Success Of Direct Current Cardioversion Research Articles

The Impact of Right Atrial Size to Predict Success of Direct Current Cardioversion in Patients With Persistent Atrial Fibrillation.

The prognostic implication of right atrial (RA) and left atrial (LA) size for an immediate success of direct current cardioversion (DCCV) in atrial fibrillation (AF) remains unclear. This study aimed to compare RA and LA size for the prediction of DCCV success. Between 2012 and 2018, 734 consecutive outpatients were screened for our prospective registry. Each eligible patient received a medical history, blood analysis, and transthoracic echocardiography with a focus on indexed RA (iRA) area and LA volume (iLAV) prior to DCCV with up to three biphasic shocks (200-300-360 J) or additional administration of amiodarone or flecainide to restore sinus rhythm. We enrolled 589 patients, and DCCV was in 89% (n=523) successful. Mean age was 68 ± 10 years, and 40% (n=234) had New York heart association class >II. A prevalence of the male sex (64%, n=376) and of persistent AF (86%, n=505) was observed. Although DCCV success was associated with female sex (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.06-3.65), with absence of coronary heart disease and normal left ventricular function (OR, 2.24; 95% CI, 1.26-4.25), with short AF duration (OR, 1.93; 95% CI, 1.05-4.04) in univariable regression, only iRA area remained a stable and independent predictor of DCCV success (OR, 0.27; 95% CI, 0.12-0.69; area under the curve 0.71), but not iLAV size (OR, 1.16; 95% CI, 1.05-1.56) in multivariable analysis. iRA area is superior to iLAV for the prediction of immediate DCCV success in AF.

34 * A one-stop-shop: a nurse led atrial fibrilation and DC cardioversion service

Introduction: Atrial fibrillation (AF) is the most common cardiac arrhythmia and in addition to atrial flutter, these conditions are associated with adverse mortality and morbidity. They are an extremely costly public health problem, with hospitalization as the primary cost driver. Direct current cardioversion (DCCV) remains an effective treatment method to restore sinus rhythm (SR), however, the likely success of DCCV depends on the duration of AF. Consequently, any reduction in waiting times for DCCV has obvious benefits.Nurse-led multidisciplinary heart failure clinics have been shown to improve clinical outcomes. The establishment of an entirely nurse led service, which accepts new community referrals, performs DCCV and then follows patients up has not been widely trialed. Methods: In 2010 Dorset County Hospital established an entirely nurse led AF service. Referrals were accepted directly from the community in order reduce waiting times. On the day of the DCCV, past and present clotting was reviewed. The patient was anesthetised and DCCV was attempted. The result was recorded and patients were followed up at one month and six months. Complications were also logged. Results: Between 5th January 2010 and 28th April 2014, 402 patients were assessed and underwent DCCV. Complete follow up was available on 308. A full retrospective analysis was performed on all patients with a complete dataset. Conclusions: Our nurse led atrial fibrillation service continues to see and treat hundreds of patients with AF. They are independently able to select and perform DCCV with a complication rate similar to that achieved in clinician led services. AF is a progressive disease and expediting appointment times through the use of a nurse led service allows patients to be seen more rapidly. The majority of our patients who were in sinus rhythm at one month post DCCV remained in sinus at six months. This highlights one of the main successes of the nurse led approach; the close follow up afforded to patients who undergo DCCV which would be difficult to match in a physician led service. | No. of patients | 308 | |:---------------------------------------------------------- | ----------- | | Age (years) | 66.9 | | LA Dimension (cm) | 4.45 | | Time from referral to appointment (Days) | 36.2 | | Waiting time for patients eligible to undergo DCCV (Weeks) | 2.8 | | Sinus rhythm: After DCCV | 281 (91.2%) | | Sinus rhythm: 1 month | 136 (44.1%) | | Sinus rhythm: 6 Months | 118 (38.3%) | | Complications | 6 (1.9%) | | Bradycardia requiring PPM | 5 (1.6%) | | CVA | 1 (0.3%) | Table 1 Results of nurse led AF/DCCV service

Warfarin vs Dabigatran for elective direct current cardioversion (DCCV)

