Factors related to the early and late success of direct current cardioversion of chronic nonrheumatic atrial fibrillation: An echocardiographic study.
Marco SzulcHubert GurbaAgnieszka Kuch‐WocialPiotr PruszczykZ MiśkiewiczI ChlewickaJ StanisławskaA GóreckiGrazyna ŚwiěcickaGrzegorz OpolskiAdam Torbicki
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Abstract:
To assess factors related to the success of restoration and one-year maintenance of sinus rhythm in chronic (more than 48 h) nonrheumatic atrial fibrillation (AF).One hundred and fifty consecutive patients aged 62+/-9 years with AF lasting 123+/-254 days were evaluated clinically with transthoracic and transesophageal echocardiography before elective direct current cardioversion. Heart chamber dimensions and left ventricular ejection fraction were measured. The presence of left atrial thrombi and spontaneous echocardiographic contrast as well as flow velocities in the left atrial appendage were assessed. The first cardioversion was followed by standardized two-step antiarrhythmic treatment including a second cardioversion, if necessary. Twenty patients (13%) spontaneously reverted to sinus rhythm (S) during anticoagulation preceding cardioversion, 81 (54%) were successfully cardioverted (Y), and in 49 (33%) cardioversion failed initially (N). No differences were noted between the two latter groups. However, S patients had smaller left atria measured in the short and long axes (42+/-4 mm, P=0.05, and 53+/-7 mm, P=0.005, respectively) than both the Y (45+/-4 and 61+/-8 mm) and the N patients (46+/-4 and 61+/-8 mm). One-year follow-up was obtained in 95 patients: 64 (67%) were in sinus rhythm while 31 (33%) had AF. Again, no initial differences predicting the maintenance of sinus rhythm were found.Spontaneous reversion of AF seems more likely with smaller left atria. Echocardiography, including trans-esophageal echocardiography, is unlikely to identify patients in whom attempts to restore and maintain sinus rhythm will fail or succeed.Cite
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A key procedure of the rhythm control strategy in atrial fibrillation (AF) is cardioversion to normal sinus rhythm. The aim of the present study was to provide a review of treatment patterns for the cardioversion of patients with AF in a hospital setting in Poland and document the success rate of various cardioversion procedures.We herein present the results from Poland of a prospective observational study to characterize patients with recent onset episodes of AF for whom cardioversion is one of the planned therapeutic options - the RHYTHM-AF registry. Consecutive patients in the hospital setting, age > 18 years, with documented AF at the time of enrollment, excluding those with atrial flutter and those treated with vernakalant, were recruited. No treatment was recommended nor discouraged.Five hundred and one patients were recruited (mean age 64.2 ± 12.1), with 294 (58.7%) patients finally undergoing cardioversion. Primary electrical cardioversion (ECV) was successful in 131 (88.5%) patients. Primary pharmacological cardioversion (PCV) was successful in 110 (75.3%) patients. Amiodarone and propafenone were most commonly used (52.1% and 24.7%, respectively). Fourteen complications and adverse events were recorded (no stroke was observed).Conversion to sinus rhythm was attempted in < 60% of the patients with AF admitted to the hospital with an intention to terminate arrhythmia. ECV was successful in ~90% of the patients, while PCV in ~75% of the patients (amiodarone and propafenone were most commonly used). The rate of complications was low (2.8%).
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Our aim was to determine the immediate and long-term outcome of direct current (DC) electrical cardioversion in patients with atrial fibrillation or flutter, and to determine factors predicting clinical outcome.A retrospective one-year follow-up study of 220 patients with atrial fibrillation or flutter undergoing electrical cardioversion between September 1998 and April 2001 was done.Electrical cardioversion was successful in 82% of the patients. Multivariate analysis revealed that female gender was associated with successful cardioversion (p=0.008). Only 29% remained in sinus rhythm after the one-year follow-up. Maintenance of sinus rhythm was associated with anti-arrhythmic drug treatment (p=0.042). Relapse of atrial fibrillation was associated with reduced left ventricular ejection fraction (p=0.002). Complications occurred in 7.7% of the electrical cardioversions; of these, 1.2% were thromboembolic events.Less than one third of the patients remained in sinus rhythm after the one-year follow-up despite the use of anti-arrhythmic drugs. Electrical cardioversion is not without risk. Thorough consideration of choice of treatment in patients with atrial fibrillation or flutter is therefore important. According to Danish and international guidelines, electrical cardioversion should be considered primarily when symptoms of AF are unacceptable despite optimal frequency regulation or in patients with AF detected for the first time.
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Electrical cardioversion
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The aim of this study is to analysis the relationship of clinical variables to the recurrence of atiral fibrillation after cardioversion to optimize the indication for rhythm control. Retrospective study analysed medical records of the atrial fibrillation patients who have undergone cardioversion from 2000 to 2002. The univariate and multivariate associations of immediate efficacy of cardioversion and long-term results with clinical variables were analyzed. Results: 386 patients who had undergone pharmacological cardioversion or electrical cardioversion were enrolled. Almost half of the patients relapsed within 1 week after successful cardioversion. At the end of one year follow-up, 135 patients (35%) recovered from atrial fibrillation. There were no significant difference between the recurrence group and unrecurrence group in age, heart disease and the methodology of cardioversion. The predictors for the recurrence of atrial fibrillation were diameter of the left atrium ≥50mm(OR=1.86, 95%CI 1.02-3.69, P=0.0472),pre-cardioversion duration ≥7 days (OR=2.08, 95%CI 1.19-3.65, P= 0.01) and the duration of atrial fibrillation (OR=1.77, 95%CI 1.01-3.06, P= 0.0456). Conclusions:The enlargement of left atrium and long duration of atrial fibrillation before cardioversion show less successful rate and more recurrence in the future
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An immediate recurrence of atrial fibrillation (IRAF) appears to be more common after early restoration of sinus rhythm with an implantable atrial defibrillator than after elective transthoracic cardioversion, which suggests that the probability of IRAF may be related to the duration of AF.Transthoracic cardioversion was performed 85 +/- 187 days (range 7 minutes to 8 years) after the onset of atrial fibrillation in 315 patients (mean age 61 +/- 13 years). IRAF was defined as a recurrence of AF within 60 seconds after restoration of sinus rhythm. IRAF occurred in 56% of patients when cardioversion was performed within 1 hour of the onset of AF compared with 12% of patients when cardioversion was performed after 24 hours of AF (P < 0.001). The duration of AF was the only independent predictor of IRAF among the clinical variables of age, gender, structural heart disease, antiarrhythmic drug therapy, and cardioversion energy (P < 0.01).IRAF is more likely to occur when the duration of AF is <1 hour than when the duration is >24 hours. This observation has clinical implications for the most appropriate timing of cardioversion, particularly in patients who receive device therapy for AF.
