Success Rate Of Cardioversion Research Articles

Comparison of two DCCV algorithms - rational versus maximum fixed energy (PROTOCOLENERGY trial)

Abstract Introduction Direct current cardioversion (DCCV) is a common procedure used to restore sinus rhythm (SR) in patients with atrial fibrillation (AF). However, there is ongoing debate about the optimal discharge energy to use during DCCV, and there are no clear guidelines on the optimal protocol for selecting the discharge energy. Purpose The aim of this study was to compare the efficacy and safety of two different DCCV algorithms, Rational and Maximum Fixed Energy, in achieving sinus rhythm after DCCV. The energy of the first shock in the Rational Algorithm was based on our retrospective data. Methods We conducted a prospective single-blind, single-centre trial that enrolled 300 patients with AF undergoing DCCV. Patients were randomised to one of two algorithms: an initial discharge of biphasic 150 J with escalation to two times 360 J discharge if needed in a Rational Algorithm, or first discharge of 360 J and additional two 360 J discharges if needed in Maximum Fixed energy algorithm. The primary endpoint was SR in the first minute after DCCV and any neurological complications. Secondary endpoints were skin changes immediately after DCCV and chest pain on the day after. Results The trial included 300 patients, divided into two arms of 150 patients each. The mean age of the patients was 68 years and 66 % were male. The mean LA diameter was 47 mm and the mean LV EF was 54.2 %. Rivaroxaban was the most frequently used NOAC (62.8 %) and the most commonly used antiarrhythmic drug was amiodarone (39 %).All patient characteristics are shown in the Table 1 below. In the Rational Algorithm arm, 92.7 % of patients had SR one minute after DCCV compared to 94 % in the Maximum Fixed Energy Algorithm arm (p=0.643). Both arms had a similar rate of SR (91.3 %) at two hours post-DCCV. There were no neurological complications in either group. The incidence of skin redness was higher in the Maximum Fixed Energy Algorithm arm (36 %) than in the Rational Algorithm arm (19.3 %) (p=0.001), while the incidence of chest pain was similar between the two arms. We found the difference in cardioversion success rates of both algorithms after the initial shock, i.e. after 150 J vs. 360 J (109 [72.7%] vs. 125 [83.3%] patients). Univariate analysis revealed significant differences in weight (mean 104 kg in AF vs mean 91 kg in sinus rhythm, p<0.001) and BMI (mean 34.1 kg/m2 in AF vs mean 30.5 kg/m2 in SR p<0.001) between those who remained in AF and those who achieved SR after the initial 150 J discharge. The results are presented in Table 2 below. Conclusion The PROTOCOLENERGY trial suggests that both algorithms are safe and effective in achieving sinus rhythm after DCCV. Although the Maximum Fixed Energy Algorithm showed a slightly higher success rate, the difference was not statistically significant. The Rational Algorithm is associated with a lower incidence of skin redness compared to the Maximum Fixed Energy Algorithm.Table 1Table 2

Elective cardioversion at a district general hospital: a retrospective evaluation of outcomes.

Direct current cardioversion is a procedure for treating abnormal heart rhythms, and cardioversion is often performed electively to restore sinus rhythm in patients with persistent atrial fibrillation or atrial flutter. A retrospective evaluation of elective cardioversion data at a local general hospital was undertaken to evaluate the success and outcomes of cardioversion. This evaluation also considered the outcomes for two subsets of patients with heart failure and obesity, as it has previously been concluded that cardioversion is unsuccessful in these patients. Immediate success rates of cardioversion were high in general and remained high initially in heart failure and obese patients, but there was a drop-off in longer term success in all groups.

Efficacy and safety of modified Valsalva maneuver for treatment of paroxysmal supraventricular tachycardia: a meta-analysis.

