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Atrial fibrillation recurrence after internal cardioversion: prognostic importance of electrophysiological parameters
M Biffi1, G Boriani, M Bartolotti
1Institute of Cardiology, University of Bologna, Bologna, Italy. mbiffi@orsola-malpighi.med.unibo.it
Insights
Internal atrial cardioversion can restore sinus rhythm (SR) in chronic atrial fibrillation (AF) patients. Electrophysiological study identifies patients at high risk for AF recurrence, guiding long-term management.
Area of Science:
- Cardiology
- Electrophysiology
Background:
- Chronic atrial fibrillation (AF) often requires interventions beyond external cardioversion.
- Internal atrial cardioversion offers an alternative for patients with persistent AF.
Purpose of the Study:
- To identify clinical and electrophysiological factors predicting arrhythmia recurrence after internal atrial cardioversion for chronic AF.
- To assess the long-term efficacy of internal atrial cardioversion and antiarrhythmic therapy.
Main Methods:
- 101 patients with chronic AF underwent internal atrial cardioversion.
- Electrophysiological studies were performed in 73 patients to assess atrial refractoriness.
- Patients were followed on antiarrhythmic treatment.
Main Results:
- Internal atrial cardioversion achieved 100% initial conversion to sinus rhythm (SR).
- AF recurrence was predicted by longer AF duration and lower sinus rate at discharge.
- Shorter atrial effective refractoriness and abnormal refractoriness-cycle length relation predicted recurrence.
Conclusions:
- Internal atrial cardioversion combined with antiarrhythmic drugs can maintain SR long-term.
- Electrophysiological parameters are crucial for identifying patients at high risk of recurrence.
- Even patients with AF > 3 years may benefit, though recurrence is more likely.
Objective:
To evaluate the clinical and electrophysiological determinants of arrhythmia recurrence in patients undergoing internal atrial cardioversion for chronic atrial fibrillation (AF).
Setting:
Tertiary cardiac referral centre.
Methods:
101 consecutive patients with failed external cardioversion or AF > or = 1 year underwent internal atrial cardioversion; once stable sinus rhythm (SR) was obtained, electrophysiological study was performed in 73 patients (72%) who gave informed consent. Patients were then followed on antiarrhythmic treatment.
Results:
101 consecutive patients underwent internal atrial cardioversion in the period 1996-1999 with 100% conversion to SR; prophylactic antiarrhythmic treatment was flecainide (52%), amiodarone (37%), and sotalol (11%). Average follow up at first AF recurrence was 18.4 (14.4) months (range 0.1-49.8 months); persistence of SR was observed in 72/101 (72%) patients. By logistic regression, AF duration (odds ratio (OR) 1.07, 95% confidence interval (CI) 1.01 to 1.13) and a lower sinus rate at discharge on antiarrhythmic drugs (OR 0.92, 95% CI 0.85 to 0.99) were independent predictors of AF recurrence, whereas age, New York Heart Association functional class, left atrial dimensions, and left ventricular ejection fraction were not predictive of arrhythmia recurrence. When electrophysiological parameters were added to the statistical model in 73 patients, a shorter atrial effective refractoriness (OR 1.04, 95% CI 1 to 1.08) and an abnormal relation of atrial effective refractoriness to cycle length (OR 31, 95% CI 3.7 to 266) were also independent predictors of AF recurrence at follow up, beyond AF duration and heart rate at discharge.
Conclusions:
Patients with failed external cardioversion or long lasting AF may benefit from internal atrial cardioversion and antiarrhythmic treatment to keep SR at long term; electrophysiological study may identify patients at the highest risk of arrhythmia recurrence. Although preservation of SR seems unlikely for AF duration > 3 years, a consistent minority of this subgroup (38%) may benefit from this approach.