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Atrial flutter is a supraventricular cardiac arrhythmia commonly characterized by two or three rapid atrial contractions for every ventricular contraction and a rapid ventricular rate that can be identified by a sawtooth pattern on an electrocardiogram. Patients often present with symptoms of heart failure and face the risk of atrial thrombus with a potential for systemic embolization. As such, pharmacologic rate and rhythm control, transesophageal echocardiogram, direct current cardioversion, and anticoagulation therapies may all be required for patient management. This case study provides an example of the patient presentation, exam findings, diagnostic results, and intervention modalities required for the health care provider to manage atrial flutter correctly in the emergency department setting. [ABSTRACT FROM AUTHOR]

BackgroundWith an increasing number of patients undergoing left atrial appendage occlusion (LAAO), more attention is being paid to relieving clinical symptoms and improving the quality of life of these patients. For patients with atrial fibrillation (AF), direct current cardioversion (DCCV) is an alternate, nonpharmacological choice to restore sinus rhythm and relieve clinical symptoms.ObjectivesThe purpose of this study was to assess the feasibility and safety of the DCCV at the time of LAAO for patients with AF.MethodsForty patients were enrolled in the DCCV group undergoing the DCCV at the time of LAAO. The control group undergoing LAAO alone was formed by 1:1 matching.ResultsIn the DCCV group, cardioversion was immediately successful in 30 (75%) patients, of which 12 (40%) had AF recurrence at the three-month follow-up. The failed-DCCV group was older (73.70 ± 4.74 vs. 62.20 ± 9.01 years old, P = 0.000), had a faster postcardioversion heart rate (88.80 ± 16.58 vs. 70.97 ± 14.73 times, P = 0.03), and had a higher mean HAS-BLED score (4.00 vs. 3.00, P = 0.01) than the successful-DCCV group. No patients experienced periprocedural pericardial effusion, occluder displacement, device embolism, or >5 mm peridevice leakage. One patient experienced a transient ischemic attack (TIA) in the DCCV group during the follow-up.ConclusionsThe DCCV at the time of LAAO is feasible and safe for AF patients with contraindications for catheter ablation or AF recurrence after previous catheter ablation to restore the sinus rhythm and relieve clinical symptoms. The DCCV at the time of LAAO is more likely to succeed for younger patients and patients with lower HAS-BLED scores.

Abstract Aims Atrial fibrillation (AF)/atrial flutter is common during cardiac amyloidosis (CA). Electrical cardioversion (EC) is a strategy to restore sinus rhythm (SR). However, left atrial thrombus (LAT) represents a contraindication for EC. CA patients with AF/atrial flutter have a high prevalence of LAT. We aimed to evaluate EC characteristics, LAT prevalence and risk factors, and AF/atrial flutter outcome in CA patients undergoing EC, predominantly treated with direct oral anticoagulants (DOACs). Methods and results All patients with CA and AF/atrial flutter referred for the first time to our national referral centre of amyloidosis for EC from June 2017 to February 2021 were included in this study. In total, 66 patients (median age 74.5 [70;80.75] years, 67% male) were included with anticoagulation consisted of DOAC in 74% of cases. All patients underwent cardiac imaging before EC to rule out LAT. EC was cancelled due to LAT in 14% of cases. Complete thrombus resolution was observed in only 17% of cases. The two independent parameters associated with LAT were creatinine [hazard ratio (HR) = 1.01; confidence interval (CI) = 1.00–1.03, P = 0.036] and the use of antiplatelet agents (HR = 13.47; CI = 1.85–98.02). EC acute success rate was 88%, and we observed no complication after EC. With 64% of patients under amiodarone, AF/atrial flutter recurrence rate following EC was 51% after a mean follow‐up of 30 ± 27 months. Conclusions Left atrial thrombus was observed in 14% of CA patients listed for EC and mainly treated with DOAC. The acute EC success rate was high with no complication. The long‐term EC success rate was acceptable (49%).

