Successful Cardioversion Of Atrial Fibrillation Research Articles

Prevalence and risk factors associated with decompensated heart failure after successful elective cardioversion for atrial fibrillation and atrial flutter

Study objectiveTo determine the incidence of and risk factors for HF after successful electrical and ablative cardioversion (CV) of atrial fibrillation (AF) and atrial flutter (AFL). DesignRetrospective cohort study. SettingSingle center academic institution. ParticipantsSeven hundred fifty-five patients underwent successful elective CV from July 1, 2018 to May 20, 2019. Patients presenting in arrhythmias other than AF or AFL, those who developed HF due to alternative etiologies, and those who developed arrhythmia recurrence within 30 days were excluded. Medical records of the remaining 451 patients were reviewed before and after CV. Main outcomes measuredDevelopment of heart failure despite sinus rhythm following CV and the risk factors associated with this outcome. ResultsThirty-three (7.3 %) of 451 patients who met inclusion criteria for our study developed new or worsening HF symptoms while maintaining sinus rhythm (SR) after successful CV. Symptoms were reported an average of 5.1 days following CV (range 0–17 days, SD 4.71). Following a multivariate stepwise logistic regression model, prior HF hospitalization (OR 3.91, 95 % CI 1.82–8.39), BMI (OR 1.06, 95 % CI 1.02–1.11), and valve disease (OR 2.51, 95 % CI 1.12–5.60) remained significant risk factors, and anti-arrhythmic drug (AAD) use was marginally significant (OR 2.02, 95 % CI 0.95–4.31). ConclusionDespite maintenance of SR, 7.3 % of patients developed decompensated HF in the 30 days following successful CV of AF or AFL, indicating this complication may be more frequent than previously believed. Predictors of HF post-CV included elevated BMI, valve disease, previous HF hospitalization, and prior AAD use.

NO CLOT, NO PROBLEM? NOT EXACTLY

NO CLOT, NO PROBLEM? NOT EXACTLY

The Impact of COVID-19 on Admissions and Management of Patients with Atrial Fibrillation Episodes in the Emergency Department.

Background: During the COVID-19 pandemic, the number of admissions to the emergency department (ED) due to a primary diagnosis of atrial fibrillation (AF) has decreased when compared to pre-pandemic times. The principal aim of the study was to assess the frequency of SARS-CoV-2 infections and sinus rhythm restoration among patients who arrived at the ED with AF. Secondary aims included determining whether patients arriving at the ED principally due to AF delayed their presentations and whether the frequency of successful cardioversion for AF was decreased during the pandemic period. Materials and Methods: A retrospective analysis of medical records of patients admitted to two hospital EDs due to AF during July–December 2019 (pre-pandemic period) versus July–December 2020 (pandemic period) was performed. Results: During the study periods, 601 ED visits by 497 patients were made due to the primary diagnosis of AF. The patients were aged 71.2+/−13.5 years and 51.3% were male. The duration of an AF episode before the ED admission was 10 h (4.5–30 h) during the pandemic period vs. 5 h (3–24 h) during the non-pandemic period (p = 0.001). A shorter duration of the AF episode before ED admission was associated with the successful restoration of the sinus rhythm. During the pandemic period, among patients with short-lasting AF who were not treated with Phenazolinum, the restoration of the sinus rhythm was more frequent in the Copernicus Memorial Hospital than in the University Hospital (p = 0.026). A positive SARS-CoV-2 test was found in 5 (1%) patients, while 2 other patients (0.5%) had a prior diagnosis of COVID-19 disease noted in their medical history. Conclusions: 1. The number of AF episodes treated in these two EDs was lower during the pandemic than non-pandemic period. 2. The patients with AF appeared at the ED later after AF onset in the pandemic period. 3. Successful cardioversion of atrial fibrillation was more frequent during the pre-pandemic period in one of the two hospitals. 4. A difference of approaches to the treatment of short-lasting AF episodes between EDs during the pandemic period may exist between these two EDs. 5. The patients with SARS-CoV-2 infection during the second wave of the COVID-19 pandemic constituted a small percentage of the patients admitted to EDs due to an AF episode.

