Use Of Cardioversion Research Articles

Modern aspects of treatment for patients with atrial fibrillation (a literature review)

The aim of the work is to analyze and summarize the data of the scientific literature which highlight modern approaches to the management of patients with atrial fibrillation (AF). In the article, on the basis of the modern literature analysis, the basic therapeutic directions and methods of surgical correction of AF are analyzed. Emphasis is placed on the need to treat AF patients in accordance with the ABC strategy, which includes the prevention of thromboembolic complications (A), control of symptoms (B), as well as treatment of comorbidities and elimination of risk factors (C). The main risk factors for AF, its relationship with other cardiovascular events (including mortality, stroke rate and acute coronary syndrome) are analyzed, the main scales used to objectively assess the risks of AF are determined, and detailed analysis of different strategies for anticoagulant therapy is conducted. The main approaches to the control of symptoms by regulating the frequency of ventricular rhythm, restoration and maintenance of sinus rhythm with the use of cardioversion, the administration of antiarrhythmic peptide and catheter ablation are considered. In addition, attention is paid to the need to identify and treat comorbidities, cardiometabolic risk factors and lifestyle, which complement stroke prevention and reduce the severity of AF and symptoms. Conclusions. A large number of clinical studies is focused on AF, the main idea of which is the integrated management of AF to improve the prognosis and quality of patients’ life. According to current recommendations, treatment of a patient with AF should be consistent and in accordance with the ABC strategy. Taking into account etiological factors, cardiometabolic risk factors, lifestyle, comorbid conditions will allow physicians to timely individualize complex treatment of patients with AF.

Austrian Analysis of the GUARDIAN Registry: Heart Transplant Effects in Europe from the Global Pandemic

PurposeDuring the global COVID-19 pandemic heart transplantation in Europe was affected due to difficultly traveling internationally and greater delays associated with crossing borders. During a similar time frame our center also adopted the Paragonix SherpaPak Cardiac Transport System (SHRP) for regular use rather than conventional ice storage (ICE). This study aims to compare heart transplant baseline characteristics and outcomes for the 18 months prior to the global pandemic with the 18 months since the pandemic began.MethodsThe Global Utilization And Registry Database for Improved heArt preservatioN (GUARDIAN) study is a retrospective, multi-institutional registry. We analyzed patients transplanted in Austria pre-pandemic, from 1 SEP 2018 to 1 MAR 2020 (PRE), with patients transplanted during the pandemic, from 1 MAR 2020 to 1 SEP 2021 (C19).Results83 patients (42 PRE, 41 C19) met these criteria to be included in the analysis. The PRE cohort utilized donor organs from statistically longer travel distances (PRE=323 v C19=179 miles, p=0.02). Despite the shorter travel distances, ischemic times were same (PRE=195 v C19=189 min, p=0.60), likely indicating the additional burdens for traveling across borders. During the PRE period the SHRP was only used for marginal cases and in the C19 period it was adopted for regular use. The proportion of cases utilizing SHRP was statistically higher in the C19 cohort (PRE=19% v C19=80%, p<0.001). The PRE cohort showed numerically higher rates of newly placed ECMO post-transplant (16.1% v 11.8% p=0.18), incidence of PGD (16.7% v 4.9%, p=0.08), incidence of severe PGD (4.8% v 2.4%, p=0.57), and rates of the use of cardioversion intra-operatively to start the donor heart (19.0% v 9.8%, p=0.32) for PRE v C19 respectively. In-hospital survival was similar (92.9% v 90.2%, p=0.67).ConclusionThe global COVID-19 pandemic caused a substantial impact on the access to donor hearts in Europe due to the ability to travel internationally. Despite this limitation on donor heart access, we saw trends towards improved outcomes in this period compared to the pre-pandemic period. This period was also highly correlated with the implementation of the Paragonix SherpaPak Cardiac Transport System as a preservation method which may have helped mitigate some of the negative effects of reduced donor access.