Data regarding optimal electrode positioning for direct current cardioversion (DCCV) of atrial fibrillation (AF) has been inconsistent. This meta-analysis was conducted to systematically compare the efficacy of anteroposterior (AP) versus anterolateral (AL) electrode placement for DCCV of AF. Electronic databases were searched for randomised controlled trials (RCTs) comparing AP versus AL electrode positioning in patients undergoing DCCV for AF. Primary endpoints were first-shock success and overall DCCV success. Subgroup analysis was performed by defibrillator waveform (monophasic versus biphasic). Meta-regression analyses were performed to assess for significant moderators. Twelve (12) RCTs, including a total of 2,046 patients, met inclusion criteria. Neither first-shock success (relative risk [RR] 0.92; 95% CI 0.79–1.07; p=0.28) nor overall DCCV success (RR 1.01; 95% CI 0.96–1.05; p=0.78) were significantly different with AP versus AL electrode positioning. The mean number of shocks (mean difference [MD] 0.3, 95% CI -0.4 to 0.9), energy level of first successful shock (MD 3 joules; 95% CI -20 to 27) and cumulative energy delivered (MD 39 joules; 95% CI -168 to 246) were similar in AP versus AL arms. In subgroup analysis of six RCTs using biphasic defibrillators, improvement in first-shock success (RR 0.85; 95% CI 0.69–1.03; p=0.10) and overall DCCV success (RR 0.97; 95% CI 0.93–1.01; p=0.09) with AL electrode positioning did not reach statistical significance. Meta-regression analyses identified older age, higher body mass index, and longer AF duration as significant moderators favouring AL electrode positioning. Pooled analysis of randomised data overall does not show a significant difference in efficacy between AP versus AL electrode positioning. Meta-regression and subgroup analyses suggest that, in contemporary practice with use of biphasic defibrillators, there may be a subset of AF patients in whom AL electrode positioning improves efficacy of DCCV. [ABSTRACT FROM AUTHOR]

Aims: Atrial fibrillation (AF)/atrial flutter is common during cardiac amyloidosis (CA). Electrical cardioversion (EC) is a strategy to restore sinus rhythm (SR). However, left atrial thrombus (LAT) represents a contraindication for EC. CA patients with AF/atrial flutter have a high prevalence of LAT. We aimed to evaluate EC characteristics, LAT prevalence and risk factors, and AF/atrial flutter outcome in CA patients undergoing EC, predominantly treated with direct oral anticoagulants (DOACs). Methods and results: All patients with CA and AF/atrial flutter referred for the first time to our national referral centre of amyloidosis for EC from June 2017 to February 2021 were included in this study. In total, 66 patients (median age 74.5 [70;80.75] years, 67% male) were included with anticoagulation consisted of DOAC in 74% of cases. All patients underwent cardiac imaging before EC to rule out LAT. EC was cancelled due to LAT in 14% of cases. Complete thrombus resolution was observed in only 17% of cases. The two independent parameters associated with LAT were creatinine [hazard ratio (HR) = 1.01; confidence interval (CI) = 1.00–1.03, P = 0.036] and the use of antiplatelet agents (HR = 13.47; CI = 1.85–98.02). EC acute success rate was 88%, and we observed no complication after EC. With 64% of patients under amiodarone, AF/atrial flutter recurrence rate following EC was 51% after a mean follow‐up of 30 ± 27 months. Conclusions: Left atrial thrombus was observed in 14% of CA patients listed for EC and mainly treated with DOAC. The acute EC success rate was high with no complication. The long‐term EC success rate was acceptable (49%). [ABSTRACT FROM AUTHOR]

Background and Objectives: Recurrence of atrial fibrillation (AF) within six months after sinus rhythm restoration with direct current cardioversion (DCC) is a significant treatment challenge. Currently, the factors influencing outcome are mostly unknown. Studies have found a link between genetics and the risk of AF and efficacy of rhythm control. The aim of this study was to examine the association between eight single-nucleotide variants (SNVs) and the risk of AF development and recurrence after DCC. Materials and Methods: Regarding the occurrence of AF, 259 AF cases and 108 controls were studied. Genotypes for the eight SNVs located in the genes CAV1, MYH7, SOX5, KCNN3, ZFHX3, KCNJ5 and PITX2 were determined using high-resolution melting analysis and confirmed with Sanger sequencing. Six months after DCC, a telephone interview was conducted to determine whether AF had recurred. A polygenic risk score (PRS) was calculated as the unweighted sum of risk alleles. Multivariate regression analyses were performed to assess SNV and PRS association with AF occurrence and recurrence after DCC. Results: The risk allele of rs2200733 (PITX2) was significantly associated with the development of AF (p = 0.012, OR = 2.31, 95% CI = 1.206–4.423). AF recurred in 60% of patients and the allele generally associated with a decreased risk of AF of rs11047543 (SOX5) was associated with a greater risk of AF recurrence (p = 0.014, OR = 0.223, 95% CI = 0.067–0.738). A PRS of greater than 7 was significantly associated (p = 0.008) with a higher likelihood of developing AF after DCC (OR = 4.174, 95% CI = 1.454–11.980). Conclusions: A higher PRS is associated with increased odds of AF recurrence after treatment with DCC. PITX2 (rs2200733) is significantly associated with an increased risk of AF. The protective allele of rs11047543 (SOX5) is associated with a greater risk of AF recurrence. Further studies are needed to predict the success of rhythm control and guide patient selection towards the most efficacious treatment. [ABSTRACT FROM AUTHOR]

