidelines from American Heart Association, American College of Cardiology, and the European Society of Cardiology. Rectilinear biphasic defibrillation was introduced in January 2004 with an appropriate protocol amendment. In the absence of complications, the aim was to discharge patients the same day. A total of 578 cardioversions (475 monophasic; 103 biphasic) were performed on 464 patients [72.1% male, mean (+/- SD) age 67.8 +/- 9.4 years] with atrial fibrillation (AF) (89.7%) and atrial flutter (10.3%). SR was restored in 84.0 and 100% of patients with AF and atrial flutter, respectively, which increased to 90.2 and 100% following the introduction of biphasic defibrillation. Biphasic shocks cardioverted AF with less energy (163 +/- 22 vs. 289 +/- 81 J) and less cumulative energy (230 +/- 139 vs. 455+/-255 J) than monophasic (P < 0.001 for both), despite no difference in the duration of AF (P = 0.26) or patient age (P = 0.78). Two patients required hospital admission due to transient bradycardia; both were discharged within 72 h, without the need for permanent pacing. A total of 99.6% of patients was discharged home the same day; there were no deaths. The provision of a nurse-led elective cardioversion service is feasible and effective, without compromising safety.

European Resuscitation Council Guidelines for Resuscitation 2005: Section 3. Electrical therapies: Automated external defibrillators, defibrillation, cardioversion and pacing

European Resuscitation Council Guidelines for Resuscitation 2005: Section 3. Electrical therapies: Automated external defibrillators, defibrillation, cardioversion and pacing

A Trial of Self-Adhesive Patch Electrodes and Hand-Held Paddle Electrodes for External Cardioversion of Atrial Fibrillation (MOBIPAPA)

A Trial of Self-Adhesive Patch Electrodes and Hand-Held Paddle Electrodes for External Cardioversion of Atrial Fibrillation (MOBIPAPA)

Effect of topic defibrillation on serum markers of myocardial damage

Serum levels of cardiac enzymes and troponins after external cardioversion (ECV) for atrial defibrillation and atrial flutter, and after endocardiac cardioverter defibrillation by implantable cardioverter defibrillator (ICD), have been well investigated. The aim of this study was to assess the effects of topic defibrillation (TD), after cardiac surgery, on cardiac enzymes in patients with uncomplicated clinical course. Biochemical markers were analyzed prospectively for 20 patients after TD (group A) and for 20 patients that were not defibrillated (Control group). We obtained serum concentrations of cardiac Troponin I (cTnI), total creatine-kinase (CK), CK MB isoenzyme (CK-MB), Myoglobin (Myo) in both groups. The difference in cTnI plasma level and curve of raise was not statistically significant between the two groups, but there was a difference in the CK-MB and Myoglobin curve of raise between the two groups. Topic defibrillation does not influence the increase of cTnI, so a high cTnI should be correlated to myocardial damage and not to TD. In patients that received TD, it would be preferable to use cTnI as a marker of myocardial disease than CK-MB which is influenced by the TD.

Inflammatory markers are not associated with outcomes following elective external cardioversion

Background Electrical cardioversion is a common modality of therapy for persistent atrial fibrillation. Unfortunately even if the cardioversion is initially successful many patients revert to atrial fibrillation. It has been proposed that there may be an inflammatory component to this arrhythmia. It is interesting to speculate that this may have a role in determining the outcome following elective cardioversion. Methods The study group consisted of 81 patients with persistent atrial fibrillation undergoing elective external cardioversion. Blood samples were taken immediately prior to the procedure. Soluble E-Selectin, P-Selectin, intra-cellular adhesion molecule and vascular cell adhesion molecule were assayed using a commercially available enzyme linked immunosorbent assay technique (R&D systems) and high sensitivity C reactive protein was measured by rate nephelometry. Patients were reviewed at 8 weeks and bloods were taken at this time. Results At baseline patients who had an unsuccessful cardioversion ( n = 15) were compared to those who had a successful cardioversion ( n = 66). Thirty-two patients of the 66 initially successful patients reverted to atrial fibrillation during the follow-up period. There was no difference in the levels of baseline serum inflammatory markers measured between those with an unsuccessful cardioversion and those who were successful. When the group who reverted to atrial fibrillation were compared to those who remained in sinus rhythm again there was no difference in the levels of serum markers measured at baseline. Conclusion There was no association between maintenance of sinus rhythm following cardioversion and serum inflammatory markers.

