Pulmonary edema following electrical cardioversion of atrial fibrillation

Impact of defibrillation threshold testing on burden of heart failure hospitalizations

Background: Defibrillation threshold testing (DT) following implantable cardioverter defibrillator (ICD) implantation has not shown to improve mortality. However, the impact of DT on burden of heart failure (HF) hospitalisations has not been well defined.Methods: We studied retrospectively consecutive patients who underwent ICD implantation or generator change between 2008 and 2014. Primary outcome was burden of HF hospitalisations within 30 days following implantation. Secondary outcomes were mortality, stroke, and ICD shock within 30 days and one-year mortality.Results: Three hundred and eleven of 501 patients (62%) were in DT+ group versus 190 (38%) were in DT- group. The percentage of new implantations was higher in DT+ group than in DT- group (69% vs 39%, p < .001) but the distributions of NYHA function classes were similar between two groups. The burden of HF hospitalisations at 30-days was significantly higher in DT+ group than in DT- group (17.4% vs 4.7%, HR 0.842, 95% CI 0.774-0.915, p < .0001). No difference in mortality, stroke or ICD shocks was found between two groups at 30 days and mortality at 1 year.Conclusions: DT after new ICD or generator replacement was associated with increased HF hospitalisation rates at 30 days after ICD implant in a non-trial HF population. However, there was no association between DT and mortality, stroke and ICD shocks at 30 days or mortality at 1 year. The increased burden of HF hospitalisation in this observational study requires validation by randomised studies.

Acute Pulmonary Edema: A Rare Cause of Dyspnea After Electrical Cardioversion

BACKGROUND

Direct current cardioversion is a common management option for termination of tachydysrhythmias, including atrial fibrillation and atrial flutter. It is generally safe and effective with infrequent reporting of side effects. Pulmonary edema is a rare complication with reported incidence of 1-3% and mortality of 18%. Our literature search did not reveal any reported cases of postcardioversion pulmonary edema in the emergency medicine literature.

CASE REPORT

We report a case of an 80-year-old woman with a history of atypical atrial flutter on warfarin, paroxysmal atrial fibrillation, and rheumatic mitral valve disease who presented with shortness of breath 12 h after transesophageal echocardiography and subsequent direct current cardioversion with reversion to sinus rhythm. She was found to be in acute pulmonary edema. She was placed on noninvasive ventilation and diuresis with eventual symptom resolution. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Postcardioversion pulmonary edema is a rare complication that may occur after reversion to sinus rhythm. Emergency physicians should be cognizant of patients, especially those with underlying structural heart disease, who present with dyspnea after a recent cardioversion procedure or after cardioversion in the emergency department. Patients cardioverted in the emergency department may be observed for around 3 h and counseled on the development of respiratory symptoms.

[Direct current cardioversion in Abidjan: report of a ten-year practice in Institute of Cardiology of Abidjan, Ivory Coast]

Direct current cardioversion is effective in arrhythmias' termination. Few is known about its use in our practice. This work aims to report its outcomes over a ten-year period in Abidjan.

METHOD

One thousand, three hundred and ninety one charts of arrhythmic patients were reviewed.

RESULTS

Cardioversion was attempted in 102 patients. One hundred and eighty one shocks were delivered with a mean energy of 262, 1 joules. Success occurred in 84 patients (82,3%). Cardioversion failed in 18 patients mostly in atrial fibrillation. Eight serious complications (7,8%) occurred including 1 sinus node dysfunction, 1 pulmonary oedema, 1 metrorrhagia, 2 stroke, 1 pulmonary embolism. Two patients with ventricular tachycardia died of end-stage heart failure and aftermath of a mitral valve surgery.

CONCLUSION

Direct current cardioversion is effective and safe in our practice. Complications are predominantly due to the medical environment such as antiarrhythmic drugs use or clinical conditions.

Acute pulmonary edema after cardioversion of cardiac arrhythmias

OBJECTIVE

To examine the occurrence of acute pulmonary edema after cardioversion of arrhythmias.

METHODS

Cases, case series, and related articles on the subject identified through a comprehensive literature search were examined.

RESULTS

Thirty cases (23 males) of post cardioversion acute pulmonary edema were identified. The mean age was 53.8 +/- 13 years (range, 18 to 75 years). Underlying arrhythmias were atrial fibrillation (69%), atrial flutter (24%), supraventricular tachycardia (4%), and ventricular tachycardia (4%). The duration of arrhythmia preceding cardioversion varied widely ranging from 1 day to 13 years. Twenty-six (87%) patients had concomitant cardiovascular disease comprising of coronary artery disease (38%), rheumatic heart disease (23%), cardiomyopathy (23%), and hypertension (8%). Direct current electrical cardioversion was used in 28 (93%) patients and pacing in two (7%) patients. Occurrence of pulmonary edema was independent of the amount of energy used for cardioversion (range 20 to 1280 Joules, mean 263 +/- 27 Joules). Short acting general anesthetic drugs were administered in 14 (47%) and sedation in eight (27%) patients. Sinus rhythm was established in 23 (77%) patients. Duration to develop pulmonary edema after cardioversion was available in 23 patients and ranged from immediately to 96 h. Pulmonary edema occurred within 15 min after cardioversion in 22%, within 3 h in 30%, within 24 h in 30%, within 48 h in 17% and within 96 h in remaining 4% of patients. Three patients required mechanical ventilation.

CONCLUSION

The rare complication of acute pulmonary edema after cardioversion has been reported mostly in patients with underlying cardiac disease, and is independent of the amount of energy used for cardioversion.

Restrictive Cardiomyopathy With Right-Sided Dominant Heart Failure After Sinus Conversion From Atrial Fibrillation-Case Report-

A 44-year-old woman with restrictive cardiomyopathy showed right-sided dominant heart failure after conversion to sinus rhythm from paroxysmal atrial fibrillation (AF). During cardiac catheterization, the hemodynamics were compared before and after cardioversion; that is, with AF and with sinus rhythm. The hemodynamic parameters worsened after conversion to sinus rhythm, with a significant decrease in heart rate, but improved with atrial pacing. Pacemaker implantation was performed to avoid bradycardia while keeping the sinus rhythm with amiodarone. As a result, the patient has been free from symptoms of heart failure for almost 1 year and her serum brain natriuretic peptide level also improved remarkably.

Acute pulmonary edema after successful electrical cardioversion of atrial fibrillation

Acute pulmonary edema is a rarely reported complication of electrical cardioversion. Most of such cases have been reported after cardioversion of atrial fibrillation. Most of the patients who have been reported to develop postcardioversion acute pulmonary edema had hypertensive or valvular heart disease. We report a case of postcardioversion acute pulmonary edema after electrical cardioversion of atrial fibrillation in a patient with severe mitral regurgitation.

Pulmonary edema after cardioversion for paroxysmal atrial flutter: left ventricular diastolic dysfunction induced by direct current shock

This report describes a patient with the pulmonary edema after cardioversion for paroxysmal atrial flutter without organic heart disease. A 68-year-old man was admitted to hospital for paroxysmal atrial flutter. Antiarrhythmic agents were not effective, and direct current cardioversion was performed on the 4th hospital day. Three hours after cardioversion, the patient complained of dyspnea, and a chest X-ray showed pulmonary edema. He responded to oxygen, intravenous furosemide and drip infusion of nitroglycerine. During tapering of the medication, his condition remained stable. The patient was discharged on the 7th day after admission. Echocardiographic findings indicated that transient left ventricular diastolic dysfunction due to direct current shock was the most likely cause of the lung edema.