Aim. To compare safety of new class III antiarrhythmic drug Refralon with direct current cardioversion (DCC) in patients with persistent atrial fibrillation (AF). Material and methods. 60 patients with persistent AF were randomized to groups of DCC (n=30) and pharmacologic conversion (PCV; n=30). There were no significant differences in age, sex, AF duration, concomitant cardiovascular diseases, CHA2DS2-VASc score and echocardiographic parameters between the groups compared. Initial assessment excluded contraindications to restore sinus rhythm (SR). In DCC group two attempts using biphasic synchronized shocks of 150 J and 170 J were performed. In PCV group patients received up to three subsequent intravenous injections of Refralon 10 μg/kg (maximal dose 30 μg/kg). Results. There were no mortality, stroke, transient ischemic attack, ventricular arrhythmia, asystole longer than 3,0 sec (primary safety criteria) in both groups. Prolongation of QT interval longer than 500 ms observed in 1 of 30 patients (3,3%) in DCC group and in 7 of 30 patients (23,3%) in PCV group. 2 patients (one patient in each group; 3,3%) developed asymptomatic bradycardia after conversion to SR that resolved spontaneously within 30 minutes. 95% confidence interval (95%CI) for secondary safety criteria is [0,02-0,38] for QT prolongation and [-0,04-0,04] for bradycardia. Conclusion. Safety of PCV is noninferior to DCC in patients with persistent AF in terms of primary safety criteria and bradyarrhythmias. More frequent QT interval prolongation to values >500 ms observed in PCV group points to necessity of precautions with use of the drug.

Introduction: Current guidelines recommend adequate anticoagulation for at least 3 weeks pre‐ and 4 weeks post‐direct current cardioversion (DCCV) to reduce thrombo‐embolic risk in patients with atrial fibrillation (AF) lasting greater than 48 h. No specific recommendations exist for DCCV in patients that have undergone left atrial appendage occlusion (LAAO), many of whom are ineligible for anticoagulation. This study aims to observe the efficacy and safety of DCCV post‐LAAO in everyday clinical practice. Methods: This prospective multicenter registry included DCCVs in patients post‐LAAO. Imaging strategy or anticoagulation treatment around DCCV were analyzed. Complications during 30‐day follow‐up were registered. DCCVs performed in accordance with current guidelines for the general AF population were compared to DCCVs performed deviating from these guidelines. Results: In 93 patients (age 65 ± 17 years, CHA2DS2‐VASC 3.0 ± 1.3) 284 DCCVs were performed between 2010 and 2018, in 271 sinus rhythm was restored. A wide variety of imaging or anticoagulation strategies around DCCV was observed; in 128 episodes strategies deviated from current guidelines. No thrombo‐embolic events were observed after any DCCV during 30‐day follow‐up. In 34 DCCVs trans‐esophageal echocardiography (TOE) was performed before DCCV to exclude cardiac thrombi and/or (re‐)verify adequate device positioning. In two patients without post‐LAAO imaging before DCCV, a device rotation or embolization was observed during scheduled TOE after LAAO. Conclusion: DCCV in AF patients after LAAO is highly effective. No thrombo‐embolic events were observed in any patient in this observational cohort, regardless of the periprocedural anticoagulation or imaging strategy. Confirmation of adequate device positioning at least once before DCCV seems recommendable. [ABSTRACT FROM AUTHOR]

