Trends in the use of electrical cardioversion for atrial fibrillation: influence of major trials and guidelines on clinical practice (original) (raw)
Related papers
European journal of arrhythmia & electrophysiology, 2022
ackground: Electrical cardioversion (ECV) is frequently performed to treat persistent atrial fibrillation (AF). Although several large trials have suggested that rate control in AF may be non-inferior to rhythm-based strategies, individual patients may have better outcomes in terms of quality of life if sinus rhythm (SR) is achieved and maintained. This real-world, retrospective, observational study aimed to define the success rate and role of ECV in the management of persistent AF in the era of catheter ablation. Methods: All patients who underwent ECV for symptomatic persistent AF at our institution between January 2014 and August 2019 were analysed. Clinical and echocardiographic baseline characteristics were used to identify independent predictors for AF recurrence at 12 and 24 months using a Cox multivariate model. Results: We identified 1,028 consecutive patients with symptomatic persistent AF, 319 of whom were subsequently excluded from the study because they either spontaneously reverted to SR prior to ECV or declined ECV. We evaluated 701 patients (mean age 71 ± 10.8 years, male 70.2%). Acute success was achieved in 96.8% of patients. SR at 12 and 24 months was seen in 26.6% and 14.3% of patients (p<0.0001), respectively. SR at 12 months was seen in 20.4% of patients with a left atrium (LA) diameter of ≤4 cm and in 6.2% of patients with an LA diameter of >4 cm (p<0.0001). At 24 months, SR was seen in 11.5% of patients with a LA diameter of ≤4 cm and in 2.8% with a diameter of >4 cm (p<0.0001). Predictors of SR at 12 months on univariate analysis were normal left ventricular systolic function and mild left ventricular systolic impairment (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.08-2.45, p=0.021 and OR 0.5, 95% CI 0.24-0.94, p=0.043, respectively). In addition, flecainide and sotalol therapy improved the chances of SR at 12 months (OR 2.87, 95% CI 1.16-7.12, p=0.021 and OR 2.25, 95% CI 0.98-5.05, p=0.049, respectively). Multivariate analysis revealed no further positive predictors for SR maintenance in 24 months. Conclusion: ECV was not an effective long-term strategy for the maintenance of SR.
The Convergent Procedure: A Multidisciplinary Atrial Fibrillation Treatment
The Heart Surgery Forum, 2010
Background: Persistent atrial fi brillation (AF) and longstanding persistent AF (LSPAF) are diffi cult to treat. Epicardial surgical and percutaneous catheter ablations have lower success rates in these patients. The convergent procedure, an endoscopic transdiaphragmatic ablation procedure with conventional percutaneous endocardial ablation, is examined. Methods: Twenty-eight patients with persistent AF or LSPAF underwent the convergent procedure. All underwent combined surgical epicardial radiofrequency ablation and electrophysiological transseptal endocardial ablation to electrically isolate the 4 pulmonary veins, to exclude the posterior left atrium, to ablate the coronary sinus, and to confi rm block at the cavotricuspid isthmus. Follow-up was with 24-hour Holter monitoring at 3 months, and 24-hour or 7-day monitoring at 6 and 12 months. Results: The mean duration of the procedure was 187 minutes (102 surgical ablation minutes; 85 endocardial ablation minutes). The mean total fl uoroscopy time was 35.1 minutes. Two patients developed symptomatic pericardial effusions requiring percutaneous drainage, and 1 patient has demonstrated phrenic nerve paresis. There were no deaths. At 3 months, 87% were in sinus rhythm, and 43% were free of AF and antiarrhythmic medications (AADs). At 6 months, 76% were free from AF and AADs. Conclusion: The convergent procedure effectively combines surgical and electrophysiological AF expertise to provide a viable treatment option to patients with persistent AF or LSPAF. Long-term follow-up is under way.
BMC cardiovascular disorders, 2017
Elective cardioversion (ECV) of atrial fibrillation (AF) is a standard procedure to restore sinus rhythm. However, predictors for ineffective ECV (failure of ECV or recurrence of AF within 30 days) are unknown. We investigated 1998 ECVs performed for AF lasting >48 h in 1,342 patients in a retrospective multi-center study. Follow-up data were collected from 30 days after ECV. Median number of cardioversions was one per patient with a range of 1-10. Altogether 303/1998 (15.2%) ECVs failed. Long (>5 years) AF history and over 30 days duration of the index AF episode were independent predictors for ECV failure and low (<60/min) ventricular rate of AF predicted success of ECV. In patients with successful ECVs an early recurrence of AF was detected in 549 (32.4%) cases. Female gender, high (>60/min) ventricular rate, renal failure and antiarrhythmic agents at discharge were the independent predictors for recurrence. In total ECV was ineffective in 852 (42.6%) cases. Female ge...