Tissue doppler imaging of left atrial appendage during transoesophageal echocardiography predicts successful cardioversion in patients with atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Restoration of sinus rhythm in patients with atrial fibrillation (AF) prevents from thromboembolic events, decreases the risk for cardiomyopathy and improves quality of life. Purpose This study aimed to determine whether Tissue Doppler Imaging (TDI) during transesophageal echo (TEE) could predict successful electrical cardioversion (CV) of AF lasting more than 48 hours but less than 6 months. Methods One hundred patients, 74 men and 26 women of mean age 64.7 ± 9.8 years old with non-valvular AF were included. Pulse wave (PW) Doppler velocities as well as TDI velocities of the medial and lateral walls of the left atrial appendage (LAA) were recorded during TEE before cardioversion. Synchronized electrical cardioversion was occurred within 12 hours after TEE using 100-200 Joules. We also evaluated LA size and the global strain of LAA. Results Sinus rhythm restoration was succeeded in 80% of patients and maintained until discharge, 48 hours later. TDI velocities > 8cm/s were correlated with successful cardioversion (sensitivity 70% and specificity 63%) and were more predictive compared to PW Doppler velocities of > 40cm/s. TDI recordings at the medial LAA wall were more accurate, with less artefacts and better positioning of the sample volume. Global longitudinal strain was not significantly correlated with CV outcome. Conclusion Our results indicate that TDI velocities of the LAA walls more than 8cm/s could be used as a cut-off value predicting successful cardioversion of AF.

Clinical effectiveness and safety of antazoline-based therapy in patients with stable coronary artery disease undergoing pharmacological cardioversion of short-duration atrial fibrillation in the emergency department.

Options for a pharmacological cardioversion (CV) of short-duration atrial fibrillation (AF) in patients with a stable coronary artery disease (CAD) are limited to amiodarone or vernakalant. Antazoline has been reported to achieve high rates of AF conversion to sinus rhythm, but data on its effectiveness and, more importantly, safety in stable CAD patients, have been sparse. To assess the effectiveness and safety of antazoline-based therapy in patients with a stable CAD undergoing pharmacological CV of short-duration AF in the emergency department (ED). A retrospective case-control study. We conducted an analysis of medical records of patients with a stable CAD undergoing CV of short duration (≤48hours) AF in the ED using intravenous antazoline. The main endpoints of the study were successful cardioversion of AF and hospitalization due to the adverse effects (AE) of the treatment. Between 2008 and 2012, out of 548 CVs, antazoline was administered 334 times: 138 in CAD and 196 in the control group. Patients in the CAD group were older and had more comorbidities than controls; 65 patients had had a history of myocardial infarction (MI). In CAD group, the effectiveness was higher (82.6% vs 63.8%, RB: 1.30 [95% CI: 1.14-1.48], P=0.0002) and the hospitalization rate due to AE was similar (1.4% vs 4.1%, RR: 0.36 [95% CI: 0.08-1.65], P=0.2054) to the control group. Among patients with CAD, a history of MI did not influence the effectiveness or safety of the CV (P=0.2252 and P=1.0000, respectively). In selected patients with a stable CAD, even with a history of MI, antazoline-based CV of short-duration AF may be an effective and safe therapeutic option.

Nursing of patient with pancreatic cancer after chemotherapy complicated with influenza B: a case report

Objective To report 1 case with pancreatic cancer after chemotherapy infected by influenza B virus, and complicated with atrial fibrillation, pulmonary infection. Methods Clinical data, treatment, outcome of this case were reviewed and the nursing emphasis was summarized. Results Through active treatment and nursing, with cured influenza, successful cardioversion of atrial fibrillation and controlled lung infection, the patient was transferred to general hospital to treat basic disease. During hospitalization, none infection occurred among medical staff and caregivers. Conclusions Key points of nursing of patient with pancreatic cancer after chemotherapy complicated with influenza B include disease observation of atrial fibrillation, lung infection and influenza B virus infection, nutritional status improvement, skin care, psychological care for patients and care-givers, disinfection and isolation to influenza B virus infection, and staff self-protection. Key words: Influenza, human; Pancreatic neoplasms; Nursing care; Atrial fibrillation; Pulmonary infection

