Unique Treatment of Atrial Fibrillation: Simultaneous Dual Direct-Current Cardioversion in Morbidly Obese Patients

Atrial fibrillation (AFib) is a prevalent arrhythmia associated with substantial health complications and economic strain on the health care system in the United States. Obesity is a challenging comorbidity to manage in this scenario, as the incidence of AFib rises alongside increasing body mass index (BMI). Furthermore, obesity presents several challenges in applying traditional treatment modalities for AFib, such as pharmacological options, ablation, and direct-current cardioversion (DCCV). Currently, there is no specific regimen for treating AFib for morbidly obese patients. This case report describes and discusses a unique treatment option for a morbidly obese patient with poorly controlled AFib. A 43-year-old male with several comorbidities including morbid obesity with a BMI of 87 kg/m² presented with AFib in the setting of sepsis and bacteremia. The patient was treated with increasing doses of metoprolol without effective control of his AFib and had previously received amiodarone as well without appropriate response. DCCV was performed under deep sedation using dexmedetomidine and propofol infusions with careful attention to maintaining spontaneous ventilation. AFib was successfully converted to normal sinus rhythm using dual biphasic DCCV (each at 200 J). Pharmacological treatment of AFib can be challenging in the obese population due to medications and traditional cardioversion being less effective with increasing BMI. The anesthetic plan was of important consideration in this case, given his BMI of 87 kg/m² and the risk for obstruction and potential airway compromise. Nasal continuous positive airway pressure and the use of dexmedetomidine supported airway patency and maintained spontaneous respirations while ensuring adequate depth of anesthesia. Morbidly obese patients likely require increased energy for cardioversion; thus, we describe the effectiveness of using simultaneous dual DCCV with two sets of pads in this patient after an unsuccessful single biphasic shock with 200 J.