Predictors of unsuccessful electrical cardioversion in atrial fibrillation
American Journal of Cardiology, 2002
R estoration of sinus rhythm improves functional capacity and alleviates palpitations in patients with atrial fibrillation (AF). 1,2 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. 3 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. 4 -9 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.
Effectiveness and costs of chemical versus electrical cardioversion of atrial fibrillation
International Journal of Cardiology, 2003
This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology The study compared the use of chemical versus electrical cardioversion as an initial treatment to convert atrial fibrillation (AF) to sinus rhythm in patients with persistent AF of less than 6 months. The authors not only compared the initial strategies, but they also evaluated whether a strategy that started with either method followed by the other was comparable to the opposite strategy. The drugs for chemical cardioversion or for sedation were left to the investigator's criteria, as were the energy, anticoagulation, and the number of shocks applied for electrical cardioversion. The most frequently used drug was quinidine (maximum dose 1,600 mg) administered orally, either isolated or following intravenous digitalis. Other intravenous regimens included procainamide (maximum dose 2 mg/kg of intravenous infusion) and amiodarone (maximum dose 600 mg intravenously). After restoration of sinus rhythm, most patients were treated with sotalol or quinidine. Type of intervention Treatment. Economic study type Cost-effectiveness analysis. Study population Patients eligible for the study were those presenting a persistent episode of AF of less than 6 months, with indication for restoration of sinus rhythm by either of two methods of cardioversion (chemical or electrical). The duration of AF was determined by the onset of symptoms or, in the case of asymptomatic or oligosymptomatic patients, it was considered as the period since the last electrocardiogram on sinus rhythm. Eligibility criteria also included haemodynamically stable patients, serum potassium greater than 3.8 mequiv./L, no anaesthetic contraindication, and absence of signs of digitalis toxicity. The exclusion criteria included a strong belief from the physician, or the patient, that either of the therapeutic options would have better results based on acquired experience in previous episodes. Other criteria were moderate or severe heart failure, hypertension (diastolic blood pressure greater than 110 mmHg), alcohol or drug abuse, pregnancy or lactation, renal failure, myocardial infarction in the last 30 days, current therapy with anti-arrhythmic drugs, and left ventricular ejection fraction less than 0.40. Ethical commissions of all the participating institutions approved the protocol. Setting The setting was tertiary care. The economic study was carried out in Brazil. Dates to which data relate The dates to which the effectiveness evidence and resource use data related were not reported. The price year was not reported.
European Heart Journal, 2010
This multicentre, randomized trial compared three strategies of AF ablation: ablation of complex fractionated electrograms (CFE) alone, pulmonary vein isolation (PVI) alone, and combined PVI þ CFE ablation, using standardized automated mapping software. Methods and results Patients with drug-refractory, high-burden paroxysmal (episodes .6 h, .4 in 6 months) or persistent atrial fibrillation (AF) were enrolled at eight centres. Patients (n ¼ 100) were randomized to one of three arms. For CFE alone (n ¼ 34), spontaneous/induced AF was mapped using validated, automated CFE software and all sites ,120 ms were ablated until AF termination/non-inducibility. For PVI (n ¼ 32), all four PV antra were isolated and confirmed using a circular catheter. For PVI þ CFE (n ¼ 34), all four PV antra were isolated, followed by AF induction and ablation of all CFE sites until AF termination/non-inducibility. Patients were followed at 3, 6, and 12 months with a visit, ECG, 48 h Holter. Atrial fibrillation symptoms were confirmed by loop recording. Repeat procedures were allowed within the first 6 months. The primary endpoint was freedom from AF .30 s at 1 year. Patients (age 57 + 10 years, LA size 42 + 6 mm) were 35% persistent AF. In CFE, ablation terminated AF in 68%. Only 0.4 PVs per patient were isolated as a result of CFE. In PVI, 94% had all four PVs successfully isolated. In PVI þ CFE, 94% had all four PVs isolated, 76% had inducible AF with additional CFE ablation, with 73% termination of AF. There were significantly more repeat procedures in the CFE arm (47%) vs. PVI (31%) or PVI þ CFE (15%) (P ¼ 0.01). After one procedure, PVI þ CFE had a significantly higher freedom from AF (74%) compared with PVI (48%) and CFE (29%) (P ¼ 0.004). After two procedures, PVI þ CFE still had the highest success (88%) compared with PVI (68%) and CFE (38%) (P ¼ 0.001). Ninety-six percent of these patients were off anti-arrhythmics. Complications were two tamponades, no PV stenosis, and no mortality. Conclusion In high-burden paroxysmal/persistent AF, PVI þ CFE has the highest freedom from AF vs. PVI or CFE alone after one or two procedures. Complex fractionated electrogram alone has the lowest one and two procedure success rates with a higher incidence of repeat procedures. ClinicalTrials.gov identifier number NCT00367757.