Use of biphasic electrical cardioversion for treatment of idiopathic atrial fibrillation in two horses

Intravenous administration of quinidine and metoprolol for treatment of atrial fibrillation in 2 neonatal foals

Atrial fibrillation (AF) is a rarely reported arrhythmia in otherwise healthy newborn foals, with a single case of cardioversion using procainamide administration described in the literature. Two neonatal Thoroughbred colts were presented to an equine hospital because of an irregularly irregular tachyarrhythmia and poor latching when trying to nurse. History, physical examination, and initial diagnostic testing including ECG and echocardiography confirmed AF without structural heart disease. The 1st foal converted into normal sinus rhythm after treatment with IV metoprolol and quinidine. The 2nd foal converted to normal sinus rhythm after a single IV dose of metoprolol, intended for rate control. Demeanor and nursing behavior improved markedly after conversion. The 2 foals had normal heart rates and sinus rhythm that persisted for 6 weeks until euthanasia in the 1st foal and for 2 years in the 2nd foal. Rate control and cardioversion should be considered as a treatment for persistent lone AF in neonatal foals.

Cloning and Sequencing of Equine Cardiac Troponin I and Confirmation of Its Usefulness as a Target Analyte for Commercial Troponin I Analyzers

The analysis of cardiac troponin I (cTnI) in the diagnosis of myocardial injury in domestic animals is gaining popularity. In this study, equine cTnI was sequenced and compared with previously characterized cTnI from other species. A 6-amino-acid N-terminal deletion unique to the horse was identified. This deletion was outside the epitope region of cTnI recognized by most commercial immunoassays and did not affect the ability of a commercial analyzer system to detect recombinant equine cTnI. No function could be ascribed to the deleted portion. These data support the use of commercial analyzers in measuring equine cTnI.

Atrial Fibrillation in Eight New World Camelids

Background

There is limited information on the incidence of clinical signs, concurrent illness and treatment options for atrial fibrillation (AF) in New World Camelids (NWC).

Objective

Describe clinical signs and outcome of AF in NWC.

Animals

Eight New World Camelids admitted with AF.

Methods

A retrospective observational study of camelids diagnosed with AF based on characteristic findings on electrocardiogram (ECG).

Results

All animals had an irregularly irregular heart rhythm detected on physical examination and 4 cases had obtunded mentation on admission. Three camelids were diagnosed with AF secondary to oleander intoxication, 3 animals had underlying cardiovascular disease, 1 was diagnosed with lone AF and 1 had AF diagnosed on examination for a urethral obstruction. Five of eight animals survived to discharge and nonsurvivors consisted of animals which died or were euthanized as a result of cardiovascular disease (2/8) or extra‐cardiac disease unrelated to the AF (1/8).

Conclusions and Clinical Importance

Atrial fibrillation occurs in NWC in association with cardiovascular disease, extra‐cardiac disease or as lone AF. Amiodarone and transthoracic cardioversion were attempted in one llama with lone AF, but were unsuccessful. Atrial fibrillation was recorded in 0.1% of admissions.

The diagnosis and management of atrial fibrillation in the horse

Atrial fibrillation is the most common performance-limiting arrhythmia in the horse. Detailed cardiovascular evaluation will help guide prognosis and treatment. Many affected horses have lone atrial fibrillation (no predisposing cardiac abnormalities). These horses have a good prognosis for return to performance if sinus rhythm can be restored. The main therapeutic option continues to be quinidine, which has been used for over 60 years. Transvenous electrical cardioversion has proven to be a successful alternative. Other therapeutic options are being explored, but are currently limited.

Cardiovascular responses to transvenous electrical cardioversion of atrial fibrillation in anaesthetized horses

OBJECTIVE

To examine the influence of direct current shock application in anaesthetized horses with atrial fibrillation (AF) and to study the effects of cardioversion to sinus rhythm (SR).

STUDY DESIGN

Prospective clinical study.

ANIMALS

Eight horses successfully treated for AF (transvenous electrical cardioversion after amiodarone pre-treatment).

METHODS

Cardioversion catheters and a pacing catheter were placed under sedation [detomidine 10 microg kg(-1) intravenously (IV)]. After additional sedation (5-10 microg kg(-1) detomidine, 0.1 mg kg(-1) methadone IV), anaesthesia was induced with ketamine, 2.2 mg kg(-1) and midazolam, 0.06 mg kg(-1) (IV) in a sling and maintained with isoflurane in oxygen. Flunixin meglumine, 1.1 mg kg(-1), was administered IV. Shocks were delivered as biphasic truncated exponential waves, synchronized with the R-wave of the electrocardiogram. Monitoring included pulse oximetry, electrocardiography, capnography, inhalational anaesthetic agent concentration, arterial blood pressure, LiDCO and PulseCO cardiac index (CI) and arterial blood gases. Values before and after the first unsuccessful shock and before and after cardioversion to SR were compared.

