Outpatient oesophageal-precordial electrical cardioversion of atrial fibrillation: an effective and safe technique to restore sinus rhythm

A dedicated cardioversion unit for the treatment of atrial fibrillation. Reducing costs by optimizing processes

BACKGROUND

Atrial fibrillation (AF) is the most frequent arrhythmia seen in man. Many patients are admitted to the hospital to undergo transesophageal echocardiography (TEE) for thrombus exclusion and subsequent electrical cardioversion (ECV) under deep sedation to restore sinus rhythm. The present study investigated prospectively how workflow optimization can contribute to reducing time and costs in AF patients scheduled for ECV in an outpatient setting.

METHODS

A cardioversion unit (CU) was established and equipped to perform all ECV-associated procedures. Between November 2007 and January 2009, ECV was performed in 115 patients in an outpatient setting. Three different settings were tested for ECV: (1) usual care (n = 19): preparation/follow-up in the outpatient clinic, blood testing in the central hospital laboratory (CHL), TEE in the echocardiography laboratory, and ECV in the intensive care unit; (2) optimized process 1 (n = 41): preparation/follow-up, TEE + ECV during one sedation in the CU, blood testing in the CHL; (3) optimized process 2 (n = 55): preparation/follow-up, TEE + ECV and point of care (POC) blood testing in the CU. All procedure-related costs were listed and classified according to material, human resources, and infrastructure.

RESULTS

From setting 1 to 3, there was a significant decrease in procedural time from 480 ± 105 min to 205 ± 85 min (p < 0.001). Likewise, ECV-associated costs could be reduced from 683 ± 104 <euro> to 299 ± 63 <euro> (p < 0.001).

CONCLUSION

Establishing a CU for AF enables a more than 50% reduction in procedural time and costs. A combination of TEE and ECV in one sedation and POC testing in the CU were the major contributors to this time and cost reduction.

Esophageal electrical cardioversion of atrial fibrillation: when esophagus gives a help to cardiologists

Atrial fibrillation is a common clinical disease especially in the elderly and in patients with organic heart disease. Electrical cardioversion is the first choice therapeutic approach for patients in which sinus rhythm could improve the quality of life and where the maintenance of sinus rhythm is considered likely. There are different techniques to perform an electrical cardioversion, each with specific indications, advantages, and limitations. The method most frequently used to restore sinus rhythm is external direct current cardioversion; however, this technique has some disadvantages, since it requires a high energy and usually general anesthesia. Esophageal cardioversion is an alternative method to obtain restoration of sinus rhythm, warranting acute and long-term results absolutely comparable with those obtained by the conventional transthoracic technique, especially in obese and COPD patients with high thoracic impedance for whom the standard technique may be less effective.

Present concepts in management of atrial fibrillation: From drug therapy to ablation

Atrial fibrillation (AF) management requires knowledge of its pattern of presentation, underlying conditions, and decisions about restoration and maintenance of sinus rhythm, control of the ventricular rate, and anti-thrombotic therapy. Maintenance of sinus rhythm is a desirable goal in AF patients because the prevention of recurrence may improve cardiac function, relieve symptoms and reduce the likelihood of adverse events. Anti-arrhythmic drug therapy is the first-line treatment for patients with paroxysmal and persistent AF based on current guidelines. However, currently used drugs have limited efficacy and cause cardiac and extracardiac toxicity. Thus, there is a continued need to develop new drugs, device and ablative approaches to rhythm management. Additionally, simpler and safer stroke prevention regimens are needed for AF patients on life-long anticoagulation, including occlusion of the left atrial appendage. The results of the Randomized Evaluation of Long-Term Anticoagulant Therapy study are encouraging in these settings. Knowledge on the pathophysiology of AF is rapidly expanding and identification of focally localized triggers has led to the development of new treatment options for this arrhythmia. Conversely, the clinical decision whether to restore and maintain sinus rhythm or simply control the ventricular rate has remained a matter of intense debate. In the minority of patients in whom AF cannot be adequately managed by pharmacological therapy, the most appropriate type of non-pharmacological therapy must be selected on an individualized basis. Curative treatment of AF with catheter ablation is now a legitimate option for a large number of patients. The evolution of hybrid therapy, in which two or more different strategies are employed in the same patient, may be an effective approach to management of AF. In any case, planning a treatment regimen for AF should include evaluation of the risks inherent in the use of various drugs as well as more invasive strategies.

Transthoracic versus transesophageal cardioversion of atrial fibrillation under light sedation: a prospective randomized trial

BACKGROUND

Electrical cardioversion (ECV) of atrial fibrillation (AF) is limited by a 5-10% failure rate and by the expense arising from a perceived need for general anesthesia. A transesophageal approach using light sedation has been proposed as a means of augmenting the success rate and avoiding the need for general anesthesia. We hypothesized that the high rate of success and the lower energy requirement associated with biphasic cardioversion might eliminate any advantage of the transesophageal approach.

METHODS

We randomly assigned 60 patients attending for ECV of persistent AF to a transesophageal or a transthoracic approach. Sedation of moderate depth was achieved with intravenous midazolam. The dose of midazolam was titrated in the same manner in both groups.

RESULTS

Sinus rhythm was restored in 29/30 patients (97%) in each group using a similar number of shocks for both groups (1.3 +/- 0.6 transesophageal vs 1.4 +/- 0.7 transthoracic, P = NS) with a similar procedure duration (14.1 +/- 8.2 minutes vs 13.8 +/- 7.5 minutes, P = NS). Both groups received similar doses of midazolam (4.2 +/- 2.7 mg vs 4.4 +/- 2.8 mg, P = NS) and both reported a similar discomfort score in (0.9 +/- 1.3 vs 1.1 +/- 1.8, P = NS). No complication occurred in either group.

CONCLUSION

AF may be cardioverted safely and effectively by either a transthoracic or a transesophageal approach. The use of sedation of moderate depth renders cardioversion by either approach acceptable. As transesophageal ECV shows no clear advantage, transthoracic cardioversion should remain the approach of first choice.