Background: In clinical practice, achieving 4 weeks of therapeutic anticoagulation with warfarin is challenging and hinders timely DCCV. Dabigatran is a safe and effective alternative. We evaluated the difference in time to DCCV and success rate between those on dabigatran compared to warfarin.Method: Patients who had DCCV between 12/1/2011 and 31/12/2013 were prospectively collected. Patient demographics and electronic clinical documentations were retrospectively reviewed.Results: Total of 168 DCCV were performed on 153 patients. Mean age was 61 years and mean BMI was 32kg/m2 with male predominance (80.4%). 87.6% of patients were referred from Cardiology and 12.4% from General Medicine. 45.2% (n = 76) were on dabigatran.The median days to DCCV with dabigatran was 63 days (IQR = 44 – 100 days) and 86 days for warfarin (IQR = 56 – 121days), p < 0.05. The overall immediate success rate of DCCV was 80.4%. 94.1% of atrial flutter (AFL) had successful cardioversion and 76.5% for atrial fibrillation (AF).At median follow-up of 108 days, 25.5% remained in sinus rhythm (SR). Those with AFL, 50% (n = 17) remained in SR at median follow up of 69 days while 18.5% of AF remained in SR at median follow up of 130.5 days.There was no difference in the immediate success of DCCV between dabigatran and warfarin groups (80.3% vs 80.4%, p = 0.89). AF accounted for 80.3% and 77.2% respectively.Conclusion: The median time to outpatient DCCV was 23 days shorter with dabigatran compared warfarin therapy. There was no difference in success rate between the 2 anticoagulation groups. Background: In clinical practice, achieving 4 weeks of therapeutic anticoagulation with warfarin is challenging and hinders timely DCCV. Dabigatran is a safe and effective alternative. We evaluated the difference in time to DCCV and success rate between those on dabigatran compared to warfarin. Method: Patients who had DCCV between 12/1/2011 and 31/12/2013 were prospectively collected. Patient demographics and electronic clinical documentations were retrospectively reviewed. Results: Total of 168 DCCV were performed on 153 patients. Mean age was 61 years and mean BMI was 32kg/m2 with male predominance (80.4%). 87.6% of patients were referred from Cardiology and 12.4% from General Medicine. 45.2% (n = 76) were on dabigatran. The median days to DCCV with dabigatran was 63 days (IQR = 44 – 100 days) and 86 days for warfarin (IQR = 56 – 121days), p < 0.05. The overall immediate success rate of DCCV was 80.4%. 94.1% of atrial flutter (AFL) had successful cardioversion and 76.5% for atrial fibrillation (AF). At median follow-up of 108 days, 25.5% remained in sinus rhythm (SR). Those with AFL, 50% (n = 17) remained in SR at median follow up of 69 days while 18.5% of AF remained in SR at median follow up of 130.5 days. There was no difference in the immediate success of DCCV between dabigatran and warfarin groups (80.3% vs 80.4%, p = 0.89). AF accounted for 80.3% and 77.2% respectively. Conclusion: The median time to outpatient DCCV was 23 days shorter with dabigatran compared warfarin therapy. There was no difference in success rate between the 2 anticoagulation groups. CSANZ NZ AbstractsHeart, Lung and CirculationVol. 23Preview Full-Text PDF

Number of shocks during elective cardioversion predicts long term recurrence of atrial fibrillation

While the impact of shock energy and number of shocks on the immediate success of direct current cardioversion (DCCV) has been previously studied [1–3], their impact on the long term recurrence of atrial fibrillation (AF) is unclear. In this retrospective study, we assessed the relationship between number of shocks and shock energy and long term AF recurrence. Consecutive patients undergoing successful elective DCCV for persistent AF or atrial flutter (AFL) at our center between October, 2003 and July, 2009 were included.

First time and repeat cardioversion of atrial tachyarrhythmias - a comparison of outcomes

Repeat cardioversion may be necessary in over 50% of patients with persistent atrial fibrillation (AF), but identifying responders remains challenging. This study evaluates the long-term success of direct current cardioversion (DCCV) and the clinical and echocardiographical parameters that influence them, in over 1000 sedation-cardioversion procedures undertaken at Eastbourne General Hospital between 1996 and 2006. A total of 770 patients of mean age (SD) 70.1(10.1) underwent 1013 DCCVs (first n = 665, repeat n = 348) for atrial tachyarrhythmias from 1996 to 2006. Time to persistent arrhythmia recurrence was compared between first and multiple DCCV, and the effect of age, gender, presence of heart disease, left atrial size, fractional shortening, arrhythmia duration, anti-arrhythmic drug therapy (AAD) and other concomitant cardiac medication was evaluated using the Kaplan-Meier method and Cox's Proportional-hazards model. In all, 33% of first and 29% of repeat DCCVs were in sinus rhythm (SR) at 12 months (m). There was no difference in median time to arrhythmia recurrence (SE) between first and multiple procedures: 1.5 +/- 0.1 m (1.3-1.7) and 1.5 +/- 0.0 m (1.4-1.6) respectively, p = 0.45. AAD use was significantly higher, arrhythmia duration shorter and more diabetic patients underwent repeat procedures. Amiodarone, OR 0.56, p = 0.04, sotalol, OR 0.61, p = 0.02 and arrhythmia duration, < 6 m, OR 0.72, p = 0.03 were independent predictors of improved outcome in first procedures only. In patients undergoing first procedures on amiodarone or sotalol, median time to arrhythmia recurrence was longer and 12 m SR rates higher, 6.0 +/- 2.4 m (42%) than those who had a repeat procedure on the same medication, 1.5 +/- 0.1 m (33%), p = 0.06. The efficacy of first and subsequent DCCV procedures is similar, achieving a similar proportion of SR maintenance at 1 year. However, the benefits of AAD therapy are the greatest following first time procedures. Concomitant AAD therapy should be considered for all first time procedures for persistent AF.