Serum troponin I level after external electrical direct current synchronized cardioversion in patients with normal or reduced ejection fraction: No evidence of myocytes injury

External electrical cardioversion (EEC) has been suggested as a cause of myocardial damage, but results from several previously published studies are conflicting. The purpose of the study was to evaluate myocardial electrical injury caused by EEC. After elective EEC for atrial fibrillation (AF), cardiac troponin I (cTnI) was measured in 193 consecutive patients attending the Cardiology Department of the San Maurizio Hospital of Bolzano for elective EEC of AF over a period of 13 months. External electrical cardioversion was performed by one of the attending cardiologists with a synchronized monophasic defibrillator. Blood sample for cTnI was taken 18-20 h after EEC. Of 193 patients, 183 (95%) were successfully cardioverted. Mean number of shocks was 1.46 and the mean total energy discharged per procedure was 379.4 +/- 229.2 J. Cardiac troponin remained under the limit of confidence for all patients with a mean value of 0.017 +/- 0.021 mcrg/l. No correlation between total energy delivered and cTnI was found. In the subgroup of patients with low ejection fraction, none had elevated cTnI, and no difference in cTnI values between these and patients with an ejection fraction > 40% was found. The results of our analysis indicate that EEC caused no myocardial injury even in patients with low ejection fraction.

The Influence of Body Weight on the Initial Energy of Biphasic Transthoracic Electrical Cardioversion

Initial energy (IE) of 200 J or greater is recommended for external electrical cardioversion (EC) of Atrial Fibrillation (AF) with monophasic waveform (MW). Devices that deliver current with a biphasic waveform (BW) appear to achieve EC at lower energy levels than that use a MW. The aim of the present study was to evaluate the influence of several factors (age, body-weight, ejection fraction, left atrial diameter, AF duration) on the results of EC with BW. 105 patients (pts) (59 male and 46 female, mean age 70 ± 8 yrs) underwent EC. Before EC, all pts were treated with oral anticoagulant for 4 weeks until the INR value achieved between 2.5 and 3, and with different antiarrhythmic drugs (sotalol, propafenone, flecainide, amiodarone). EC was done under general anaesthesia, in the presence of anaesthetist. The initial energy used for the first shock was 50 J/100 J, increasing up to 150-200 J, if the first shock unsuccessful (protocol 50/100J to 150-200 J). Reversion of AF to sinus rhythm was obtained in 92 % of the pts. Correlated with shock energy of 50 J, 100 J, 150 J, 200 J, the successful CE was found for the body-weight 69 ± 5, 70 ± 12, 78 ± 4 and 80 ± 9 kg, respectively. There was no statistical different between the four groups, regarding age, left atrial diameter, ventricular systolic function, duration of arrhythmia. In conclusion, an IE of 50 J could be used in pts weighing ⊂ 75 kg, an IE of 100 J could be used in pts with weight ⊇ 75 but ⊆ 82 kg, while for pts with a weight ⊃ 82 kg an IE of 150 J should be recommended.