Comparative effectiveness and safety of antazoline‑based and propafenone‑based strategies for pharmacological cardioversion of short‑duration atrial fibrillation in the emergency department

INTRODUCTION Numerous studies described the effectiveness and safety of antazoline in pharmacologicalcardioversion of short‑durationatrial fibrillation (AF). However, there are no data on the comparisonof antazoline and antiarrhythmic drugs listed in clinical guidelines. OBJECTIVES The aim of the study was to assess the comparative effectiveness and safety of antazoline‑based and propafenone‑basedstrategies in pharmacological cardioversion of short‑durationAF performedin our emergency department. PATIENTS AND METHODS We conducted a retrospective case‑controlstudy based on the analysis of medical records of patients undergoing pharmacological cardioversion of short‑durationAF with intravenousantazoline or propafenone at our department in the years 2008-2012. The primary endpoint was the successful cardioversion of AF. The primary safety endpoint was hospitalization due to the adverse effects of the treatment. RESULTS We analyzed 432 cases of cardioversion. The mean age of patients was 68.9 ±9.8 years; 65% of the patients were male; 90% of the patients had a history of AF. Antazoline was administered 334 times and propafenone-98 times. The mean dose of antazoline was 172 ±65 mg, while all patients in the propafenone group received the drug at a fixed dose of 70 mg (1 vial). Cardioversion with antazoline was successful in 239 cases (71.6%) and with propafenone-in 54 patients (55.1%) (relative risk [RR], 1.30; 95% confidence interval [CI], 1.07-1.57). The rate of hospitalization due to the adverse effects of the treatment were low and similar between the study groups: 10 (3.0%) for antazoline and 4 (4.1%) for propafenone (RR, 0.73; 95% CI, 0.23-2.27). CONCLUSIONS The antazoline‑based strategy was more effective and safer in comparison with propafenone‑basedstrategy in the pharmacological cardioversion of short‑duration AF in our emergency department.

Acute atrial wall stretch and the efficacy of flecainide-induced conversion of atrial fibrillation

Acute atrial wall stretch and the efficacy of flecainide-induced conversion of atrial fibrillation

Dronedarone: the new kid on the block

Dronedarone is a new anti-arrhythmic drug with similar properties to amiodarone. It is indicated in the maintenance of sinus rhythm following successful cardioversion of atrial fibrillation or flutter but is recommended to be prescribed only after alternative treatment options have been considered. The recommended dosage is 400 mg twice daily taken with food. Although efficacious in the treatment of atrial fibrillation or flutter, concern exists regarding its use in patients with poor left ventricular function owing to its potential to exacerbate heart failure symptoms and cause myocardial decompensation. Although it does not possess the same toxic adverse event profile as amiodarone, particularly in relation to the thyroid gland, gastric disturbance is commonly reported following start of treatment, which is usually self-limiting. Its efficacy and impact on the patient from a rhythm management perspective, and its impact on patients with heart failure, have been investigated in several randomized, controlled trials, the largest of which was ATHENA. From a nurse prescribing perspective, baseline assessment and follow-up is integral to the optimal care of patients receiving dronedarone, particularly in relation to its effect on the conduction system, the renal system, and the hepatic system. Patient education is the cornerstone in identifying early-onset heart failure and liver injury as well as potential for drug interactions.

