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      Intracardiac Low-Energy versus Transthoracic High-Energy Direct-Current Cardioversion of Atrial Fibrillation: A Randomised Comparison

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          Abstract

          Of 54 patients with long-standing atrial fibrillation (mean duration 8.3 months), 27 patients were randomised to transvenous low-energy intracardiac biphasic direct-current (DC) cardioversion (ICV) using a single-lead balloon-tipped catheter, and 27 patents were randomised to conventional high-energy transthoracic monophasic DC cardioversion (TCV). ICV was performed with increasing energy levels (7.5–10–12.5–15 J) during mild sedation. TCV was performed with 200–360–360 J during general anaesthesia. Cardioversion to sinus rhythm occurred in 93% (25/27) following ICV and in 67% (18/27) following TCV (p = 0.04). Due to the higher cardioversion rate following ICV, more patients were in sinus rhythm during 180 days of follow-up (log rank test, p = 0.04). Low-energy intracardiac cardioversion represents a highly efficacious alternative to high-energy transthoracic cardioversion.

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          Most cited references 7

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          Facilitating transthoracic cardioversion of atrial fibrillation with ibutilide pretreatment.

          Atrial fibrillation cannot always be converted to sinus rhythm by transthoracic electrical cardioversion. We examined the effect of ibutilide, a class III antiarrhythmic agent, on the energy requirement for atrial defibrillation and assessed the value of this agent in facilitating cardioversion in patients with atrial fibrillation that is resistant to conventional transthoracic cardioversion. One hundred patients who had had atrial fibrillation for a mean (+/-SD) of 117+/-201 days were randomly assigned to undergo transthoracic cardioversion with or without pretreatment with 1 mg of ibutilide. We designed a step-up protocol in which shocks at 50, 100, 200, 300, and 360 J were used for transthoracic cardioversion. If transthoracic cardioversion was unsuccessful in a patient who had not received ibutilide pretreatment, ibutilide was administered and transthoracic cardioversion attempted again. Conversion to sinus rhythm occurred in 36 of 50 patients who had not received ibutilide (72 percent) and in all 50 patients who had received ibutilide (100 percent, P<0.001). In all 14 patients in whom transthoracic cardioversion alone failed, sinus rhythm was restored when cardioversion was attempted again after the administration of ibutilide. Pretreatment with ibutilide was associated with a reduction in the mean energy required for defibrillation (166+/-80 J, as compared with 228+/-93 J without pretreatment; P<0.001). Sustained polymorphic ventricular tachycardia occurred in 2 of the 64 patients who received ibutilide (3 percent), both of whom had an ejection fraction of 0.20 or less. The rates of freedom from atrial fibrillation after six months of follow-up were similar in the two randomized groups. The efficacy of transthoracic cardioversion for converting atrial fibrillation to sinus rhythm was enhanced by pretreatment with ibutilide. However, use of this drug should be avoided in patients with very low ejection fractions.
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            ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology.

             ,  Robert D. Wyse,  L Wann (2001)
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              Biphasic versus monophasic shock waveform for conversion of atrial fibrillation

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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2003
                April 2003
                25 April 2003
                : 99
                : 2
                : 72-77
                Affiliations
                Department of Cardiovascular Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
                Article
                69724 Cardiology 2003;99:72–77
                10.1159/000069724
                12711881
                © 2003 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 3, Tables: 2, References: 24, Pages: 6
                Categories
                Arrhythmias, Electrophysiology and Electrocardiography

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