Predictors of unsuccessful electrical cardioversion in atrial fibrillation

R of sinus rhythm improves functional capacity and alleviates palpitations in patients with atrial fibrillation (AF). The advantages of direct-current cardioversion include the immediate restoration of sinus rhythm, as opposed to the unpredictable time to cardioversion in pharmacologic intervention, and the avoidance of potential adverse drug reactions. Although direct-current cardioversion is thought to have a higher success rate than pharmacologic intervention, it may fail to restore sinus rhythm in 5% to 30% of procedures. Few data are available regarding the association between clinical variables and the failure of direct-current cardioversion. Also, the relation between abnormalities of cardiac function and the success of direct-current cardioversion has not been studied in a large number of patients. This study assesses the success rate of direct-current cardioversion in patients with AF and the relation between clinical and echocardiographic variables and the success of direct-current cardioversion. • • • We studied 692 patients (459 men [66%] and 233 women [34%], mean age SD 67 13 years) with AF who had a first elective direct-current cardioversion at Mayo Clinic (Rochester, Minnesota). This study was approved by the Institutional Review Board of the Mayo Foundation. The duration of AF was 48 hours in 653 patients (94%) and 48 hours in 39 patients (6%). All patients underwent transthoracic echocardiography before cardioversion. Transesophageal echocardiography was performed in 201 patients (29%) before cardioversion. A history of coronary artery disease was considered present if the patient had had a previous myocardial infarction, myocardial revascularization, significant coronary artery stenosis on angiography, or typical anginal complaints. Valvular heart disease was considered present if the patient had more than mild stenosis or regurgitation of 1 cardiac valve. Idiopathic dilated cardiomyopathy was defined as left ventricular dilatation and global hypokinesia without significant coronary artery disease. The duration of AF was determined by the time of documentation of AF on the electrocardiogram or the onset of symptoms, whichever occurred earlier. Two-dimensional and M-mode imaging were performed with commercially available echocardiographic machines equipped with 2.5and 3.5-MHz phased-array transducers. M-mode echocardiography was used to measure cardiac dimensions and wall thickness. A left atrial diameter of 40 mm defined left atrial dilatation. This was considered mild for values 50 mm and marked for values 50 mm. Ejection fraction at rest was measured using a previously validated modification of the method of Quinones in Dujardin et al or by visual estimation. Structural heart disease was defined as any of the following: valvular heart disease, coronary heart disease, cardiomyopathy, or ejection fraction 50%. All procedures were performed with electrocardiographic monitoring and full equipment for cardiopulmonary resuscitation. Digitalis preparations were withheld for 24 to 48 hours before the procedure. After administration of intravenous sedation, synchronized direct-current monophasic shock was administered using the anteroposterior paddle position (sternal body angle of the left scapula). If sinus rhythm was not restored after the first shock, the procedure was repeated (up to 4 times) using a larger number of joules (up to 360 J). The number of joules with which cardioversion was initiated was determined for each patient according to physician discretion. Electrocardiography was performed before and after the procedure to verify cardiac rhythm. Successful cardioversion was defined as restoration of sinus rhythm after administration of direct-current shock. Unless specified, data are presented as mean values SD or as frequency percentages. The rank sum and chi-square tests were used to compare differences between continuous variables and proportions, respectively. Univariate and multivariate stepwise logistic regression models were used to identify individual and joint predictors of unsuccessful cardioversion. Analyses of success were done using both the patient and the individual shock as the unit of observation to harvest information when multiple shocks were needed. Differences were considered significant if the null hypothesis could be rejected at the 0.05 probability level. These diseases were present in the study population: systemic hypertension in 355 patients (51%), coronary artery disease in 233 patients (34%), valvular heart disease in 227 patients (33%), and cardiomyopathy (idiopathic dilated, restrictive, or hypertrophic) in 125 patients (18%). Cardioversion was successful in 592 patients (86%) and unsuccessful in 100 (14%). The mean number of shocks was 2.1 1.2/patient. The mean number of joules was 222 100. In 74 patients, 50 J was used initially, with success achieved From the Division of Cardiovascular Diseases and Internal Medicine and the Section of Biostatistics, Mayo Clinic, Rochester, Minnesota. Dr. Khandheria’s address is: Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. Manuscript received June 13, 2001; revised manuscript received and accepted September 6, 2001.