Clinical Value of Left Atrial Volume by 3D-CT for the Prediction of the Long-Term Sinus Rhythm Maintenance after Pulmonary Vein Isolation for Persistent Atrial Fibrillation

Introduction: Echocardiographic parameters are useful for the prediction of the long-term preservation of sinus rhythm in patients with successful cardioversion of atrial fibrillation . We assessed the echocardiographic parameters and left atrial volume by 3D-CT in 44 consecutive patients who had undergone circumferential pulmonary vein isolation for persistent AF. Methods: Transthoracic echocardiographic data, transesophageal echocardiographic data and LAV by 3D-CT of 44 consecutive patients were analyzed. We examined left atrial appendage flow, left atrial spontaneous echocardiographic contrast, mitral valve regurgitation during TEE, and also left atrial parasternal diameter, left ventricular end-diastolic diameter, left ventricular ejection fraction in TTE. Results: At a half year follow-up, 59.1% of the patients who had undergone pulmonary vein isolation continued to have SR. LAV was significantly smaller in patients remaining in SR for a half year than in those with AF recurrence . Between SR groups and AF recurrence groups, there were no significant differences in echocardiographic parameters. Conclusions: In echocardiography and 3D-CT guided management of persistent AF, LAV will be useful to predict the long-term SR maintenance after circumferential pulmonary vein isolation.

A Decrease in Serum Aldosterone Level is Associated with Maintenance of Sinus Rhythm after Successful Cardioversion of Atrial Fibrillation

The activation of the renin-angiotensin-aldosterone system has been implicated in the progression of atrial structural remodeling during atrial fibrillation (AF). However, consequences of the changes of aldosterone in AF have not been evaluated. This study's aim was to evaluate changes of serum aldosterone concentration after successful cardioversion of persistent AF and to determine the prognostic value of these changes. The prospective, single center study included 45 consecutive patients with nonvalvular persistent AF and preserved left ventricular systolic function, referred for cardioversion. None of the patients were taking aldosterone antagonists. Blood samples for aldosterone measurement were collected twice: 24 hours before and 24 hours after cardioversion. Forty-three patients were successfully converted to sinus rhythm. On the 30th day following cardioversion, 24 patients maintained sinus rhythm (group A), 19 patients relapsed to AF (group B). Serum aldosterone concentration before cardioversion did not differ significantly between both groups (175.6 +/- 112.82 pg/mL vs 125.8 +/- 51.2 pg/mL; P = 0.25). However, in group A serum aldosterone level decreased significantly within 24 hours after cardioversion, from 175.6 +/- 112.8 pg/mL to 101.4 +/- 44.2 pg/mL (P = 0.0034). In group B, the aldosterone level before and after cardioversion did not differ significantly (125.8 +/- 51.2 pg/mL vs 118.2 +/- 59.6 pg/mL; P = 0.68). Logistic regression analysis revealed that a decrease in plasma aldosterone concentration after direct current cardioversion more than 13.2 pg/mL predicted sinus rhythm maintenance in a 30-day follow-up, with 87% sensitivity and 64% specificity. There is a positive correlation between the fall in aldosterone concentration 24 hours after cardioversion and maintenance of sinus rhythm during 30 days of observation.

Defibrillation testing in patients with atrial fibrillation

Implantable cardioverter defibrillator implantation in patients with atrial fibrillation (AF) is complicated by the need for anticoagulation during defibrillation testing. In this retrospective study, we evaluated the factors associated with successful cardioversion of AF during ventricular defibrillation testing and the safety of our local anticoagulation protocol.

The effect of pretreatment with renin-angiotensin-aldosterone system blockers on cardioversion success and acute recurrence of atrial fibrillation

Renin-angiotensin-aldosterone system (RAS) may be activated during atrial fibrillation (AF). It is unclear whether RAS inhibition may facilitate cardioversion from AF and may prevent acute recurrence of AF (ARAF). We thus investigated the effect of pretreatment with RAS blockers on cardioversion success and ARAF in patients with AF scheduled for elective cardioversion. This observational study included 356 patients with AF undergoing elective pharmacological or electrical cardioversion. Of these patients, 135 were not included based on exclusion criteria and the remaining 221 patients were divided into RAS group (n = 116, 69 male) or non-RAS group (n = 105, 58 male) based on precardioversion use of any RAS blocker. Hypertension, coronary heart disease and heart failure were more frequent in the RAS group. Cardioversion from AF was more successful in the RAS group than in the non-RAS group (%92 vs. %82, p = 0.026). The rate of ARAF was lower in RAS group compared with that in non-RAS group (17% vs. 31%, p = 0.026). In multivariate analysis, pretreatment with RAS blockers in addition to shock number and enlarged left atrium, independently predicted ARAF (OR: 0.33, 95% CI: 0.15-0.75, p = 0.008). Independent predictors of cardioversion success were shock number and left atrial dilatation, but not use of RAS blocker. Precardioversion use of RAS blockers may reduce ARAF following successful cardioversion of AF, but did not improve electrical cardioversion.