To compare the efficacy and safety of the modified versus standard Valsalva maneuver in the treatment of paroxysmal supraventricular tachycardia (PSVT). The PubMed, Embase, Web of Science, CNKI, WanFang Data, and VIP electronic databases were searched to identify studies comparing the modified and standard Valsalva maneuvers in the treatment of PSVT from database inception to 1 May 2023. Two reviewers independently screened the literature, extracted the data, and assessed the risk of bias of all included studies. Nineteen randomized controlled trials involving 2527 patients with PSVT were included. The overall rate of cardioversion was higher in the modified than standard Valsalva group (risk ratio [RR] = 1.80, 95% confidence interval [CI] = 1.61-2.01), as was the success rate of cardioversion after a single Valsalva maneuver (RR = 2.05, 95% CI = 1.74-2.41). There was no statistically significant difference in adverse reactions between the two groups (RR = 1.07, 95% CI = 0.82-1.38). Current evidence suggests that the modified Valsalva maneuver can significantly improve the success rate of cardioversion in patients with PSVT without increasing adverse reactions. The modified Valsalva maneuver is therefore worth promoting and should be considered as a routine first treatment.INPLASY registration number: 2023100092.

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

Comparative Effectiveness of Direct Current Cardioversion in Patients With Atrial Fibrillation and Obesity With Body Mass Index ≥50 kg/m2

Atrial fibrillation is one of the most frequently encountered arrhythmia, with obesity being an independent risk factor. There are sparse data on the success rates of direct current cardioversion (DCCV) in patients with severe obesity. We compared the effectiveness of DCCV in patients with a body mass index (BMI) >50kg/m2 with those with a BMI <30kg/m2. A retrospective chart review of 111 patients was performed between January 1, 2011 and January 1, 2022. The study cohort was stratified into 2 groups: BMI ≥50kg/m2 and BMI <30kg/m2. The primary outcome was successful achievement of normal sinus rhythm after DCCV. The secondary outcomes included number of attempted shocks, number of successful shocks on first attempts, and energy of successful shock. The primary outcome occurred in 94.6% of patients with a BMI <30kg/m2 group compared with 81.8% in the patients with a BMI ≥50kg/m2 (p=0.042). Patients in the higher BMI cohort had a higher median energy during a successful shock than the lower BMI cohort (250J [200 to 360J] vs 200J [150 to 200J], p <0.001). There was no difference in the number of shocks used between the 2 groups or in the success of the first shock delivered between BMI ≥50kg/m2 and BMI <30 kg/m2 (75% vs 58.2%, p=0.093). In conclusion, patients with a BMI ≥50kg/m2 had lower rates of successful DCCV than patients with a BMI <30kg/m2; therefore, clinicians must be aware of the alternative strategies to improve DCCV success and the possibility of DCCV failure in patients with higher BMIs.

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.

The Relation between Atrial Fibrillation Cardioversion Success Rate with Vitamin D Level in Patients Underwent Elective Cardioversion in King Abdulaziz Cardiac Center, King Abdulaziz Medical City for National Guards, Riyadh Saudi Arabia.

To investigate the relation between serum Vitamin D (Vit-D) levels and the success rate of cardioversion for atrial fibrillation (AF). To examine the association between Vit-D level and successful cardioversion. This study also describes the general characteristics of patients with successful cardioversion. In this retrospective study, patients with AF who were treated using electrical cardioversion at King Abdulaziz Cardiovascular Center (KACC) between 2010 and 2021 were included. The information on demographic and clinical characteristics as well as outcome variables was collected. Of 100 patients who were admitted to KACC during the study period, 63% were females and 9% were diagnosed with Vit-D deficiency. Furthermore, 66% of patients had successful cardioversion. Moreover, no significant difference in Vit-D deficiency was observed between patients who had successful cardioversion and those with unsuccessful outcomes (P = 0.485). There is no association between serum Vit-D levels and the success rate of cardioversion in patients with AF. However, further studies are needed for more conclusive evidence.

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.

Predictors of recurrence after catheter ablation and electrical cardioversion of atrial fibrillation: an umbrella review of meta-analyses.