Aim. We aimed to compare effectiveness of new class III antiarrhythmic drug Refralon with direct current cardioversion (DCC) in patients with persistent atrial fibrillation (AF).Material and methods. 60 patients with persistent AF were randomized to groups of DCC (n=30) and pharmacologic conversion (PCV; n=30). There were no differences in age, sex, AF duration, concomitant cardiovascular diseases, CHA2DS2-VASc score and echocardiographic parameters between the groups compared. Initial assessment excluded contraindications to restore sinus rhythm (SR). In DCC group two attempts using biphasic synchronized shocks of 150 J and 170 J were performed. In PCV group patients received up to three subsequent intravenous injections of Refralon 10 μg/kg (maximal dose 30 μg/kg).Results. SR was restored in 27 of 30 patients (90%) in DCC group and in 28 of 30 patients (93.3%) in PCV group. 95% confidence interval (CI) for primary effectiveness criterion was [-0.1 – 0.16]. AF recurred in 1 patient after successful DCC. There were no AF recurrences in PCV group. 26 of 30 patients (86.7%) in DCC group and 28 of 30 patients (93.3%) in PCV group remained in SR 24 hours after cardioversion. 95%CI for secondary effectiveness criterion was [-0.07 – 0.19].Conclusion. Effectiveness of Refralon is noninferior to DCC in patients with persistent AF.

Background and Objectives: Recurrence of atrial fibrillation (AF) within six months after sinus rhythm restoration with direct current cardioversion (DCC) is a significant treatment challenge. Currently, the factors influencing outcome are mostly unknown. Studies have found a link between genetics and the risk of AF and efficacy of rhythm control. The aim of this study was to examine the association between eight single-nucleotide variants (SNVs) and the risk of AF development and recurrence after DCC. Materials and Methods: Regarding the occurrence of AF, 259 AF cases and 108 controls were studied. Genotypes for the eight SNVs located in the genes CAV1, MYH7, SOX5, KCNN3, ZFHX3, KCNJ5 and PITX2 were determined using high-resolution melting analysis and confirmed with Sanger sequencing. Six months after DCC, a telephone interview was conducted to determine whether AF had recurred. A polygenic risk score (PRS) was calculated as the unweighted sum of risk alleles. Multivariate regression analyses were performed to assess SNV and PRS association with AF occurrence and recurrence after DCC. Results: The risk allele of rs2200733 (PITX2) was significantly associated with the development of AF (p = 0.012, OR = 2.31, 95% CI = 1.206–4.423). AF recurred in 60% of patients and the allele generally associated with a decreased risk of AF of rs11047543 (SOX5) was associated with a greater risk of AF recurrence (p = 0.014, OR = 0.223, 95% CI = 0.067–0.738). A PRS of greater than 7 was significantly associated (p = 0.008) with a higher likelihood of developing AF after DCC (OR = 4.174, 95% CI = 1.454–11.980). Conclusions: A higher PRS is associated with increased odds of AF recurrence after treatment with DCC. PITX2 (rs2200733) is significantly associated with an increased risk of AF. The protective allele of rs11047543 (SOX5) is associated with a greater risk of AF recurrence. Further studies are needed to predict the success of rhythm control and guide patient selection towards the most efficacious treatment.

Background: Direct current cardioversion (DCCV) is a common rhythm control strategy in patients with symptomatic atrial fibrillation or flutter. There is no long-term data regarding the safety of DCCV in patients with endocardial left atrial appendage occlusion (LAAO) devices.Objectives: The purpose of this study was to assess the feasibility and safety of DCCV in patients with an LAAO device.Methods: This multicenter retrospective study included 148 patients with an LAAO device who underwent DCCV for symptomatic atrial fibrillation or atrial flutter.Results: The average age of the included patients was 72 ± 7 years and 59% were men. All patients (100%) had a transesophageal echocardiogram prior to DCCV. Device-related thrombus was seen in 2.7%. They were all successfully treated with oral anticoagulation (OAC) and were able to undergo DCCV after 6 to 8 weeks. DCCV restored sinus rhythm in all patients. None of the patients had DCCV-related thromboembolic complications. A total of 22% of patients were newly started on OAC after DCCV. There was no difference in DCCV-related complications between patients treated with or without OAC post-DCCV. Patients receiving OAC post-DCCV were found to undergo cardioversion at an earlier time after implantation (3.6 months [interquartile range (IQR): 0.7 to 8.6 months] vs. 8.6 months [IQR: 2.5 to 13.3 months]; p = 0.003). Three transient ischemic attacks, unrelated to DCCV, were found during follow-up. During a median follow-up of 12.8 months (IQR: 11.8 to 14.2 months), no device or left atrial thrombosis, device dislodgement, or a new device leak were observed. One patient died during follow-up due to noncardiac cause.Conclusions: DCCV is feasible in high-risk AF patients with an LAAO device without the need for oral anticoagulation if pre-procedural transesophageal echocardiography shows good device position, absence of device-related thrombus, and peridevice leak of ≤5 mm. The preliminary results are encouraging, but further large studies are warranted to establish safety. [ABSTRACT FROM AUTHOR]