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To analyse the safety and impact on maintenance of sinus rhythm of transoesophageal echocardiographically guided early cardioversion associated with short-term anticoagulation in a large series of patients with atrial fibrillation and atrial flutter. Patients who were candidates for cardioversion were eligible for inclusion if they had atrial fibrillation or atrial flutter lasting longer than 2 days or of unknown duration. Patients received short-term anticoagulation with warfarin or heparin and underwent transthoracic echocardiography followed by transoesophageal echocardiography. Early cardioversion was performed if no thrombus was seen on the transoesophageal study. Warfarin was maintained for 1 month after cardioversion. In patients with atrial thrombi, cardioversion was deferred and prolonged anticoagulation was prescribed. The study population included 183 patients. One hundred and sixty nine patients without atrial thrombi underwent early cardioversion. Fourteen patients with atrial thrombi (7·6%) underwent a second transoesophageal echocardiogram after a median of 4 weeks of oral warfarin, and cardioversion was performed if clot regression was documented. No patient in our study population had a clinical thromboembolic event at 1 month follow-up (95% C.I. 0–0·016). The immediate success rate of cardioversion was better among patients with atrial fibrillation <4 weeks duration compared with patients with atrial fibrillation of longer or of unknown duration: 96·6% vs 85%, respectively ( P =0·014). At 1 month follow-up, the percentage of arrhythmia relapses in patients with initially successful cardioversion was similar in the two groups (29% vs 26%, P =ns); thus the initial better outcome in patients with recent-onset arrhythmia was not lost. Transoesophageal echocardiography-guided early cardioversion in concert with short-term anticoagulation is safe. This approach permits abbreviation of the overall duration of atrial fibrillation and has a better impact on the maintenance of sinus rhythm for patients in whom the duration of atrial fibrillation is <4 weeks.
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Objective
To analyze the effect and influencing factor of cardioversion on atrial fibrillation or atrial flutter and the factors affecting the success of cardioversion in patients after heart valve surgery.
Methods
Ninety-one patients with atrial fibrillation or atrial flutter treated with cardioversion after heart valve surgery in Nanjing Gulou Hospital from January 2011 to June 2014 were retrospectively analyzed. Under intensive care unit (ICU) ECG monitoring, patients received synchronous cardioversion with bi-directional wave energy of 100 J -150 J after general anesthesia. Successful patients received oral amiodarone for 3 months. The immediate success rate of cardioversion and the sinus rhythm stability rate of follow-up for 1 to 6 months were counted. The patients were divided into two groups according to whether the cardioversion was successful or not: the successful cardioversion group and the unsuccessful cardioversion group, and the influencing factors that might affect the immediate success of cardioversion were analyzed.
Results
Among 91 patients, 39 were males and 52 were females, ranging in age from 26 to 76 years, with an average age of (54.3+ 11.1) years. Seventy-five patients (82.4%) immediately converted to sinus rhythm, and 64 patients (85.3%) maintained sinus rhythm after 1 to 6 months of follow-up. Low NYHA class, low BNP level, small left atrial diameter, atrial flutter and short duration of atrial fibrillation before surgery had higher success rate of cardioversion, but the operation method and the time distance between surgery and cardioversion had no significant effect on the success of cardioversion. Univariate and multivariate logistic regression analyses showed that left atrial diameter is an independent predictor of successful cardioversion.
Conclusion
Cardioversion is an effective method for patients with atrial fibrillation or flutter after cardiac valve surgery. Left atrial diameter before cardioversion is an independent predictor of successful cardioversion.
Key words:
Heart valvular disease; Atrial fibrillation; Atrial flutter; Cardioversion
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Although the high rate of success after cardioversion, less than 50% of patients maintain sinus rhythm for the first year. In view for the high percentage of relapse into atrial fibrillation, it is interesting to analyze the relationship between atrial stunning after cardioversion and relapse into atrial fibrillation. Thus, we evaluated 101 patients with atrial fibrillation and successful cardioversion. Atrial mechanical function was assessed by measures of transmitral peak A wave velocity, determined before and weekly after cardioversion during 1 month. Fifty-five percent of patient relapse into atrial fibrillation during follow-up. No significant differences were found in clinical and echocardiographic variables between the group with and without relapse. However, the group of patients who relapsed into atrial fibrillation showed a lower peak A wave velocity immediately after cardioversion than patients who maintain in sinus rhythm at month (0.44 T0.27 vs. 0.60 T0.38 m/s p<0.01). Impaired atrial function improves during the first 14 days after cardioversion. D 2005 Elsevier Ireland Ltd. All rights reserved.
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