The recurrence rates after catheter ablation (CA) and direct current (DC) cardioversion remain high, although they have been established treatments of rhythm control of atrial fibrillation (AF). This umbrella review systematically appraises published meta-analyses of both observational and randomized controlled trials (RCTs) for the association of risk and protective factors for arrhythmia recurrence after CA and DC cardioversion of AF. Three bibliographic databases were searched up to June 2021. Evidence of association was rated as convincing, highly suggestive, suggestive, weak, or not significant with respect to observational studies and as high, moderate, low, or very low with respect to RCTs, according to established criteria. Thirty-one meta-analyses were included. Of the 28 associations between CA and the risk of arrhythmia recurrence, none presented convincing evidence, and only the time from diagnosis to ablation over 1 year provided highly suggestive evidence. The association between hypertension and metabolic profile provided suggestive evidence. The associations of Class IC and III antiarrhythmic drugs use with the recurrence after DC cardioversion were supported by an intermediate level of evidence. Although AF is a major health issue, few risk- and protective factors for AF recurrence have been identified. None of these factors examined were supported by convincing evidence, whereas established factors such as female gender and left atrial volume showed only weak association. An early CA strategy combined with treatment of metabolic syndrome and hypertension prior to CA may reduce the risk of arrhythmia recurrence. The use of antiarrhythmics can increase the success rate of DC cardioversion. PROSPERO registry number: CRD42021270613.

How to Optimize Cardioversion of Atrial Fibrillation.

Cardioversion (CV) is an essential component of rhythm control strategy in the treatment of atrial fibrillation (AF). Timing of CV is an important manageable factor in optimizing the safety and efficacy of CV. Based on observational studies, the success rate of CV seems to be best (≈95%) at 12–48 h after the onset of arrhythmic symptoms compared with a lower success rate of ≈85% in later elective CV. Early AF recurrences are also less common after acute CV compared with later elective CV. CV causes a temporary increase in the risk of thromboembolic complications. Effective anticoagulation reduces this risk, especially during the first 2 weeks after successful CV. However, even during therapeutic anticoagulation, each elective CV increases the risk of stroke 4-fold (0.4% vs. 0.1%) during the first month after the procedure, compared with acute (<48 h) CV or avoiding CV. Spontaneous CVs are common during the early hours of AF. The short wait-and-see approach, up to 24–48 h, is a reasonable option for otherwise healthy but mildly symptomatic patients who are using therapeutic anticoagulation, since they are most likely to have spontaneous rhythm conversion and have no need for active CV. The probability of early treatment failure and antiarrhythmic treatment options should be evaluated before proceeding to CV to avoid the risks of futile CVs.

Non-Valvular Atrial Fibrillation Cardioversion: Experience of the Cardiology department of Mohammed V Military Teaching Hospital

anticoagulation therapy would be the removal of this arrhythmia and any future recurrence, a goal often difficult to achieve.The aim of this work is to evaluate the efficacy of atrial fibrillation cardioversion as well as the success predictive factors of sinus rhythm maintenance at one year following a successful cardioversion. Materials and methods: 50 patients with non-valvular atrial fibrillation underwent cardioversion: 70% by electrical shock and 30% by pharmacological means, the clinical characteristics of the patients the results of cardioversion and follow-up were collected and analyzed. Results: The average age of our patients was 53 years with a sex ratio of 2. 30% of patients had hypertensive heart disease, 8% ischemic heart disease, 8% dilated cardiomyopathy and the rest had no underlying heart disease. The average diameter of the left atrium was 41 mm and the average surface area was 20 cm². Primary success rate of cardioversion was 82% with better efficacy of electric shock compared to pharmacological cardioversion. The maintenance rate of sinus rhythm at 1 year was 70%. Predictive factors of failure and / or recurrence at 1 year were old atrial fibrillation and significant dilation of the left atrium. Conclusion: This study confirms the interest of atrial fibrillation cardioversion and underlines the importance of preliminary selection of the patients, such a selection must be made on the basis of the predictive factors of success usually recognized in the literature.

The reinvented old player – an antazoline is effective in pharmacological cardioversion of atrial fibrillation

