1
|
Ikeda S, An Y, Yanagisawa M, Ishigami K, Aono Y, Doi K, Ishii M, Iguchi M, Ogawa H, Masunaga N, Abe M, Akao M. Iatrogenic ventricular fibrillation caused by inappropriately synchronized cardioversion in a patient with pre-excited atrial fibrillation: A case report. J Cardiol Cases 2021; 23:31-34. [PMID: 33437337 DOI: 10.1016/j.jccase.2020.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/21/2020] [Accepted: 08/30/2020] [Indexed: 11/29/2022] Open
Abstract
Direct-current (DC) cardioversion is effective at terminating arrhythmias in an emergency. During treatment, energy delivery synchronizing with the QRS complex is essential to avoid ventricular fibrillation (VF) caused by a shock on the T wave, which is the vulnerable period of ventricular repolarization. However, distinguishing the QRS from the T wave is difficult in some patients with abnormal, irregular, and varying QRS complexes. We report the case of a 45-year-old man who had iatrogenic VF caused by inappropriate synchronization with the T wave during cardioversion of pre-excited atrial fibrillation due to high ventricular rates and varying R wave amplitude affected by an accessory pathway. <Learning objective: During direct-current cardioversion, energy delivery synchronizing with the QRS complex is essential to avoid ventricular fibrillation (VF) caused by a shock on the T wave. However, distinguishing the QRS from the T wave is difficult in some patients with abnormal, irregular, and varying QRS complexes. We report a case of iatrogenic VF caused by failed synchronization with the R wave in a patient with pre-excited atrial fibrillation (AF). Clinicians managing pre-excited AF should be aware of the possibility of iatrogenic VF triggered by cardioversion.>.
Collapse
Affiliation(s)
- Syuhei Ikeda
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yoshimori An
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Masami Yanagisawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kenjiro Ishigami
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yuya Aono
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kosuke Doi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Moritake Iguchi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Nobutoyo Masunaga
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| |
Collapse
|
2
|
Kaufmann MR, McKillop MS, Burkart TA, Panna M, Conti JB, Miles WM. Iatrogenic Ventricular Fibrillation after Direct-Current Cardioversion of Preexcited Atrial Fibrillation Caused by Inadvertent T-Wave Synchronization. Tex Heart Inst J 2018; 45:39-41. [PMID: 29556151 DOI: 10.14503/thij-16-6162] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Direct-current cardioversion is an important means of managing arrhythmias. During treatment, carefully synchronizing energy delivery to the QRS complex is necessary to avoid ventricular fibrillation caused by a shock during the vulnerable period of ventricular repolarization, that is, a shock on the T wave. The presence of an accessory pathway and ventricular preexcitation can lead to difficulty in distinguishing the QRS complex from the T wave because of bizarre, wide, irregular QRS complexes and prominent repolarization. We present the cases of 2 patients who had iatrogenic ventricular fibrillation from inappropriate T-wave synchronization during direct-current cardioversion of preexcited atrial fibrillation. Our experience shows that rapidly recognizing the iatrogenic cause of VF and immediate treatment with unsynchronized defibrillation can prevent adverse clinical outcomes.
