A South Australian registry of biphasic cardioversions of atrial arrhythmias: efficacy and predictors of success

Atrial fibrillation: real-life experience of a rhythm control with electrical cardioversion in a community hospital

BACKGROUND

Atrial fibrillation is the most prevalent sustained cardiac arrhythmia. Electrical cardioversion, a well-established part of the rhythm control strategy, is probably underused in community settings. Here, we describe its use, safety, and effectiveness in a cohort of patients with atrial fibrillation treated in rural settings.

METHODS

It is a retrospective cohort study. Data on all procedures from January 1, 2016, till December 1, 2022, in Tarusa Hospital, serving mostly a rural population of 15,000 people, were extracted from electronic health records. Data on the procedure's success, age, gender, body mass index, comorbidities, previous procedures, echocardiographic parameters, type and duration of arrhythmia, anticoagulation, antiarrhythmic drugs, transesophageal echocardiography, and settings were available.

RESULTS

Altogether, 1,272 procedures in 435 patients were performed during the study period. The overall effectiveness of the procedure was 92%. Effectiveness was similar across all prespecified subgroups. Electrical cardioversion was less effective in patients undergoing the procedure for the first time (86%, 95% CI: 82-90) compared to repeated procedures (95%, 95% CI: 93-96), OR 0.39 (95% CI: 0.26-0.59). Complications were encountered in 13 (1.02%) procedures but were not serious.

CONCLUSIONS

Electrical cardioversion is an immediately effective procedure that can be safely performed in community hospitals, both in inpatient and outpatient settings. Further studies with longer follow-up are needed to investigate the rate of sinus rhythm maintenance in these patients.

Wide QRS complex tachycardia with a mysterious mask-Tricuspid isthmus-dependent atrial flutter with preexcitation syndrome and dual atrioventricular nodal pathway conduction

Key Clinical Message

Atrial flutter (AFL) and supraventricular tachycardia (SVT) are common arrhythmias in clinic. However, some AFL cases may present additional complexities, such as both accessory pathways (AP) and dual atrioventricular node pathways, putting on a mysterious mask and making it challenging to distinguish on electrocardiograms (ECGs).

Abstract

A 60-year-old male patient had a sudden syncope, and an ECG showed wide QRS complex tachycardia. This diagnostic ambiguity is further compounded by the fact that SVT via AP conduction can exhibit wide QRS complex tachycardia characteristics resembling ventricular tachycardia (VT). Consequently, a definitive diagnosis through electrophysiological (EP) examination becomes imperative, as it dictates subsequent ablation strategies. In this article, we present a rare case involving three distinct arrhythmias including AFL, AP, and dual atrioventricular node pathways, and successfully treated through ablation.

[Adult advanced life support]

These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

European Resuscitation Council Guidelines 2021: Adult advanced life support

These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

Randomized trial comparing the effectiveness of internal (through implantable cardioverter defibrillator) versus external cardioversion of atrial fibrillation

PURPOSE

When patients with implantable cardioverter defibrillators (ICD) develop symptomatic atrial fibrillation (AF), external direct current cardioversion (EDCCV), as well as internal cardioversion using their ICD, are the options available. It is currently unknown which of these two methods are more effective. We compared the effectiveness of EDCCV versus internal cardioversion to terminate AF in patients with a single-coil ICD.

METHODS

This randomized controlled trial (clinicaltrial.gov NCT03164395) enrolled consecutive patients with a single-coil ICD that presented with symptomatic AF of less than 1-year duration. They received either the maximum energy internal shock through the ICD or an EDCCV using transcutaneous pads of 200 J. The primary endpoint was a successful conversion to sinus rhythm after one shock. Crossover was permitted if the first shock was unsuccessful.

RESULTS

Thirty-one patients were enrolled in the study, including 16 in the internal ICD cardioversion group. The study included patients with a mean age of 59.5 ± 16.0 years, 41.9% females, median AF duration 1 month (interquartile range 1-3), 45.2% non-ischemic cardiomyopathies, mean EF 28.6 ± 16.0%, and 45.2% biventricular ICD. There were no significant differences in baseline clinical characteristics between the two groups. In the internal cardioversion group, 5/16 patients (31.3%) met the primary endpoint versus 14/15 (93.3%) in the EDCCV group, p < 0.001. All patients that failed the first shock were subsequently cardioverted externally.

CONCLUSION

Among patients with a single-coil ICD and symptomatic AF of less than 1 year, external direct current cardioversion is much more effective than internal shock through the ICD.

Supraventricular Arrhythmias in Patients with Adult Congenital Heart Disease

An increasing number of patients with congenital heart disease survive to adulthood; such prolonged survival is related to a rapid evolution of successful surgical repairs and modern diagnostic techniques. Despite these improvements, corrective atrial incisions performed at surgery still lead to subsequent myocardial scarring harbouring a potential substrate for macro-reentrant atrial tachycardia. Macroreentrant atrial tachycardias are the most common (75 %) type of supraventricular tachycardia (SVT) in patients with adult congenital heart disease (ACHD). Patients with ACHD, atrial tachycardias and impaired ventricular function - important risk factors for sudden cardiac death (SCD) - have a 2-9 % SCD risk per decade. Moreover, ACHD imposes certain considerations when choosing antiarrhythmic drugs from a safety aspect and also when considering catheter ablation procedures related to the inherent cardiac anatomical barriers and required expertise. Expert recommendations for physicians managing these patients are therefore mandatory. This review summarises current evidence-based developments in the field, focusing on advances in and general recommendations for the management of ACHD, including the recently published recommendations on management of SVT by the European Heart Rhythm Association.

Executive Summary: European Heart Rhythm Association Consensus Document on the Management of Supraventricular Arrhythmias: Endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE)

This paper is an executive summary of the full European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, published in Europace. It summarises developments in the field and provides recommendations for patient management, with particular emphasis on new advances since the previous European Society of Cardiology guidelines. The EHRA consensus document is available to read in full at http://europace.oxfordjournals.org.