Abstract Introduction Antazoline (ANT) is an old antihistaminic medication with antiarrhythmic properties. After intravenous administration ANT exerts rapid antiarrhythmic effect often resulting in conversion of atrial fibrillation (AF) to sinus rhythm (SR) and is widely used in Poland for this purpose in the last years. However, published data on its effectiveness, safety and clinical utility for rapid AF termination are limited and ANT is not recognized as a cardioversion drug. Aim To assess the real-world efficacy of ANT for pharmacological cardioversion of paroxysmal and persistent non-valvular AF. Methods Our single center, retrospective, observational study included patients (pts) with history paroxysmal or persistent AF episode lasting less than 6 months, in stable cardiopulmonary condition who were qualified for elective pharmacological cardioversion with intravenous ANT. The primary end-point was the conversion of AF to SR confirmed in electrocardiography (ECG) during the 6-hours observation. Results A total of 176 pts (mean age 68.4±12.0 years, 49% male) were enrolled into the study. In 93 patients (52%) AF duration was shorter than 48 hours and median AF duration time was 24 (7–432) hours. The overall success rate of pharmacological cardioversion of AF with intravenous ANT was 45.5% (80/176 pts). The mean used dose of ANT was 250.9±65.4mg. The subgroup analysis, regarding the AF duration, suggested the effectiveness of ANT mainly in in short-lasting AF (effectiveness of antazoline based cardioversion for AF lasting &amp;lt;48h vs others: 75.3% vs 12.0%, p&amp;lt;0.001). In multivariable logistic regression model AF duration (for every 24h in AF – OR=0.97; 95% CI 0.96–0.98), the left atrium antero-posterior diameter (OR=0.92; 95% CI 0.86–0.99) and the serum creatinine level (OR=0.15; 95% CI 0.03–0.73) were identified as independent predictors of antazoline based pharmacological cardioversion effectiveness, even after adjustment for comorbidities. The ROC curves revealed that the optimal cut-off value for AF duration time predicting ANT's effectiveness was 48h (AUC=0.876; 95% CI 0.815–0.922) – Figure 1. There were only one episode of bradycardia &amp;lt;45 bpm related to ANT administration. Conclusions Antazoline is effective and safe in rapid pharmacological cardioversion of paroxysmal AF, especially in the short-lasting AF (&amp;lt;48 hours) and in patients without the left atrium enlargement and significant renal disease. Funding Acknowledgement Type of funding sources: None. Figure 1. ROC curve analysis

ELECTIVE CARDIOVERSION: INDICATIONS, SUCCESS AND COMPLICATIONS. FIVE YEAR EXPERIENCE IN A TERTIARY CARE HOSPITAL IN PAKISTAN

Objectives: This study aimed to determine the indications, success rate of elective cardioversion and its manifest complications. Methodology: It is a retrospective study involving 53 patients. We reviewed the hospital records files for the demographic data including age, gender, as well as indication of cardioversion, duration of arrhythmia and date of cardioversion along with complications. Results: Out of 53 patients, 58.5% (31) were males with a mean age of 48.17 ± 18.43 years. Arrhythmia related symptoms (palpitations and fatigue) were the indication for cardioversion in 44% (23) of the subjects. Our data showed that 98.1%( 52) were cardioverted to sinus rhythm successfully with a median energy of 100 joules. Out of those who underwent successful cardioversion, 92.5% (49) were followed up till 1 year after the cardioversion. At six week follow up, all the patients were found in sinus rhythm. At 6 months follow up, 94.2% (49) remained in sinus rhythm, while at 1 year follow up, 73% (38) of the patients remained in sinus rhythm. All patients were anticoagulated for at least four weeks after cardioversion. None of the patients required pacemaker and none of them developed stroke after cardioversion. Conclusion: Electrical cardioversion for atrial fibrillation and flutter is a low risk procedure in our population and it has a high success rate and relatively low complications.

The efficacy and safety of a nurse-led electrical cardioversion service for atrial fibrillation over a two-year time period