Collapse
|
3
|
Taylor N. Direct current cardioversion causing ventricular fibrillation in Wolff-Parkinson-White syndrome. Emerg Med Australas 2013; 25:612-4. [DOI: 10.1111/1742-6723.12150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Nicholas Taylor
- Emergency Department; The Canberra Hospital; Canberra Australia
| |
Collapse
|
4
|
Park YM, Lee HS, Lim RS, Choi JI, Lim HE, Park SW, Choi IS, Kim YH. Inadvertently Developed Ventricular Fibrillation during Electrophysiologic Study and Catheter Ablation: Incidence, Cause, and Prognosis. Korean Circ J 2013; 43:474-80. [PMID: 23964294 PMCID: PMC3744735 DOI: 10.4070/kcj.2013.43.7.474] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 06/04/2013] [Accepted: 06/27/2013] [Indexed: 11/29/2022] Open
Abstract
Background and Objectives Ventricular fibrillation (VF) can inadvertently occur during electrophysiologic study (EPS) or catheter ablation. We investigated the incidence, cause, and progress of inadvertently developed VF during EPS and catheter ablation. Subjects and Methods We reviewed patients who had developed inadvertent VF during EPS or catheter ablation. Patients who developed VF during programmed ventricular stimulation to induce ventricular tachycardia or VF were excluded. Results Inadvertent VF developed in 11 patients (46.7±9.3 years old) among 2624 patients (0.42%); during catheter ablation for atrial fibrillation (AF) in nine patients, frequent ventricular premature beats (VPBs) in one, and Wolff-Parkinson-White (WPW) syndrome were observed in one. VF was induced after internal cardioversion in six AF patients due to incorrect R-wave synchronization of a direct current shock. Two AF patients showed spontaneous VF induction during isoproterenol infusion while looking for AF triggering foci. The remaining AF patient developed VF after rapid atrial pacing to induce AF, but the catheter was accidentally moved to the right ventricular (RV) apex. A patient with VPB ablation spontaneously developed VF during isoproterenol infusion. The focus of VPB was in the RV outflow tract and successfully ablated. A patient with WPW syndrome developed VF after rapid RV pacing with a cycle length of 240 ms. Single high energy (biphasic 150-200 J) external defibrillation was successful in all patients, except in two, who spontaneously terminated VF. The procedure was uneventfully completed in all patients. At a mean follow-up period of 17.4±15.5 months, no patient presented with ventricular arrhythmia. Conclusion Although rare, inadvertent VF can develop during EPS or catheter ablation. Special caution is required to avoid incidental VF during internal cardioversion, especially under isoproterenol infusion.
Collapse
Affiliation(s)
- Yae Min Park
- Division of Cardiology, Korea University College of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | |
Collapse
|
5
|
Lévy S. Internal defibrillation: where we have been and where we should be going? J Interv Card Electrophysiol 2006; 13 Suppl 1:61-6. [PMID: 16133857 DOI: 10.1007/s10840-005-1824-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2005] [Accepted: 04/29/2005] [Indexed: 10/25/2022]
Abstract
Internal cardioversion has been developed as an alternative technique for patients who are resistant to external DC cardioversion of atrial fibrillation (AF) and was found to be associated with higher success rates. It used initially high energies (200-300 J) delivered between an intracardiac catheter and a backplate. Subsequent studies have shown that it is possible to terminate with energies of 1 to 6 Joules, paroxysmal or induced AF in 90 percent of patients and persistent AF in 75 percent of patients, using biphasic shocks delivered between a right atrium-coronary sinus vectors. Consequently, internal atrial defibrillation can be performed under sedation only without the need for general anesthesia. Recently developed external defibrillators, capable of delivering biphasic shocks, have increased the success rates of external cardioversion and reduced the need for internal cardioversion. However, internal defibrillation is still useful in overweight or obese patients, in patients with chronic obstructive pulmonary disease or asthma who are more difficult to defibrillate, and in patients with implanted devices which may be injured by high energy shocks. Low energy internal defibrillation has also proven to be safe and this has prompted the development of implantable devices for terminating AF. The first device used was the Metrix system, a stand-alone atrial defibrillator (without ventricular defibrillation) which was found to be safe and effective in selected groups of patients. Unfortunately, this device is no longer being marketed. Only double chamber defibrillators with pacing capabilities are presently available: the Medtronic GEM III AT, an updated version of the Jewel AF and the Guidant PRIZM AVT. These devices can be patient-activated or programmed to deliver automatically ounce atrial tachyarrhythmias are detected, therapies including pacing or/and shocks. Attempts to define the group of patients who might benefit from these devices are described but the respective role of atrial defibrillators versus other non-pharmacologic therapies for AF, such as surgery and radiofrequency catheter ablation, remains to be determined. Advantages and limitations or atrial defibrillators and approaches to reduce shock related discomfort which may be a concern in some patients, are reviewed. Studies have shown that despite shock discomfort, quality of life was improved in patients with atrial defibrillators and the need for repeated hospitalizations was reduced. The cost of these devices remains a concern for the treatment of a non-lethal arrhythmia. Attention that atrial defibrillators will receive from cardiologists and from the industry in the future, will depend of the long-term results of other non-pharmacological options and of the identification of the group of AF patients which will require restoration and maintenance of sinus rhythm. But there is no doubt that selected subsets of patients with AF could benefit from atrial defibrillation.