Non-Invasive Prediction of Successful Cardioversion of Atrial Fibrillation by Surface Electrocardiogram Analysis

Non-Invasive Prediction of Successful Cardioversion of Atrial Fibrillation by Surface Electrocardiogram Analysis

Mitral annular velocity by Doppler tissue imaging for the evaluation of atrial stunning after cardioversion of atrial fibrillation

Atrial and/or appendage stunning (AS) usually occur after successful cardioversion of atrial fibrillation (AF). Several parameters except mitral annular velocity were previously evaluated to determine AS. We investigated whether mitral annular velocity was useful for determining of AS. This study consisted of 52 consecutive patients with AF <3 months who converted to the sinus rhythm. Mitral inflow and annular velocities were measured before and after cardioversion. Left atrial appendage (LAA) size and flow were assessed. The average velocity of septal and lateral segments of mitral annulus was considered as the final annular velocity. Thrombus and/or spontaneous echo contrast (SEC) were also investigated. Of 52 patients, 29 (56%) had AS but 23 did not. There was no significant difference in age, gender, and cardioversion type between two groups. Hypertension was more prevalent in patients without AS compared to those with AS (P = 0.02). Mitral annular systolic and E-wave velocities were comparable in both groups (P > 0.05). Mitral annular A-wave velocity (3.1 +/- 2.9 vs. 7.1 +/- 2.2 cm/s, P < 0.001), and its velocity-time integral (0.27 +/- 0.22 vs. 0.74 +/- 0.19 cm, P < 0.001) were significantly lower in patients with AS compared with those without AS. The annular A-wave velocity < or =3.3 cm/s predicted AS with a sensitivity of 59% and specificity of 76%. It was correlated with mitral inflow A velocity (r = 0.85, P < 0.001), LAA emptying velocity (r = 0.41, P = 0.003) and presence of SEC (r = -0.52, P < 0.001). After cardioversion of AF, mitral annular A-wave velocity may be a new marker to determine AS.

Atrial Activation Occurring Immediately after Successful Cardioversion of Atrial Fibrillation

Electrical defibrillation is very effective in interrupting atrial fibrillation (AF). However, its mechanism is not completely understood. We report our observations in patients subjected to external electriocardioversion (ECV) of atrial fibrillation and contrast them with recent theories about defibrillation mechanism. In 13 consecutive patients transthoracic electrical cardioversion for AF was performed during an electrophysiological study (11 monophasic -200-360 J- and 9 biphasic shocks -50-150 J-). About 10-16 electrograms were obtained with multipolar catheters recording right atrium, coronary sinus, and right pulmonary artery. AF was defined by interelectrogram intervals and changing sequences among recordings, indicating complete lack of organization. We evaluated the presence of propagated activations immediately (<300 ms) after successful shocks (>or=1 discrete electrogram in all recordings). In unsuccessful shocks we evaluated changes in electrogram morphology (discrete/fragmented) and interelectrogram intervals before and after defibrillation. About 16/20 shocks terminated AF. In 6/16 one or two cycles of atrial activation were recorded just after the shock and before AF ended. In 10/16 AF was interrupted immediately after the shock. 4/20 shocks did not interrupt the arrhythmia. After these shocks, transient organization of recorded activity with longer interelectrogram cycle length and disappearance of fragmented activity were transiently observed. Our clinical findings in atrial defibrillation in vivo reproduce experimental data that show myocardial activations early after successful direct current shocks. These observations suggest that successful defibrillation depends not only on the immediate effects of the shock, but also on transient effects on electrophysiological properties of the myocardium, capable of interrupting persistent or reinitiated activations.