Estimation of PQ distance dispersion for atrial fibrillation detection

Background and objective: Atrial fibrillation (AF) is the most common cardiac arrhythmia in the world. It is associated with significantly increased morbidity and mortality. Diagnosis of the disease can be based on the analysis of the electrical atrial activity, on quantification of the heart rate irregularity or on a mixture of the both approaches. Since the amplitude of the atrial waves is small, their analysis can lead to false results. On the other hand, the heart rate based analysis usually leads to many unnecessary warnings. Therefore, our goal is to develop a new method for effective AF detection based on the analysis of the electrical atrial waves.Methods: The proposed method employs the fact that there is a lack of repeatable P waves preceding QRS complexes during AF. We apply the operation of spatio-temporal filtering (STF) to magnify and detect the prominent spatio-temporal patterns (STP) within the P waves in multi-channel ECG recordings. Later we measure their distances (PQ) to the succeeding QRS complexes, and we estimate dispersion of the obtained PQ series. For signals with normal sinus rhythm, this dispersion is usually very low, and contrary, for AF it is much raised. This allows for effective discrimination of this cardiologic disorder.Results: Tested on an ECG database consisting of AF cases, normal rhythm cases and cases with normal rhythm restored by the use of cardioversion, the method proposed allowed for AF detection with the accuracy of 98.75% on the basis of both 8–channel and 2–channel signals of 12 s length. When the signals length was decreased to 6 s, the accuracy varied in the range of 95%−97.5% depending on the number of channels and the dispersion measure applied.Conclusions: Our approach allows for high accuracy of atrial fibrillation detection using the analysis of electrical atrial activity. The method can be applied to an early detection of the desease and can advantageously be used to decrease the number of false warnings in systems based on the analysis of the heart rate.

Likelihood of Spontaneous Cardioversion of Atrial Fibrillation Using a Conservative Management Strategy Among Patients Presenting to the Emergency Department

Numerous emergency department (ED) atrial fibrillation (AF) protocols have been developed to reduce hospitalizations, focusing on the use of cardioversion in the ED. An alternative strategy of rate control with early specialty follow-up may be more widely applicable. The likelihood of spontaneous cardioversion with such a protocol is unknown. Between 2015 and 2018, 157 patients who presented to the ED with a primary diagnosis of AF and were hemodynamically stable and with low to moderate symptom severity were discharged with early follow-up at an AF specialty clinic. Rhythm at short-term (within 72 hours), within 30-day follow-up, and need for electrical cardioversion was tabulated. Various demographic and co-morbidity variables were assessed to determine their association with likelihood of spontaneous cardioversion. At an average of 2.3 days, 63% and within 30 days, 83% had spontaneous cardioversion. By 90 days, only 6.3% required electrical cardioversion. Diabetes (38% vs 69%, p <0.01), coronary artery disease (39% vs 66%, p = 0.02), reduced ejection fraction (40% vs 72%, p <0.01), dilated right atrium (43% vs 73%, p <0.01) and moderate-to-severely dilated left atrium (38% vs 78%, p <0.01) predicted those who were less likely to convert to sinus rhythm. Most patients who present to the ED with AF will spontaneously convert to sinus rhythm by short-term (2 to 3 days) follow-up with a rate control strategy. In conclusion, aggressive use of electrical cardioversion in the ED may be unnecessary in hemodynamically stable patients without severe symptoms.

Use of cardioversion in acute atrial fibrillation: A prospective audit from Christchurch Hospital

Use of cardioversion in acute atrial fibrillation: A prospective audit from Christchurch Hospital

Emerging Options for Patients with Atrial Fibrillation

Dr Jeffrey Weitz chaired the symposium and welcomed Dr Christian Ruff, who discussed and summarised recent results from key trials of new oral anticoagulants (NOACs) in atrial fibrillation (AF) with a focus on edoxaban. Prof Andreas Goette then evaluated the current guidelines for the use of cardioversion in AF treatment and recent findings from NOAC trials. Dr Jack Ansell described the current management strategies for NOACs and the limitations therein, as well as novel reversal strategies for NOACs currently under development. Finally Prof John Camm, co-chair, summed up the use of NOACs as an alternative to warfarin in the prevention of stroke in patients with AF, and closed the meeting.