Collapse
Affiliation(s)
- Samuel Lévy
- Division of Cardiology, School of Medicine, University of Marseille, Chemin des Bourrellys, Marseille, France.
| |
Collapse
|
6
|
Schmitt C, Ndrepepa G. Use of atrial defibrillators to convert atrial fibrillation at home: psychosocial aspects. J Cardiovasc Electrophysiol 2003; 14:817-8. [PMID: 12890041 DOI: 10.1046/j.1540-8167.2003.03236.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
7
|
|
8
|
Tse HF, Lau CP, Camm AJ. Transvenous atrial defibrillation--techniques and clinical applications. Clin Cardiol 1999; 22:614-22. [PMID: 10526684 PMCID: PMC6655977 DOI: 10.1002/clc.4960221005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/1998] [Accepted: 02/09/1999] [Indexed: 11/09/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia requiring treatment. The most desirable therapy may be restoration and maintenance of sinus rhythm. Limitations of the current methods for cardioversion of AF have prompted the development of transvenous atrial defibrillation (TADF) as an alternative and more effective technique for converting AF. Recent advances in the technique of TADF, particularly in the design and configuration of the electrodes, and the use of an optimal biphasic shock waveform have dramatically improved the efficacy of TADF for the termination of all types of AF. The reduction in voltage and energy requirements for cardioversion by TADF may allow the procedure to be performed with little or no sedation and the risk of general anesthesia may be avoided. Both experimental and clinical studies have demonstrated the feasibility, safety, and efficacy of using TADF as a new temporary or "permanent" mode of electrical therapy for AF. It has several potential applications, from acute termination of AF in the electrophysiology laboratory and in patients who have failed to respond to external cardioversion, to its use as an implantable device for treating recurrent AF. This article reviews the current technique and clinical applications of TADF for treatment of AF.
Collapse
Affiliation(s)
- H F Tse
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, China
| | | | | |
Collapse
|
9
|
Tse HF, Lau CP, Sra JS, Crijns HJ, Edvardsson N, Kacet S, Wyse DG. Atrial fibrillation detection and R-wave synchronization by Metrix implantable atrial defibrillator: implications for long-term efficacy and safety. The Metrix Investigators. Circulation 1999; 99:1446-51. [PMID: 10086968 DOI: 10.1161/01.cir.99.11.1446] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The long-term efficacy of atrial fibrillation (AF) detection and R-wave synchronization are critical safety requirements for the development of an implantable atrial defibrillator (IAD) for treatment of AF. METHODS AND RESULTS The long-term efficacy of the Metrix IAD for AF detection and R-wave synchronization was tested in 51 patients. The mean duration of follow-up was 259+/-138 days (72 to 613 days). AF detection tests were performed 2240 times during observed operation with 100% specificity and 92.3% sensitivity for differentiation between sinus rhythm and AF; 2219 episodes and their electrograms stored in the device during AF detection were analyzed. The positive predictive value of the AF detection algorithm was 97.4% (lower 95% confidence limit [CL], 94.5%) in the out-of-hospital setting. A total of 242 435 R waves were analyzed for R-wave synchronization. Of these, 49% were marked for synchronized shock delivery, 82% of sinus rhythm and 36% of AF R waves, respectively. All shock markers were properly synchronized and within the R wave (overall synchronization accuracy, 100%; lower 95% CL, 99.999%). Overall, 3719 shocks have been delivered via the IAD with no instance of unsynchronized shock delivery or any episode of proarrhythmia. The observed proarrhythmic risk was 0%, with an estimated maximum proarrhythmic risk of 0.084% per shock (95% upper CL). CONCLUSIONS The Metrix IAD can appropriately detect AF with a high specificity and sensitivity and reliably synchronize within a suitable R wave for shock delivery to minimize the risk of ventricular proarrhythmia.