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Aims: Clinicians frequently pre-treat patients with amiodarone to increase the efficacy of electrical cardioversion for atrial fibrillation (AF). Our objective was to determine the precise effects of amiodarone pre- and post-treatment on conversion efficacy and sinus rhythm maintenance.Methods and Results: We conducted a systematic review and meta-analysis of trials comparing pre- and post-treatment for electrical cardioversion with amiodarone vs. no therapy on (i) acute restoration and (ii) maintenance of sinus rhythm after 1 year. We searched MEDLINE and EMBASE from inception to July 2018 for randomized controlled trials. We evaluated the risk of bias for individual studies with the Cochrane tool and overall quality of evidence with the GRADE framework. We identified eight eligible studies (n = 1012). Five studies were deemed to have unclear or high risk of selection bias. We found the evidence to be of high quality based on GRADE. Treatment with amiodarone (200-800 mg daily for 1-6 weeks pre-cardioversion; 0-200 mg daily post-cardioversion) was associated with higher rates of acute restoration [relative risk (RR) 1.22, 95% confidence interval (CI) 1.07-1.39, P = 0.004, n = 1012, I2 = 65%] and maintenance of sinus rhythm over 13 months (RR 4.39, 95% CI 2.99-6.45, P < 0.001, n = 695, I2 = 0%). The effects of amiodarone for acute restoration were maintained when considering only studies at low risk of bias (RR 1.22, 95% CI 1.10-1.36, P < 0.001, n = 572, I2 = 0%). Adverse effects were typically non-serious, occurring in 3.4% (6/174) of subjects receiving amiodarone.Conclusion: High-quality evidence demonstrated that treatment with amiodarone improved the restoration and maintenance of sinus rhythm after electrical cardioversion of AF. Short-term amiodarone was well-tolerated. [ABSTRACT FROM AUTHOR]

Patients with atrial fibrillation are faced with an increased risk of thromboembolic events, myocardial infarction, chronic heart failure and death. For some patients with atrial fibrillation, direct current cardioversion (DCCV) is a strategy that can be used to reacquire sinus rhythm. Our aim was to analyse the most commonly used medications after an electrical cardioversion, the reasons for not using them, the effects of pharmacotherapy on recurrence rates, and compare results with data from studies in 2014. The prospective study includes patients with electrocardiographically confirmed atrial fibrillation who underwent direct current cardioversion, hospitalised at Pauls Stradiņš Clinical University Hospital (Rīga, Latvia). The average age was 64.6 years. 50% of the patients were female. During the six-month study period, 14.3% patients were using amiodarone, 8.3% patients were on etacizine, 7.1% received propafenone, and 57.1% used beta blockers in monotherapy or in combination. Warfarin was used in 28.0% patients, direct oral anticoagulants (DOAC's) in 29.9%, 21,4% of patients received aspirin and 16.7% did not use any antithrombotic therapy. Comparing the recurrence rate in patients using different antiarrhythmic drugs, amiodarone showed a statistically significant superiority compared to etacizine and propafenone (p = 0.02). The obtained data showed that over four years, the use of anticoagulants increased by 11.6%. [ABSTRACT FROM AUTHOR]