RESULTS

Values before the first shock were comparable to reported values in healthy, isoflurane anaesthetized horses. Reliable CI measurements could not be obtained using the PulseCO technique. Intermittent positive pressure ventilation was required in most horses (bradypnea and/or PaCO(2) >8 kPa, 60 mmHg), while dobutamine was administered in two horses (0.3-0.5 microg kg(-1) minute(-1)). After the 1st unsuccessful shock application, systolic arterial pressure (SAP) was decreased (p = 0.025), other recorded values were not influenced (CI measurements not available for this analysis). SR was associated with increases in CI (p = 0.039) and stroke index (p = 0.002) and a decrease in SAP (p = 0.030).

CONCLUSIONS AND CLINICAL RELEVANCE

Despite the presence of AF, cardiovascular function was well maintained during anaesthesia and was not affected by shock application. Cardiac index and stroke index increased and SAP decreased after cardioversion.

Complications in equine anesthesia

General anesthesia of horses entails considerable risk of morbidity and mortality. A large-scale, multicenter study reported that the death rate from non-colic-related anesthetics was 0.9%, while the perianesthetic mortality rate at a single, busy equine surgical practice was somewhat more favorable, at 0.12%. While any perianesthetic death is devastating, mortality figures alone do not reflect the overall morbidity of equine anesthesia in terms of nonterminal events or injuries related to recovery. In some circumstances, recognition of perianesthetic complications may allow appropriate intervention to prevent the complication from worsening or progressing to mortality. This article describes some of the complications that may occur during and after general anesthesia of horses, and suggests ways to prevent or mitigate them.

Use of propafenone for conversion of chronic atrial fibrillation in horses

OBJECTIVE

To investigate effects of IV administration of propafenone for naturally occurring and experimentally induced chronic atrial fibrillation in horses.

ANIMALS

2 horses with naturally occurring atrial fibrillation and 4 horses with pacing-induced atrial fibrillation.

PROCEDURES

Horses received a bolus of propafenone (2 mg/kg, IV over 15 minutes). If atrial fibrillation persisted after 20 minutes, a continuous infusion of propafenone (7 microg/kg/min) was given for 120 minutes. Before, during, and after treatment, plasma propafenone concentrations, hematologic and serum biochemical values, and electolyte concentrations analyses were determined and clinical signs were monitored. Surface ECGs were recorded. If propafenone treatment failed, quinidine sulfate was administered.

RESULTS

Bolus and continuous infusion induced minimal adverse effects. During the 15-minute bolus administration, a slight increase in heart rate was observed and horses appeared more sensitive to external stimuli. Throughout treatment, no significant changes were observed in respiratory rate, QRS or corrected QT duration, or results of hematologic analyses. Although a significant increase in F-wave interval and atrial fibrillation cycle length was observed and plasma propafenone concentrations (569 to 1,268 ng/mL) reached the human therapeutic range (64 to 1,044 ng/mL), none of the horses cardioverted to sinus rhythm. Sinus rhythm could be restored in all horses via standard oral administration of quinidine.

CONCLUSIONS AND CLINICAL RELEVANCE

A slow IV bolus of 2 mg of propafenone/kg followed by a continuous infusion of 7 microg/kg/min over 2 hours was not an effective treatment for chronic atrial fibrillation in horses.

Management and complications of anesthesia for transvenous electrical cardioversion of atrial fibrillation in horses: 62 cases (2002-2006)

OBJECTIVE

To describe management of anesthesia for transvenous electrical cardioversion (TVEC) in horses and report perianesthetic complications.

DESIGN

Retrospective case series.

ANIMALS

62 horses with atrial fibrillation and without underlying cardiac disease and 60 horses without atrial fibrillation.

PROCEDURES

Medical records of horses with atrial fibrillation anesthetized for TVEC were reviewed, as were records of horses without atrial fibrillation anesthetized for magnetic resonance imaging (MRI). The TVEC group horses were compared with MRI group horses for incidence of intraoperative bradycardia and use of inotropic drugs. Data obtained included patient signalment, weight, duration of anesthesia, heart rate and arterial blood pressure during anesthesia, anesthetic drugs administered, mode of ventilation, perioperative complications, and quality of recovery.