Collapse
Affiliation(s)
- H F Tse
- Queen Mary Hospital, the University of Hong Kong, Hong Kong, China
| | | | | | | | | | | | | |
Collapse
|
10
|
Abstract
Atrial fibrillation (AF) is an extremely common arrhythmia seen in clinical practice. Because of the limited efficacy of traditional therapeutic strategies to restore and maintain normal sinus rhythm, several nonpharmacologic options have evolved. The promising results achieved with internal atrial defibrillation have facilitated the development of an implantable atrial defibrilator. Preliminary results obtained from an initial study on a small number of highly selected patients with refractory AF suggest that atrial defibrillation can be performed effectively and safely with adequate patient tolerance by using a stand-alone device. The extension of this therapy will depend on the results of well-designed prospective studies comparing this new therapeutic option with traditional methods. Several acute studies have shown that internal conversion of AF is feasible at low energies with current endocardial transvenous lead configurations primarily designed for ventricular defibrillation, but long-term efficacy has, to date, only been demonstrated with atrial implantable defibrillator lead systems. As AF is a frequent arrhythmia in implantable cardioverter defibrillator (ICD) recipients, it would seem desirable to incorporate the capability for atrial defibrillation into an ICD. Clinical studies have shown that an atrial defibrillator, as part of a combined dual-chamber ICD system, may not require a potentially complicated switching network for establishing different electrode configurations for atrial and ventricular tachyarrhythmia. The efficacy in atrial cardioversion of such a combined, less complex device seems to be as high as reported for a pure atrial defibrillator, but generally at somewhat higher energy requirements. The results of further investigations will show whether a dual-chamber cardioverter defibrillator would be of clinical relevance in patients with ventricular and supraventricular tachyarrhythmia.
Collapse
Affiliation(s)
- A Heisel
- Medizinische Universitätsklinik, Universitätskliniken des Saarlandes, Homburg/Saar, Germany
| | | |
Collapse
|
11
|
Barold HS, Shander G, Tomassoni G, Simons GR, Wharton JM. Effect of increased parasympathetic and sympathetic tone on internal atrial defibrillation thresholds in humans. Pacing Clin Electrophysiol 1999; 22:238-42. [PMID: 9990638 DOI: 10.1111/j.1540-8159.1999.tb00340.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
UNLABELLED Although changes in autonomic tone affect ventricular defibrillation, little is known about the effect of increased parasympathetic or sympathetic tone on the atrial defbrillation threshold. METHODS To evaluate the effect of reflexly increased parasympathetic and increase alpha- and beta-adrenergic tone on the atrial defibrillation threshold (ADFT), atrial fibrillation was induced in 14 patients. ADFTs, right atrial refractory period (RARP), and monophasic action potential duration (MAPD) were determined before and after autonomic intervention. ADFTs were determined with a step-up protocol using 3/3-ms biphasic shocks delivered through decapolar catheters in the right atrial appendage and coronary sinus. Two groups were studied. Group I (N = 8) had ADFTs determined at baseline, after receiving phenylephrine (PE), and with PE plus atropine (A). Group 2 (N = 6) had ADFTs determined at baseline and after receiving isoproterenol (ISO). RESULTS Group I: PE significantly increased sinus cycle length (SR-CL) compared to baseline (742 +/- 123 to 922 +/- 233 ms) without significantly changing RARP, MAPD, or ADFT (2.3 +/- 1.3 J vs 2.3 +/- 0.8 J). With PE + A, SR-CL significantly decreased (529 +/- 100 ms vs 742 +/- 123 ms) and MAPD shortened (231 +/- 41 ms vs 279 +/- 49 ms) without altering RARP or ADFT (1.94 +/- 0.9 J vs 2.25 +/- 1.25 J). Group 2: ISO decreased SR-CL (486 +/- 77 ms vs 755 +/- 184 ms) and MAPD (169 +/- 37 ms vs 226 + 58 ms) but not RARP or ADFT (2.25 +/- 1.21 J vs 2.33 +/- 1.75 J). CONCLUSIONS Increasing parasympathetic, alpha-, or beta-adrenergic tone does not affect the ADFT despite causing significant electrophysiological changes in the atria.