Aims: Obesity is associated with higher electrical cardioversion (ECV) failure in persistent atrial fibrillation (PeAF). For ease‐of‐use, many centers prefer patches over paddles. We assessed the optimum modality and shock vector, as well as the safety and efficacy of the Manual Pressure Augmentation (MPA) technique. Methods: Patients with obesity (BMI ≥ 30) and PeAF undergoing ECV using a biphasic defibrillator were randomized into one of four arms by modality (adhesive patches or handheld paddles) and shock vector (anteroposterior [AP] or anteroapical [AA]). If the first two shocks (100 and 200 J) failed, then patients received a 200‐J shock using the alternative modality (patch or paddle). Shock vector remained unchanged. In an observational substudy, 20 patients with BMI of 35 or more, and who failed ECV at 200 J using both patches/paddles underwent a trial of MPA. Results: In total, 125 patients were randomized between July 2016 and March 2018. First or second shock success was 43 of 63 (68.2%) for patches and 56 of 62 (90.3%) for paddles (P = 0.002). There were 20 crossovers from patches to paddles (12 of 20 third shock success with paddles) and six crossovers from paddles to patches (three of six third shock success with patches). Paddles successfully cardioverted 68 of 82 patients compared with 46 of 69 using patches (82.9% vs 66.7%; P = 0.02). Shock vector did not influence first or second shock success rates (82.0% AP vs 76.6% AA; P = 0.46). MPA was successful in 16 of 20 (80%) who failed in both (patches/paddles), with 360 J required in six of seven cases. Conclusion: Routine use of adhesive patches at 200 J is inadequate in obesity. Strategies that improve success include the use of paddles, MPA, and escalation to 360 J. [ABSTRACT FROM AUTHOR]

Background: With an increasing number of patients undergoing left atrial appendage occlusion (LAAO), more attention is being paid to relieving clinical symptoms and improving the quality of life of these patients. For patients with atrial fibrillation (AF), direct current cardioversion (DCCV) is an alternate, nonpharmacological choice to restore sinus rhythm and relieve clinical symptoms., Objectives: The purpose of this study was to assess the feasibility and safety of the DCCV at the time of LAAO for patients with AF., Methods: Forty patients were enrolled in the DCCV group undergoing the DCCV at the time of LAAO. The control group undergoing LAAO alone was formed by 1:1 matching., Results: In the DCCV group, cardioversion was immediately successful in 30 (75%) patients, of which 12 (40%) had AF recurrence at the three-month follow-up. The failed-DCCV group was older (73.70 ± 4.74 vs. 62.20 ± 9.01 years old, P  = 0.000), had a faster postcardioversion heart rate (88.80 ± 16.58 vs. 70.97 ± 14.73 times, P  = 0.03), and had a higher mean HAS-BLED score (4.00 vs. 3.00, P  = 0.01) than the successful-DCCV group. No patients experienced periprocedural pericardial effusion, occluder displacement, device embolism, or >5 mm peridevice leakage. One patient experienced a transient ischemic attack (TIA) in the DCCV group during the follow-up., Conclusions: The DCCV at the time of LAAO is feasible and safe for AF patients with contraindications for catheter ablation or AF recurrence after previous catheter ablation to restore the sinus rhythm and relieve clinical symptoms. The DCCV at the time of LAAO is more likely to succeed for younger patients and patients with lower HAS-BLED scores., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Meng, Chen, Wang, Lu, Hu, Shen and Guo.)

Purpose: Left atrial thrombus (LAT) may be detected by transesophageal echocardiography (TEE) in patients with atrial fibrillation (AF) or flutter (AFL) despite continuous anticoagulation therapy. We sought to examine the rates and timing of LAT resolution in response to changes in anticoagulation regimen.Methods: A retrospective study of 1517 consecutive patients on ≥ 4 weeks continuous oral anticoagulation (OAC) undergoing TEE prior to either direct current cardioversion or catheter ablation for AF or AFL was performed. Patients who had LAT on index TEE imaging and had follow-up TEEs were analyzed.Results: Despite ≥ 4 weeks of continuous anticoagulation therapy, 63 (4.2%) patients had LAT. Forty-four patients (median age 67 [IQR 58, 74]; 33 [75%] male; 25 [57%] on direct oral anticoagulant [DOAC]) had follow-up TEEs performed. Upon detection of LAT on index TEE, 8 patients switched from warfarin to a DOAC, 21 patients switched from a DOAC to warfarin or another DOAC, and 15 patients remained on the same OAC. Over median 4.2 months (IQR 2.9, 6.6), LAT resolution was seen in 25 (57%) patients. Of the 25 patients who had LAT resolution, 7 (28%) required TEE imaging > 6 months after index TEE to show clearance of thrombus. Rates of LAT resolution were similar between patients who had alterations in OAC and those who did not (52 vs. 60%; P = 0.601).Conclusions: After initial detection of left atrial thrombus despite uninterrupted anticoagulation for atrial fibrillation or flutter, > 40% patients have persistent clot despite additional extended anticoagulation. [ABSTRACT FROM AUTHOR]

