Electrical energy by electrode placement for cardioversion of atrial fibrillation: a systematic review and meta-analysis

Vinter, Nicklas; Holst-Hansen, Mikkel Zacharias Bystrup; Johnsen, Søren Paaske; Lip, Gregory Y H; Frost, Lars; Trinquart, Ludovic

doi:10.1136/openhrt-2023-002456

Cited by 3 publications

(1 citation statement)

References 28 publications

(37 reference statements)

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“…A simultaneous observational substudy (n = 20) performed to assess manual pressure augmentation, timed to the end-expiratory phase of respiration, in patients with morbid obesity (BMI ≥35) and cardioversion-refractory AF (ie, failed up to 200 J with paddles and patches) showed 50% and 86% success in 200-J and 360-J shocks, respectively. There was no efficacy difference associated with electrode orientation, which is consistent with a recent metanalysis, 44 although conflicting evidence exists. 45 Lastly, antiarrhythmic drugs may be beneficial not only in maintaining sinus rhythm but also in their role as upstream facilitator of cardioversion success.…”

Section: Discussionsupporting

confidence: 87%

Dual vs Single Cardioversion of Atrial Fibrillation in Patients With Obesity

Aymond,

Sanchez,

Castine

et al. 2024

JAMA Cardiol

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ImportanceAtrial fibrillation and obesity are common, and both are increasing in prevalence. Obesity is associated with failure of cardioversion of atrial fibrillation using a standard single set of defibrillator pads, even at high output.ObjectiveTo compare the efficacy and safety of dual direct-current cardioversion (DCCV) using 2 sets of pads, with each pair simultaneously delivering 200 J, with traditional single 200-J DCCV using 1 set of pads in patients with obesity and atrial fibrillation.Design, Setting, and ParticipantsThis was a prospective, investigator-initiated, patient-blinded, randomized clinical trial spanning 3 years from August 2020 to 2023. As a multicenter trial, the setting included 3 sites in Louisiana. Eligibility criteria included body mass index (BMI) of 35 or higher (calculated as weight in kilograms divided by height in meters squared), age 18 years or older, and planned nonemergent electrical cardioversion for atrial fibrillation. Patients who met inclusion criteria were randomized 1:1. Exclusions occurred due to spontaneous cardioversion, instability, thrombus, or BMI below threshold.InterventionsDual DCCV vs single DCCV.Main Outcomes and MeasuresReturn to sinus rhythm, regardless of duration, immediately after the first cardioversion attempt of atrial fibrillation, adverse cardiovascular events, and chest discomfort after the procedure.ResultsOf 2079 sequential patients undergoing cardioversion, 276 met inclusion criteria and were approached for participation. Of these, 210 participants were randomized 1:1. After exclusions, 200 patients (median [IQR] age, 67.6 [60.1-72.4] years; 127 male [63.5%]) completed the study. The mean (SD) BMI was 41.2 (6.5). Cardioversion was successful more often with dual DCCV compared with single DCCV (97 of 99 patients [98%] vs 87 of 101 patients [86%]; P = .002). Dual cardioversion predicted success (odds ratio, 6.7; 95% CI, 3.3-13.6; P = .01). Patients in the single cardioversion cohort whose first attempt failed underwent dual cardioversion with all subsequent attempts (up to 3 total), all of which were successful: 12 of 14 after second cardioversion and 2 of 14 after third cardioversion. There was no difference in the rating of postprocedure chest discomfort (median in both groups = 0 of 10; P = .40). There were no cardiovascular complications.Conclusions and RelevanceIn patients with obesity (BMI ≥35) undergoing electrical cardioversion for atrial fibrillation, dual DCCV results in greater cardioversion success compared with single DCCV, without any increase in complications or patient discomfort.Trial RegistrationClinicalTrials.gov Identifier: NCT04539158

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Section: Discussionsupporting

confidence: 87%

Dual vs Single Cardioversion of Atrial Fibrillation in Patients With Obesity

Aymond,

Sanchez,

Castine

et al. 2024

JAMA Cardiol

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Initial Defibrillator Pad Position and Outcomes for Shockable Out-of-Hospital Cardiac Arrest

Lupton,

Newgard,

Dennis

et al. 2024

JAMA Netw Open

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ImportanceVentricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) are the most treatable causes of out-of-hospital cardiac arrest (OHCA). Yet, it remains unknown if defibrillator pad position, placement in the anterior-posterior (AP) or anterior-lateral (AL) locations, impacts patient outcomes in VF or pVT OHCA.ObjectiveTo determine the association between initial defibrillator pad placement position and OHCA outcomes for patients presenting with VF or pVT.Design, Setting, and ParticipantsThis prospective cohort study included patients with OHCA and VF or pVT treated by a single North American emergency medical services (EMS) agency from July 1, 2019, through June 30, 2023. The study included patients with OHCA treated by a large suburban fire-based EMS agency that covers a population of 550 000. Consecutive patients with an initial EMS-assessed rhythm of VF or pVT receiving EMS defibrillation were included. Pediatric patients (younger than 18 years), interfacility transfers, arrests of obvious traumatic etiology, and patients with preexisting do-not-resuscitate status were excluded.ExposureAP or AL pad placement.Main Outcomes and MeasuresReturn of spontaneous circulation (ROSC) at any time with secondary outcomes of pulses present at emergency department (ED) arrival, survival to hospital admission, survival to hospital discharge, and functional survival at hospital discharge (cerebral performance category score of 2 or less). Measures included adjusted odds ratios (aOR), multivariable logistic regressions, and Fine-Gray competing risks regression.ResultsA total of 255 patients with OHCA were included (median [IQR] age, 66 [55-74] years; 63 females [24.7%]), with initial pad positioning documented as either AP (158 patients [62.0%]; median [IQR] age, 65 [54-74] years; 37 females [23.4%]) or AL (97 patients [38.0%]; median [IQR] age, 66 [57-74] years; 26 females [26.8%]). Patients with AP placement had higher adjusted odds ratio (aOR) of ROSC at any time (aOR, 2.64 [95% CI, 1.50-4.65]), but not significantly different odds of pulses present at ED arrival (1.34 [95% CI, 0.78-2.30]), survival to hospital admission (1.41 [0.82-2.43]), survival to hospital discharge (1.55 [95% CI, 0.83-2.90]), or functional survival at hospital discharge (1.86 [95% CI, 0.98-3.51]). Competing risk analysis found significantly greater cumulative incidence of ROSC among those at risk with initial AP placement compared with AL (subdistribution hazard ratio, 1.81 [95% CI, 1.23-2.67]; P = .003).Conclusions and RelevanceIn this cohort study of patients with OHCA and VF or pVT, AP defibrillator pad placement was associated with higher ROSC compared with AL placement.

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