Collapse
Affiliation(s)
- H S Barold
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA
| | | | | | | | | |
Collapse
|
12
|
Hnatkova K, Murgatroyd FD, Alferness CA, Camm AJ, Malik M. Distribution of fast heart rate episodes during paroxysmal atrial fibrillation. HEART (BRITISH CARDIAC SOCIETY) 1998; 79:497-501. [PMID: 9659199 PMCID: PMC1728697 DOI: 10.1136/hrt.79.5.497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the defibrillator waiting time (time between the recognition of atrial fibrillation and the actual shock) by studying paroxysmal atrial fibrillation episodes with RR intervals shorter than a certain limit (that is, episodes during which defibrillation should not be attempted). METHODS Long term 24 hour Holter recordings from a digoxin v placebo crossover study in patients with paroxysmal atrial fibrillation were analysed. In all, 23 recordings with atrial fibrillation episodes of at least 1000 ventricular cycles and with < 20% Holter artefacts or noise were used (11 recorded on placebo and 12 on digoxin). For each recording, the mean ("mean waiting time") and maximum ("maximum waiting time") duration of continuous sections of atrial fibrillation episodes with all RR intervals shorter than a certain threshold were evaluated, ranging the threshold from 400 to 1000 ms in 10 ms steps. For each threshold, the mean and maximum waiting times were compared between recordings on placebo and on digoxin. RESULTS Both the mean and maximum waiting times increased exponentially with increasing threshold. Practically acceptable mean waiting times less than one minute were observed with thresholds below 600 ms. There were no significant differences in mean waiting times and maximum waiting times between recordings on placebo and digoxin, and only a trend towards shorter waiting times on digoxin. CONCLUSIONS Introduction of a minimum RR interval threshold required to deliver atrial defibrillation leads to practically acceptable delays between atrial fibrillation recognition and the actual shock. These delays are not prolonged by digoxin treatment.
Collapse
Affiliation(s)
- K Hnatkova
- Department of Cardiological Sciences, St George's Hospital Medical School, London, UK.
| | | | | | | | | |
Collapse
|
13
|
Costeas C, Kassotis J, Blitzer M, Reiffel JA. Rhythm management in atrial fibrillation--with a primary emphasis on pharmacological therapy: Part 2. Pacing Clin Electrophysiol 1998; 21:742-52. [PMID: 9584306 DOI: 10.1111/j.1540-8159.1998.tb00132.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Atrial fibrillation (AF) is the most common, sustained, symptomatic tachyarrhythmia that clinicians are called upon to manage. Management strategies include ventricular rate control coupled with anticoagulation, versus restoration and maintenance of sinus rhythm. Rate control may be achieved pharmacologically, with agents that impair AV nodal conduction directly and/or by increasing parasympathetic/sympathetic balance, or by modifying or ablating the AV nodal region anatomically. Rhythm control may be achieved by electrical or pharmacological conversion followed by maintenance of sinus rhythm by pharmacological (or occasionally ablative) therapies. This article will present current approaches to rate and rhythm control issues in AF. Part 1, published previously, dealt with rate control. Part 2, the current article, details approaches to the restoration of sinus rhythm by electrical and pharmacological means. The former may use transthoracic or catheter-based energy delivery systems. The latter may use intravenous or oral drug approaches. Part 3, to be published in a subsequent edition of PACE will deal with the maintenance of sinus rhythm.
Collapse
Affiliation(s)
- C Costeas
- Department of Medicine, Columbia University, New York, New York, USA
| | | | | | | |
Collapse
|