RESULTS

The TVEC group horses were > 1 year of age and were predominantly Standardbreds. The TVEC group horses underwent a total of 76 anesthetic episodes. For 40 (52.6%) anesthetic episodes, horses received xylazine only for premedication, and for 26 (34.2%) anesthetic episodes, horses received xylazine and butorphanol. Induction of anesthesia consisted of ketamine administration in various combinations with diazepam and guaifenesin for 74 (97.4%) anesthetic episodes and ketamine alone for 2 (2.6%). Bradycardia in horses was encountered during 15 of 76 (19.7%) anesthetic episodes. Minor signs of possible postanesthetic myopathy occurred following 6 (7.9%) anesthetic episodes. No significant difference was found between TVEC and MRI group horses regarding incidence of bradycardia and inotropic drug administration.

CONCLUSIONS AND CLINICAL RELEVANCE

Short-duration anesthesia for TVEC of atrial fibrillation in horses without underlying cardiac disease was a safe procedure.

Transvenous electrical cardioversion of atrial fibrillation in six horses using custom made cardioversion catheters

Pharmacological conversion of atrial fibrillation (AF) to sinus rhythm in horses can be difficult. The objective of this study was to investigate the feasibility of transvenous electrical cardioversion with custom made catheters in eight horses, of which three had failed cardioversion using quinidine sulfate. Two cardioversion catheters and one pacing/sensing electrode were inserted via the right jugular vein and placed using ultrasound guidance into the left pulmonary artery, the right atrium and the right ventricle, respectively. Because immediate recurrence of AF was encountered in the second horse treated, pre-treatment with amiodarone was given to each of the remaining six horses. Induction of general anaesthesia was associated with dislocation of the cardioversion catheter in three horses, requiring a second catheterisation procedure. During general anaesthesia, biphasic R wave synchronised shocks of up to 360 J were delivered between both cardioversion electrodes. In six horses (75%), including two which had failed quinidine sulfate treatment, sinus rhythm was restored with a mean energy level of 295+/-62 J. No side effects were observed. Blood analysis 3 h after cardioversion revealed normal parameters, including cardiac troponin I values. Transvenous electrical cardioversion of atrial fibrillation with custom made cardioversion catheters can be considered as a treatment option for atrial fibrillation in horses, especially when conventional drugs fail.

Serum and plasma cardiac troponin I concentrations in clinically normal Thoroughbreds in training in Australia

Cardiac troponin I is a potentially useful test to identify cardiac muscle damage in the horse. Measurements of cardiac troponin I from serum or heparinised plasma samples from 23 clinically normal Thoroughbred horses in race training were analysed through a standard Australian commercial laboratory using the ADVIA Centaur Assay. The cardiac troponin I concentrations were < 0.15 microg/L from all samples. The test was then validated using macerated equine myocardium. Cardiac troponin I concentration may be useful in determining whether poor performance in Thoroughbred horses is related to active myocardial disease.

How to perform transvenous electrical cardioversion in horses with atrial fibrillation

Electrical cardioversion of atrial fibrillation is a well-established technique for restoration of sinus rhythm in humans. While transthoracic cardioversion is more commonly used, transvenous electrical cardioversion (TVEC) has been reported as having higher efficacy at substantially lower energy levels. In horses, treatment of atrial fibrillation has essentially been limited to the administration of quinidine salts either orally or intravenously. TVEC provides an alternative to quinidine salts, especially for those animals in which quinidine is neither effective nor tolerated. The present report details this technique in horses, discusses possible complications of the procedure, and provides guidance for successful outcome. Still and video images are used to illustrate details with regard to TVEC techniques in horses. Please view supplemental material for the videos.

Transient complete atrioventricular block following transvenous electrical cardioversion of atrial fibrillation in a horse

Transvenous electrical cardioversion was attempted in a horse with drug refractory atrial fibrillation. A temporary pacing catheter and two defibrillation catheters were inserted transvenously into the right ventricular apex, the right atrium and the pulmonary artery, respectively. Under general anaesthesia 100, 200, 300 and 360 J monophasic shocks were delivered between both defibrillation catheters but sinus rhythm could not be restored. Immediately after the 200, 300 and 360 J shock, transient third-degree atrioventricular block occurred for a period of, respectively, 15, 40 and 55 s. These periods of profound bradycardia were corrected by temporary right ventricular pacing until spontaneous conduction resumed. It is concluded that temporary right ventricular pacing should be available during electrical cardioversion of atrial fibrillation in horses.

Management of atrial fibrillation

Atrial fibrillation (AF) is the most common clinically important arrhythmia in veterinary medicine. Electrical cardioversion of AF to sinus rhythm is feasible, but pharmacologic rate control is an effective and achievable treatment strategy for most veterinary patients. Recent human trials suggest that rate control and rhythm control are almost equally beneficial. Nevertheless, AF can be a challenging arrhythmia to manage, because most affected animal shave numerous other concurring problems associated with the underlying heart disease that dictate or influence the clinician's choice of treatment and monitoring strategy for each patient.