Ibutilide‐Induced Cardioversion of Atrial Fibrillation During Pregnancy

We present two cases of successful cardioversion of atrial fibrillation using intravenous ibutilide during pregnancy. One patient had atrial fibrillation, complicating the Wolff-Parkinson-White syndrome and the other had a history of nonobstructive hypertrophic cardiomyopathy. No adverse maternal or fetal effects were observed during or after pregnancy in either case.

The prognostic impact of successful cardioversion of atrial fibrillation in patients with organic heart disease

The aim of the study was to evaluate the prognostic impact of successful cardioversion (CV) compared to failed CV in patients with atrial fibrillation (AF) and organic heart disease. A total of 471 consecutive patients with organic heart disease from the prospective single center anticoagulation registry ANTIK who underwent CV of AF or atrial flutter were analyzed. 417 patients (89%) could be successfully cardioverted. In 54 patients (11%) CV failed, these patients remained in AF. After 5 years there were 92 (24%) deaths among patients with restored sinus rhythm at index admission and 20 (38%) deaths among those who remained in AF after CV (unadjusted OR 1.9, 95% CI 1.1-3.6). After adjustment for age, gender and ejection fraction, successful CV was not associated with a beneficial effect on mortality (OR 0.72, 95% CI 0.43-1.21). Thus, successful CV is not an independent predictor of mortality on multivariate analysis. However, it remains a marker for a better prognosis in patients with organic heart disease as these patients have a lower unadjusted longterm mortality.

Prevention of atrial fibrillation recurrence by statin therapy in patients with lone atrial fibrillation after successful cardioversion

The aim of this study was to investigate the effect of statin therapy on arrhythmia recurrence in patients with lone atrial fibrillation (AF). From July 1998 to December 1999, 62 patients with lone persistent AF lasting ≥3 months underwent successful external cardioversion. After a mean follow-up of 44 months, 85% had recurrence of AF. The use of statins was associated with a significant decrease in the risk of arrhythmia recurrence after successful cardioversion of AF. The result of this retrospective study demonstrates that the use of statins in patients with lone AF was associated with a significant decrease in the risk of arrhythmia recurrence after successful cardioversion.

Atrial stunning: Determinants and cellular mechanisms

BackgroundAtrial stunning is a transient depression of atrial and atrial-appendage mechanical function after successful cardioversion of atrial fibrillation compared with its precardioversion state. MethodAtrial stunning associated with different methods of cardioversion of atrial fibrillation and the determinants and cellular mechanisms of atrial stunning were elaborated by thoroughly examining the studies on the subject identified through a comprehensive literature search. Results and conclusionAtrial stunning has been reported with all methods of cardioversion of atrial fibrillation, including transthoracic electrical, low-energy internal electrical, pharmacological, and spontaneous. It is a function of the underlying atrial fibrillation becoming apparent at the restoration of sinus rhythm, regardless of the method used for conversion. Unsuccessful cardioversion does not result in atrial stunning. The duration of the preceding atrial fibrillation, atrial size, and underlying structural heart disease are the determinants of atrial stunning. A shorter duration of atrial fibrillation and smaller atrial diameters are associated with a relatively less severe stunning, lasting for a shorter duration. Atrial stunning after cardioversion of atrial fibrillation of <1 week usually resolves within 24 hours, and atrial stunning after cardioversion of chronic atrial fibrillation usually resolves within 4 weeks. Tachycardia-induced atrial cardiomyopathy, atrial cytosolic calcium alterations with down-regulation of the L-type Ca2+ channels and up-regulation of the Na+/Ca2+ exchanger, atrial hibernation with myocyte dedifferentiation and myolysis, and atrial fibrosis are the suggested mechanisms underlying atrial stunning. Atrial stunning determines the risk of postcardioversion thrombus formation in atria and atrial appendages, the duration of postcardioversion anticoagulation therapy, the recovery of the atrial contribution to the ventricular function, and the functional recovery of the patients after successful cardioversion of atrial fibrillation.