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Safety of high energy internal cardioversion for atrial fibrillation
J Mansourati1, J M Larlet, G Salaun
1Brest University Hospital, France.
Insights
High energy internal cardioversion effectively converts atrial fibrillation but carries risks. Careful patient selection, especially for those with hypertrophic cardiomyopathy, is crucial for safe and successful treatment.
Area of Science:
- Cardiology
- Electrophysiology
Background:
- Atrial fibrillation is a common arrhythmia.
- Drug refractory or external cardioversion refractory atrial fibrillation poses treatment challenges.
- High energy internal cardioversion is an alternative therapeutic approach.
Purpose of the Study:
- To evaluate the safety and efficacy of high energy internal cardioversion for atrial fibrillation.
- To identify potential risks and complications associated with this procedure.
Main Methods:
- Retrospective review of 53 patients undergoing 55 sessions of high energy internal cardioversion.
- Shocks delivered ranged from 70-270 Joules.
- Patient outcomes and adverse events were analyzed.
Main Results:
- An 89% success rate in immediate conversion to normal sinus rhythm was observed.
- Complications included transient atrioventricular block (11%), low cardiac output (one fatal case in a patient with severe hypertrophic cardiomyopathy), pericardial effusion, and venous puncture site issues.
- The technique was less optimal in patients with advanced hypertrophic cardiomyopathy.
Conclusions:
- High energy internal cardioversion is effective for atrial fibrillation conversion.
- Caution is advised in patients with advanced hypertrophic cardiomyopathy, limiting shocks and considering external cardioversion first.
- Recommendations include temporary ventricular pacing and pre-discharge echocardiography.
Abstract:
High energy internal cardioversion has been proposed as an alternative method to cardiovert drug refractory or external cardioversion refractory atrial fibrillation. However, the safety of this technique has not been clearly evaluated. We reviewed findings in 53 patients who underwent 55 sessions of high energy internal cardioversion (2 patients underwent 2 sessions) for termination of longstanding atrial fibrillation. Shocks energy varied from 70-270 J. Three patients had 3 shocks during the same session, 5 had 2, and 47 only 1. Success rate was 89% (success was defined as immediate conversion to normal sinus rhythm). Low cardiac output occurred in two patients, and resulted in the death of one of these individuals, a patient with significant hypertrophic cardiomyopathy and heart failure. The other patient recovered completely. In 11% of the cases, shock induced transient atrioventricular block, necessitating ventricular pacing until sinus rhythm was restored. In three patients, a moderate but asymptomatic and uncomplicated pericardial effusion was diagnosed on echocardiogram. Finally, four patients had side effects related to venous puncture, which resolved spontaneously. These results suggest that high energy internal cardioversion is effective for conversion of atrial fibrillation. However, the technique may not be optimal in patients with advanced hypertrophic cardiomyopathy and in such cases the technique should be used carefully and only in the case of failure of external cardioversion; no more than two shocks should be delivered during the same procedure. Temporary ventricular pacing should be provided in all patients and an echocardiogram should be performed before patients are being discharged.