Abstract Funding Acknowledgements Type of funding sources: None. Background &amp; Purpose Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia worldwide, with a significant impact on morbidity, mortality and utilisation of healthcare resources. Electrical direct-current cardioversion (DCCV) is offered to patients with ongoing symptoms despite medical management. In this study we aim to evaluate the safety and efficacy of a specialised nurse-led DCCV cardioversion service. Methods This was a retrospective cohort study analysing the outcome of patients presenting with atrial fibrillation or flutter, who were subsequently referred for a nurse-led DCCV procedure between August 2017 and December 2019. Results Analysis included a total of 341 patients (mean age = 68.37; STDV = 10.96) who presented with either atrial fibrillation (N = 267; 78.30%) or atrial flutter (N = 74; 21.70%). Approximately 30% of patients were female (N = 101); and 70% were male (N = 240). Of the 341 patients who underwent DCCV, 299 were successfully cardioverted (87.68%), whilst 42 patients remained in AF (12.32%). Of those patients successfully cardioverted, 167 remained in sinus rhythm after 6 weeks (55.85%); 93 patients reverted back to AF (31.10%). 38 patients were lost to follow up (12.71%). Of all 341 patients who underwent DCCV, only 24 patients were admitted to hospital during the subsequent 3 month period (7.04%). Of these admissions, 11 were due to persistent AF (45.83%), and 13 were due to other non-related reasons (54.17%). Importantly, no patients were admitted as a direct complication of the DCCV procedure. Using a Chi-squared analysis, we found a significant difference in cardioversion success rates between patients presenting with atrial flutter (97% success rate) versus those in atrial fibrillation (85% success rate) (χ2 = 8.089; p = 0.004; α&amp;lt;0.05). We did not find a significant difference in cardioversion success rates between males and females (χ2 = 1.651; p = 0.199; α&amp;lt;0.05); nor did we witness a significant impact from the presence of ischaemic heart disease (χ2 = 1.545; p = 0.214; α&amp;lt;0.05) or hypertension (χ2 = 2.075; p = 0.150; α&amp;lt;0.05). Similarly, we found negligible impact of LV ejection fraction (χ2 = 1.494; p = 0.684; α&amp;lt;0.05) or LA size (χ2 = 1.310; p = 0.727; α&amp;lt;0.05) upon cardioversion success rates. We witnessed a dramatic improvement in DC cardioversion success rates in patients taking antiarrhythmic medication in preference to a rate control strategy alone (χ2 = 11.825; p = 0.008; α&amp;lt;0.05). Conclusion Overall, data gathered from this study provides positive evidence to support the use of a nurse-led DCCV service. In addition to obtaining very successful cardioversion rates, we found low remission rates, with a very low hospital readmission rate for AF related issues after successful DCCV.

Cinderella drug: an antazoline is effective in pharmacological cardioversion of atrial fibrillation - Single center experience

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Antazoline (ANT) is an old antihistaminic medication with antiarrhythmic properties. After intravenous administration ANT exerts rapid antiarrhythmic effect often resulting in conversion of persistent atrial fibrillation (AF) to sinus rhythm (SR). However, published data on its effectiveness, safety and clinical utility for rapid AF termination are limited and ANT is not recognized as a cardioversion drug. Aim To assess the real-world efficacy of ANT for pharmacological cardioversion of paroxysmal and persistent non-valvular AF. Methods We conducted a single center, retrospective, observational study including patients (pts) with history paroxysmal or persistent AF episode lasting less than 6 months, in stable cardiopulmonary condition who were qualified for elective pharmacological cardioversion with intravenous ANT. The primary end-point was the conversion of AF to SR confirmed in electrocardiography (ECG) during the 6-hours observation. Results A total of 176 pts (mean age 68.4 ± 12.0 years, 49% male) were enrolled into the study. In 93 patients (52%) AF duration was shorter than 48 hours and median AF duration time was 24 (7 – 432) hours. The overall success rate of pharmacological cardioversion of AF with intravenous ANT was 45.5% (80/176 pts). The mean used dose of ANT was 250.9 ± 65.4mg. The subgroup analysis, regarding the AF duration, suggested the effectiveness of ANT mainly in in short-lasting AF (effectiveness of antazoline based cardioversion for AF lasting &amp;lt;48h vs others: 75.3% vs 12.0%, p &amp;lt; 0.001). In multivariable logistic regression model AF duration (for every 24h in AF - OR = 0.97; 95% CI 0.96 – 0.98), the left atrium antero-posterior diameter (OR = 0.92; 95% CI 0.86 – 0.99) and the serum creatinine level (OR = 0.15; 95% CI 0.03 – 0.73) were identified as independent predictors of antazoline based pharmacological cardioversion effectiveness, even after adjustment for comorbidities. The ROC curves revealed that the optimal cut-off value for AF duration time predicting ANT’s effectiveness was 48h (AUC = 0.876; 95% CI 0.815 – 0.922). There were only one episode of bradycardia &amp;lt;45 bpm related to ANT administration. Conclusions Intravenous antazoline administration is effective and safe in rapid pharmacological cardioversion of paroxysmal AF, especially in the short-lasting AF (&amp;lt;48 hours) and in patients without the left atrium enlargement and significant renal disease. Abstract Figure.