The Effect of Pharmacotherapy on the Results of External Cardioversion

The Effect of Pharmacotherapy on the Results of External Cardioversion

Sedation with Midazolam for External Cardioversion

Sedation with Midazolam for External Cardioversion

Überwachung multipler Herzkreislaufparameter mittels Telemonitoring bei Patienten mit chronischer Herzinsuffizienz

Progression of chronic heart failure depends on various additional pathophysiologic factors like blood pressure, arrhythmias, congestion. Early detection of any alteration using telemonitoring of multiple vital parameters may avoid severe decompensation requiring hospital admission. The feasibility and the clinical outcome using a new telemonitoring device for recording multiple vital parameters and allowing communication on individual state of health is investigated. Twenty-four patients with chronic heart failure (mean age 65 years, mean LV ejection fraction 35%) requiring at least one hospital admission during the past year were investigated. Twice a day, the vital-parameters were measured (weight, blood pressure, heart rate and rhythm, oxygen saturation, respiration rate) and patients information on well being, shortness of breath, medication, and request for contact were received. Intra-individual comparison was carried out between the 12 month before inclusion in this study and 12 month under telemonitoring surveillance (extrapolated, if necessary). Performing over 10 500 measurements during 5751 patient days, critical events were diagnosed for 55 events concerning relative weight gain (43 episodes), blood pressure (6), decrease in oxygen saturation (3), new onset of atrial fibrillation with tachyarrhymia (3). Of these, 45 events were controlled on an outpatient basis by changing medication or external cardioversion. Only 10 patients required re-admission. Thus, the number of admission to the hospital could be reduced by 62%, those of days spent in hospital by 69%. Non-invasive telemonitoring of multiple vital parameters combined with patients statements on their health condition and out-patient treatment on the basis of these findings is found to be an effective and reliable approach to avoid hospital readmission for patients with chronic heart failure.

Internal Defibrillation: Where we Have Been and Where we Should be Going?

Internal cardioversion has been developed as an alternative technique for patients who are resistant to external DC cardioversion of atrial fibrillation (AF) and was found to be associated with higher success rates. It used initially high energies (200-300 J) delivered between an intracardiac catheter and a backplate. Subsequent studies have shown that it is possible to terminate with energies of 1 to 6 Joules, paroxysmal or induced AF in 90 percent of patients and persistent AF in 75 percent of patients, using biphasic shocks delivered between a right atrium-coronary sinus vectors. Consequently, internal atrial defibrillation can be performed under sedation only without the need for general anesthesia. Recently developed external defibrillators, capable of delivering biphasic shocks, have increased the success rates of external cardioversion and reduced the need for internal cardioversion. However, internal defibrillation is still useful in overweight or obese patients, in patients with chronic obstructive pulmonary disease or asthma who are more difficult to defibrillate, and in patients with implanted devices which may be injured by high energy shocks. Low energy internal defibrillation has also proven to be safe and this has prompted the development of implantable devices for terminating AF. The first device used was the Metrix system, a stand-alone atrial defibrillator (without ventricular defibrillation) which was found to be safe and effective in selected groups of patients. Unfortunately, this device is no longer being marketed. Only double chamber defibrillators with pacing capabilities are presently available: the Medtronic GEM III AT, an updated version of the Jewel AF and the Guidant PRIZM AVT. These devices can be patient-activated or programmed to deliver automatically ounce atrial tachyarrhythmias are detected, therapies including pacing or/and shocks. Attempts to define the group of patients who might benefit from these devices are described but the respective role of atrial defibrillators versus other non-pharmacologic therapies for AF, such as surgery and radiofrequency catheter ablation, remains to be determined. Advantages and limitations or atrial defibrillators and approaches to reduce shock related discomfort which may be a concern in some patients, are reviewed. Studies have shown that despite shock discomfort, quality of life was improved in patients with atrial defibrillators and the need for repeated hospitalizations was reduced. The cost of these devices remains a concern for the treatment of a non-lethal arrhythmia. Attention that atrial defibrillators will receive from cardiologists and from the industry in the future, will depend of the long-term results of other non-pharmacological options and of the identification of the group of AF patients which will require restoration and maintenance of sinus rhythm. But there is no doubt that selected subsets of patients with AF could benefit from atrial defibrillation.