Objectives: Evaluate the efficacy, outcomes, and complications associatedwith direct current cardioversion (DCCV) in the treatment of arrhythmias in pediatric and adult congenital heart disease (CHD) populations and identify patient and procedural characteristics associated with adverse events. Background: Pediatric and adult patients with CHD are at risk of atrial arrhythmias. DCCV is effective but is associated with potential complications. Methods: In this single-center retrospective series, patients who underwent DCCV between January 2010 and May 2015 were identified and categorized as pediatric (<18 years) or adult (> 18 years). Records were reviewed for demographic, arrhythmic, and CHD-specific characteristics; acute efficacy; and 3-month arrhythmia recurrence. Complications were categorized as lifethreatening (LT) or non-life-threatening (NLT). Univariate followed by multiple variable and logistic regression (LR) analyses were used to identify characteristics associated with complications. Results: We identified 104 patients with 152 discrete DCCV events with median age 17.4 years (0.15-62.2). DCCV efficacy was 89% with 3-month recurrence of 46%. There were 52 complications among 24 patients, median age 17.7 years (0.15-49). Risks associated with NLT complications are as follows: moderate-severe systolic dysfunction (8/152 encounters, P = < 0.01) and more than one shock per DCCV encounter (P = < 0.01). Six of eight encounters with moderate-severe systolic dysfunction were <18 years (P = 0.1). Risks for LT complications included age >18 years and associated NLT complication. Adults had more frequent arrhythmia recurrence within 3 months than children (P = < 0.01). Conclusions: DCCV is effective for arrhythmias but is associated with frequent recurrence, particularly in adult patients. Complications associated with DCCV may be greater than previously reported. Additional support and precautions should be in place for those at greatest risk. [ABSTRACT FROM AUTHOR]

Stress cardiomyopathy (SCM), also called broken heart syndrome and Takotsubo cardiomyopathy is an increasingly reported syndrome generally characterized by transient systolic dysfunction of the apical and or mid segments of the left ventricle that mimics myocardial infarction, in the absence of obstructive coronary artery disease. Typically patients present within a few hours of exposure to physical or emotional stress. However, the mechanism by which these stressors result in myocardial dysfunction is unclear. Proposed factors include catecholamine excess and coronary vasospasm1. We present the case of a 61-year-old female who experienced acute pulmonary edema secondary to stress cardiomyopathy, on two occasions immediately after undergoing elective direct current cardioversion (DCCV) for atrial fibrillation (Afib). After an urgent hospitalization for management of acute left ventricular failure, she made a complete clinical and echocardiographic recovery. The incidence, clinical implications and prognosis of DCCV induced SCM is unknown. Given DCCV for Afib is a common outpatient procedure and DCCV induced SCM can lead to acute clinical deterioration it is important that physicians are vigilant about this newly recognized DCCV complication.

Introduction: Direct current cardioversion (DCCV) is considered as the most effective treatment for atrial fibrillation (AF). AF is associated with an increased risk of thromboembolism, and DCCV may increase this risk. The current recommendation is, therefore, to anticoagulate for at least 3 weeks before DCCV and 4 weeks after the procedure. Methods: A retrospective study of patients referred for elective DCCV as treatment for AF in Hampshire Hospitals NHS Foundation Trust was performed to compare the safety and efficacy of dabigatran with warfarin in this setting. Results: During a 12-month period, 129 patients were referred for DCCV for the treatment of AF and 107 patients received DCCV. Fifty-four patients were anticoagulated with dabigatran, 42 patients with warfarin, and 11 patients with other direct oral anticoagulants (DOACs) with choice of agent determined following an informed discussion with the patient. The average number of days between the date of referral for DCCV and the date of DCCV for patients who were on dabigatran was 51 days, while for warfarin, this was 82 ( P = 0.001). The proportion of cancelation and rescheduling for warfarin patients was 21.4%, while for dabigatran, this was 5.5%. Patients were reviewed 6-20 weeks after DCCV; the success rate of DCCV for dabigatran patients was 61%, whilst for warfarin patients, this was 52%. The success rate went up to 69% for patients who received DCCV within 45 days of referral ( P = 0.165). Conclusion: This retrospective study supports clinical experience that DCCV is more likely to be successful when there is a shorter duration between the onset of AF and the date of DCCV, and shows that the use of dabigatran in comparison with warfarin facilitates earlier DCCV. [ABSTRACT FROM AUTHOR]