Relationship between atrial fibrillatory rate based on analysis of a modified base-apex surface electrocardiogram analysis and the results of transvenous electrical cardioversion in horses with spontaneous atrial fibrillation

ObjectivesTo compare the atrial fibrillatory rate (AFR) derived from a local right atrial intracardiac recording (RA-FR) and from a single-lead surface electrocardiogram (ECG) during atrial fibrillation (AF) and to evaluate the correlation with transvenous electrical cardioversion (TVEC) threshold (in Joules), number of shocks and cardioversion success rate in horses. AnimalsECGs and clinical records of horses with AF treated by TVEC. Horses were included if a simultaneous recording of the right atrial intracardiac electrogram and a modified base-apex ECG were available. Materials and methodsClinical records of horses with AF treated by TVEC were reviewed. Three-minute long episodes of simultaneous electrograms and surface ECG during AF were selected for analysis and compared using Bland-Altman analysis. The mean RA-FR was measured from the deflections on the intracardiac electrogram, while the AFR was extracted from the surface ECG using spatiotemporal QRS and T-wave cancellation. ResultsSeventy-three horses satisfied the inclusion criteria. The mean difference between RA-FR and AFR was −13 fibrillations per minute (fpm), the 95% limits of agreement were between −66 and 40 fpm, and there was a moderate (ρ = 0.65) correlation between RA-FR and AFR (p < 0.001). Neither RA-FR nor AFR appeared to influence the TVEC cardioversion threshold or the number of TVEC shocks applied. ConclusionsThe AFR may allow non-invasive long-term monitoring of AF dynamics. Neither RA-FR nor AFR could be used to predict the minimal defibrillation threshold for TVEC.

Chemical cardioversion of atrial flutter and fibrillation in the pediatric population with Ibutilide.

Atrial flutter (AFL) and atrial fibrillation (AF) are common in pediatric patients with congenital heart disease and structurally normal hearts as well. Chemical cardioversion is attractive for patients with AFL/AF for a short period of time because of the ability to avoid sedation. We review a single center's experience with Ibutilide in pediatric patients in an effort to report on its safety and efficacy. We performed a retrospective chart review of pediatric patients (0-21 years) who underwent chemical cardioversion for AFL/AF with Ibutilide (January 2011-February 2019). Patients on another antiarrhythmic medication or attempted chemical cardioversion with another drug were excluded. There were 21 patients who met inclusion criteria. Thirteen of the 21 (62%) patients were successfully cardioverted with Ibutilide (10 out of 13 had AF and four out of 13 required a second dose). There were no significant differences in baseline characteristics between those who were successfully cardioverted compared to those who were not. Administration of magnesium prior to administration did not appear to have an effect on the success rate. There was a significant increase in rate corrected QT interval (QTc) post Ibutilide administration, which returned to baseline prior to discharge. One patient had symptomatic bradycardia needing intravenous fluids and another had torsades requiring electrical cardioversion during Ibutilide administration. The success rate of chemical cardioversion with Ibutilide was similar in our experience as compared to studies in the adult population and the other lone pediatric study. Although adverse events were uncommon, Ibutilide administration warrants close monitoring and fully defining its efficacy warrants further pediatric experience.

Observation of the effect of postural modified Valsalva manoeuvre in terminating paroxysmal supraventricular tachycardia