The Incidence of Asymptomatic Cerebral Microthromboembolism after Atrial Fibrillation Ablation: Comparison of Warfarin and Dabigatran

Cerebral microthromboembolism after atrial fibrillation (AF) ablation has been reported in 4-20% with perioperative warfarin. Dabigatran is a new anticoagulant in patients with nonvalvular AF. We investigated the incidence of asymptomatic cerebral microthromboembolism after AF ablation with perioperative warfarin or dabigatran using diffusion-weighted and T2-weighted magnetic resonance imaging (MRI). Our study included 210 consecutive patients with AF (111 paroxysmal and 99 persistent) who underwent complex fractionated atrial electrogram-guided ablation (combined with pulmonary vein isolation, n = 110). Catheter irrigation was performed in all cases. Uninterrupted warfarin therapy was used in 180 patients (warfarin group) and interrupted only on the morning of the procedure with dabigatran in 30 (dabigatran group). All patients underwent cerebral MRI the day after ablation. New microthromboemboli were detected in 10.0% of the warfarin group and 26.7% of the dabigatran group (P < 0.05). The incidence of hemopericardium treated with pericardiocentesis was lower in the warfarin group than in the dabigatran group (2.5% vs 11.1%, P < 0.05). In multivariate analysis, the use of cardioversion was a predictor of new microthromboembolism development after AF ablation. The incidence of asymptomatic cerebral microthromboembolism and hemopericardium after AF ablation was significantly lower with perioperative warfarin therapy than with dabigatran therapy. Dabigatran may not be an effective alternative to warfarin for AF ablation, especially in patients who undergo cardioversion.

Types and outcomes of cardioversion in patients admitted to hospital for atrial fibrillation: results of the German RHYTHM-AF Study

Atrial fibrillation (AF) accounts for approximately one-third of hospitalizations for cardiac rhythm disturbances. Little is known about the characteristics of current use of cardioversion (CV) and its success rates in clinical practice in Germany. As part of the international RHYTHM-AF Study, 655 consecutive patients with documented AF (mean age 68.3 ± 10.5 years, 64.9 % males) who were considered candidates for CV were prospectively enrolled in 22 German hospitals (21 academic/teaching and 1 non-teaching). CV was considered successful if sinus rhythm or atrial rhythm was obtained within 1 day after start of pharmacological CV (PCV) or if sinus rhythm was achieved and maintained for at least 10 min after electrical CV (ECV). Patients with AF considered for CV had ECG in 94.4 %, Holter ECG in 25.8 %, and transesophageal echocardiography (TEE) in 73.1 % of cases. They underwent ECV (after mean 16 h, range 4-48), in 65.3 % and PCV in 6.7 % of patients (amiodarone in 47.7 %, flecainide in 27.3 %, propafenone in 2.3 %) as first CV procedure. No CV was performed in 27.9 %, mainly due to spontaneous CV or pathologic TEE. Primary success rates were 86.7 % for electrical CV and 54.5 % for pharmacological CV. More patients in the ECV group compared to the PCV group received oral anticoagulation at discharge (79.2 vs. 59.1 %, p < 0.001), and at 60 days (77.5 vs. 56.8 %, p < 0.001). Further, at 60 days the proportion of patients in sinus rhythm was not different between groups (ECV 76.8 % vs. PCV 77.3 %). In large academic centres in Germany, the preferred CV method is electrical, mainly due to its easy access and to its higher success rate for the initial restoration of sinus rhythm. Considering the limitations of the open-label, non-randomised study design, overall short-term success rates appeared higher after ECV compared to PCV during hospitalisation, but not after 60 days.

Cardioversion for atrial fibrillation in current European practice: results of the European Heart Rhythm Association survey

This survey was conducted to provide an insight into the current clinical practice regarding the use of cardioversion for atrial fibrillation (AF) in Europe. Responses were received from 57 centres across Europe, 71.9% of which were university hospitals. For electrical cardioversion, general anaesthesia was managed by an anaesthesiologist in 73.9% of centres and by a cardiologist in 37%. In the majority of centres, electrical cardioversion was performed using a biphasic defibrillator (85.1%). Antiarrhythmic drugs were routinely prescribed prior to electrical cardioversion by 54.3% of hospitals. For pharmacological cardioversion in patients with no or minimal heart disease, the majority of centres (63.1%) chose intravenous flecainide or propafenone, whereas vernakalant was used by 35% of centres in patients with no or minimal-to-moderate structural heart disease. Most centres (71.7%) used a mandatory strategy of 3 weeks of oral anticoagulation prior to elective cardioversion in patients AF > 48 h, but 28.3% performed immediate cardioversion after a transoesophageal echocardiogram. Many centres are now performing electrical cardioversion on treatment with novel oral anticoagulants (up to 23.6% of cardioversions).

