External Direct Current Cardioversion¶

• Indications
  • Persistent Afib
• Considered successful if sinus rhythm of any duration is achieved post cardioversion
  • Unsuccessful in >10%
    • More likely to fail if:
      • BMI ≥30, ≥35, ≥40 are associated with 1.87, 2.50, and 4.9 Relative risk of requiring more than one attempt¹
• Predictors of recurrence after catheter ablation and electrical cardioversion of atrial fibrillation: an umbrella review of meta-analyses
  • Address HTN, OSA, Depression, Metabolic Syndrome
  • AADs may increase the success rate of DC cardioversion
• Amiodarone pretreatment with intravenous bolus few hours before electrical cardioversion reduces short-term recurrences of atrial fibrillation

Setup¶

• Goal: Optimize Transthoracic Impedance
  • Determined by position of the electrodes
    • The lower the better
    • Optimal when atria completely encompassed
  • RAFF2: No difference between AP vs. AL pad locations in achieving cardioversion success
    • AP to have better success over AL in patients with lone AF and LA size <45mm

[Protocol]¹¶

• 200J AP Biphasic Shock

• 1 + External Compression (60-100N) at end-expiration¶

• 2 but anterior pad changed to right parasternal location¶

• Use 2 defibrillators with crossing pad in AP and right parasternal to deliver 400J shock with external compression at end-expiration
• Position pads under fluoroscopy

Complications¶

• Asystole >5s
• Severe Transient Bradycardia w/HR <40 bmp (<1%)
• Sustained ventricular arrhythmia