Background: The QTc in sinus rhythm (SR) following direct current cardioversion (DCCV) of atrial fibrillation (AF) is commonly used as a baseline QTc for patients who require initiation of antiarrhythmic drugs for rhythm control. Inaccurate baseline QTc may cause drug-induced torsades de pointes., Objectives: This study sought to assess time-dependent QTc changes following DCCV., Methods: We prospectively assessed QTc changes with Bazett's QTc and Fridericia's QTc formulas in 65 patients following conversion of AF to SR. Among these 65 patients, 48 underwent DCCV and 17 spontaneously converted to SR., Results: There was a large and statistically significant decrease in QTc in SR immediately following DCCV in 40 patients, which occurred with an abrupt reduction in heart rate postcardioversion. This finding excluded 8 patients with ventricular-paced QRS. The mean decrease from QTc in AF was 70.7 ± 37.2 milliseconds in the QTc interval for heart rate using Bazett's formula and 33.8 ± 17.9 milliseconds in the QTc interval for heart rate using Fridericia's formula at 1-minute post-DCCV. In 17 patients with spontaneous conversion from AF to SR, the QTc reduction was comparable to those in patients with DCCV. The QTc increased with time and reached a steady state at 5 minutes following conversion. Initiation of Class III drugs based on the "shortened" baseline QTc following DCCV was associated with drug-induced torsades de pointes., Conclusions: In patients with AF following conversion, regardless spontaneous or DCCV, the QTc shortened significantly with decreases in heart rate, likely via the mechanism of time-dependent rate adaption of ventricular repolarization. A steady-state QTc at 5-minutes following DCCV should be used as real baseline for guidance of pharmacotherapy in patients with AF., Competing Interests: Funding Support and Author Disclosures Dr Yan is supported by the Sharpe-Strumia Research Foundation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The modern generation of transthoracic defibrillators now employ impedance compensated biphasic waveforms. These new devices are superior to those with monophasic waveforms and practice is currently switching to biphasic defibrillators for the treatment of both ventricular and atrial fibrillation. However, there is no universal guideline for the use of biphasic defibrillators in direct current cardioversion of atrial fibrillation. This article reviews the use of biphasic defibrillation waveforms for transthoracic cardioversion of atrial fibrillation.

Background Atrial fibrillation (AF) recurrence is common after successful direct current cardioversion (DCCV), with a 40% rate of recurrence within the first month. Several studies have investigated the potential association between brain natriuretic peptide (BNP) or N-terminal (NT)-proBNP levels before DCCV and the risk of AF recurrence, but results have been inconsistent. We, therefore, conducted a systematic review and meta-analysis of all available data to determine whether sinus rhythm (SR) maintenance after successful DCCV may be determined by preprocedural BNP and NT-proBNP levels. Methods We systematically searched Scopus, the Cochrane library, EMBASE, and MEDLINE databases to identify publications evaluating BNP or NT-proBNP levels in relation to post-DCCV AF recurrence, indexed from inception to September 2013. Among the initial 1,067 citations, 18 studies fulfilled the specified criteria. The difference in BNP and NT-proBNP concentrations in the AF recurrence and the SR-maintaining group was estimated by the standardized mean difference and the estimates of the pooled outcomes were evaluated using random-effects models. Results Baseline BNP levels in the AF recurrence group were significantly higher compared to BNP levels in the SR-maintaining group (standardized mean difference [SMD] -1.51, confidence interval [CI] [-2.53, -0.48], P = 0.004). Similar results were observed for NT-proBNP levels, which were significantly higher in the AF recurrence group compared with the SR-maintaining group (SMD -0.63, CI [-1.13, -0.14], P = 0.01). Conclusions Our analysis suggests that low preprocedural BNP/NT-proBNP levels are associated with SR maintenance. The use of BNP or NT-proBNP for prediction of long-term response to DCCV appears to be useful and should be further evaluated. [ABSTRACT FROM AUTHOR]