Intraoperative insulin therapy does not reduce the need for inotropic or antiarrhythmic therapy after cardiopulmonary bypass

Objective: To determine whether attempted glucose control through intraoperative insulin therapy reduces the need for inotropic or antiarrhythmic therapy after cardiopulmonary bypass (CPB). Design:Post hoc analysis of a randomized, masked clinical trial of insulin therapy for prevention of neurobehavioral deficits. Setting: Single university hospital. Participants: Nondiabetic patients undergoing elective coronary artery bypass graft surgery (n = 381). Interventions: Patients received either insulin infusions in an attempt to maintain blood glucose at 80 to 120 mg/dL (n = 188) or placebo (saline; n = 193). Inotropic therapy was defined as the initiation of vasoactive support with epinephrine or amrinone infusions or mechanical support with the initiation of an intra-aortic balloon pump in the operating room or within 12 hours postoperatively. Antiarrhythmic therapy was defined as cardioversion, antiarrhythmic medications, or pacing. Measurements and Main Results: Of patients, 64 in the placebo group and 71 in the insulin group required inotropic support after CPB (p = not significant). The use of cardioversion (55 in placebo group v 61 in insulin group), antiarrhythmic medications (64 in placebo group v 76 in insulin group), and pacing (118 in placebo group v 117 in insulin group) was similar between groups. Inotropic drug support was associated with age >60 years, female gender, reduced preoperative ejection fraction, history of angina, and increased duration of CPB. Conclusion: Intraoperative insulin therapy did not reduce the use of inotropic or antiarrhythmic support after cardiac surgery with CPB. The lack of benefit may be due to the inability to prevent hyperglycemia during the physiologic stress of CPB or a tribute to the effectiveness of modern myocardial preservation techniques. Copyright 2002, Elsevier Science (USA). All rights reserved.

Twelfth Annual Meeting of the Society for Pediatric Anesthesia, Orlando, Florida, October 16, 1998

Twelfth Annual Meeting of the Society for Pediatric Anesthesia, Orlando, Florida, October 16, 1998

Termination and Acceleration of Ventricular Tachycardia with Autodecremental Pacing, Burst Pacing, and Cardioversion in Patients with an Implantable Cardioverter Defibrillator

This multicenter study reports the outcome of ventricular tachycardia (VT) therapy (conversion or acceleration) and the relationship to initial tachycardia cycle length and other clinical variables using an implantable device with the capability of autodecremental or burst pacing, cardioversion, and defibrillation. The device was implanted in 444 patients (mean age 58 +/- 15 years) with 1,240 episodes of VT induced with noninvasive programming and reported in a multicenter database. Only the first sequence attempted for conversion by pacing or cardioversion was assessed, and cardioversion energies were 0.2-5 J. Autodecremental pacing was used to treat 700 induced episodes of VT during titration of pacing therapies (57% converted and 12% accelerated), burst pacing to treat 357 episodes (49% converted under 11% accelerated), and cardioversion to treat 183 episodes (82% converted and 4% accelerated). Cardioversion was the most effective treatment and had the lowest acceleration rate. Shorter VT cycle lengths were more likely to accelerate with burst pacing and longer VT cycle lengths to convert with both burst and autodecremental pacing. Patients with higher ejection fractions were more likely to convert with autodecremental and burst pacing. Use of cardioversion, higher ejection fraction, absence of unrepaired aneurysm, longer VT cycle lengths, coronary artery disease, and use of autodecremental pacing predicted conversion. Lower ejection fraction and VT cycle lengths < or = 300 msec predicted tachycardia acceleration.

Intravenous diazepam for direct-current cardioversion.

The induction of anaesthesia with intravenous diazepam is a valuable contribution to the simpler use of cardioversion and is the method of choice because it is readily available for elective cardioversion. Fifty-six cardioversion procedures were carried out by this method in an African hospital. No special premedication or drug preparation was used. There were no hazards apart from transient apnoea in two patients and persisting amnesia in one patient.