Single shock endocavitary low energy intracardiac cardioversion of chronic atrial fibrillation

Discomfort related to low-energy internal cardioversion (LEIC) represents a real problem in patients (pts) with atrial fibrillation (AF). The aim of our study was to verify if a single shock could restore sinus rhythm (SR) with a lower discomfort for the pt.

Thirty pts with chronic AF were randomized to receive a single 350 V shock (15 pts) or multiple shocks of increasing energy (15 pts). Three leads were positioned, respectively, in the coronary sinus and in the lateral right wall for shock delivery, and in the right ventricular apex for R wave synchronization. Truncated, biphasic shocks were used. In the first group a single 350 V shock was directly delivered and a second 400 V shock was given only if SR has not been restored. In the second group, beginning at 50 volts the voltage was increased in steps of 50 volts until SR restoration. No patient was sedated. After each shock the pts were asked to rate their discomfort on a scale of 1 to 5 (1 = not perceived, 5 = severe discomfort).

SR was restored in all the subjects. In group 1 SR was obtained in 12/15 (80%) pts with the first 350 V (8.1 +/- 0.8 joules) shock, while the remaining 3 patients required the second 400 V (10.2 +/- 0.3 joules) shock. In group 2 the mean atrial defibrillation threshold was 346.7 +/- 1029.7 volts (8.0 +/- 101.5 joules). Then discomfort score was 2.5 +/- 0.6 in group 1 and 3.3 +/- 10.6 in group 2 (p < 0.01).

A single shock of 350 V restores SR in the majority of pts with chronic AF; by use this new approach, LEIC is tolerated better than the multiple shocks step-up protocol.