Objective To observe the efficacy and safety of postural modified Valsalval manoeuvre in terminating paroxysmal supraventricular tachycardia (PSVT). Methods From January 2017 to June 2018, a total of 98 patients with PSVT were selected in the Affiliated Hospital of Xuzhou Medical University.They were randomly allocated to standard Valsalval manoeuvre group(48 cases) and postural modified Valsalval manoeuvre group(50 cases) according to sealed envelope method.The patients in standard Valsalval manoeuvre group carried out standard semi-recumbent Valsalva manoeuvre, while the other group received semi-recumbent with supine repositioning and passive leg raise immediately after the Valsalva strain.The general clinical data, total cardioversion success rate, first-time cardioversion success rate and the incidence of adverse reactions were compared between the two groups. Results There were no statistically significant differences in male proportion, age, history of PSVT or coronary heart disease, incidence of hypertension, diabetes and heart rate, systolic and diastolic blood pressure at attack between the two groups(all P>0.05). The total cardioversion success rate [40.0%(20/50)], first-time cardioversion success rate [28.0%(14/50)] in the modified group were significantly higher than those in the standard group [16.7%(8/48), 12.5%(6/48)](χ2=27.924, 16.308, all P 0.05). Conclusion Postural modified Valsalval manoeuvre can effectively improve the cardioversion success rate of PSVT, and has high safety, which is worthy of clinical promotion. Key words: Tachycardia, supraventricular; Valsalval manoeuvre; Syringe; Mechanical stimulation; Vagus nerve; Treatment outcome; Comparative effectiveness research

Cardioversion of Atrial Fibrillation and Flutter: Comparative Study of Pulsed vs. Low Energy Biphasic Truncated Exponential Waveforms.

Despite the widespread use of biphasic waveforms for cardioversion and defibrillation, the efficacy and safety of shocks has only been compared in a few studies. This retrospective study aims at comparing the efficacy and safety of biphasic truncated exponential (BTE) pulsed energy (PE) waveform with a BTE low energy (LE) waveform for cardioversion of atrial fibrillation (AF) and atrial flutter (AFL). The treatment energies were following an escalating protocol for PE waveform (120-200-200J in AF and 30-120-200J in AFL) and LE waveform (100-200-200J in AF and 30-100-200J in AFL). The protocol was stopped at successful cardioversion (sinus rhythm at 1 minute post-shock), otherwise after the 3rd shock. If the 3rd BTE shock failed, a monophasic shock of 360J was delivered. From May 2008 to November 2017, 193 patients (153 PE, 40 LE) were included in the study. Both groups significantly differed in a few characteristics, including chest circumference (p<0.05). After adjustment, the success rate was not significantly different for the two waveforms (94.5% PE vs 92.5% LE, Odds Ratio [95% Confidence Interval] = 0.25 [0.03-2.2]).There was no difference in safety: post-shock changes in Hsc-TnI levels were similar (p=0.25). The efficient cumulative energy was particularly related with BSA (β = 131.5, p=0.05), AF/AFL duration (β = 0.24, p=0.01) and gender (β = 61.8, p=0.05). The major clinical implications of this study concern the high success rate of cardioversion with both biphasic pulses and no superiority of LE over PE waveform with an excellent safety profile without post-shock myocardial injuries.

Amiodarone versus direct current cardioversion in treatment of atrial fibrillation after cardiac surgery

Aim: Postoperative atrial fibrillation is common after cardiac surgery and is associated with higher rates of complications and mortality. Despite the importance of postoperative atrial fibrillation, the most effective management strategy for this common surgical complication remains uncertain. The aim of this study was to evaluate the effectiveness of amiodarone and early direct current cardioversion to restore sinus rhythm in new onset postoperative atrial fibrillation.Material and Methods: This was a prospective, open-labeled randomized- controlled trial. A total of 50 patients who had new onset postoperative atrial fibrillation longer than 30 minutes were enrolled in the study; 26 patients were randomized to control group and 24 to amiodarone group. Patients in whom sinus rhythm did not return within 24 hours, then external electrical direct current cardioversion was performed for both groups. The primary endpoint of the study was a restoration of sinus rhythm at the 24th hour. Secondary endpoints needed for direct current cardioversion, success rate, sinus rhythm at discharge, sinus rhythm at 30th days and crossover rates.Results: There was a significantly higher number of patients with sinus rhythm at the 24th hour in the amiodarone group than the control group (79.2% vs. 46.2%, p=0.022). Need for direct current cardioversion (p=0.022) and crossover ratio (p=0.021) were significantly higher in control group than amiodarone group. Direct current cardioversion success rate, normal sinus rhythm at discharge and 1st month did not differ significantly between groups. Conclusion: Amiodarone therapy seems effective in restoring sinus rhythm within 24 hours and decreases the need for direct current cardioversion. Keywords: antiarrhythmic agents; atrial fibrillation; cardiovascular surgery; post-CABG