INTERNAL INTERNAL CARDIOVERSIONCARDIOVERSION

Lancashire & South Cumbria Cardiac Network

DC DC CardioversionCardioversion

AF & AFL safe AF & AFL safe 1,2 efficacious efficacious 3,4 (60(60--94%) 94%) 5

SR SR -- Increases exercise tolerance Increases exercise tolerance 6

Maintainence Maintainence SR unlikely in patients in SR unlikely in patients in AF > 3years duration AF > 3years duration 3

Indications Indications –– internal CV internal CV

Failed external (on Failed external (on amiodaroneamiodarone) ) 7

High thoracic impedance (obesity & High thoracic impedance (obesity & COPD) COPD) 8

ContraContra--indication to GAindication to GA

ProtocolProtocolPatients Patients anticoagulatedanticoagulated INR 2.0INR 2.0--3.0 3.0 9,2

Normal electrolytesNormal electrolytesECG recorded on admissionECG recorded on admissionPatient prepped as for femoral approach (usually)Patient prepped as for femoral approach (usually)8F sheath 8F sheath –– femoral vein (or right internal femoral vein (or right internal jugular)jugular)Single pass electrode Single pass electrode –– placed in left Pulmonary placed in left Pulmonary arteryarterySupplemental O2, pulse Supplemental O2, pulse oximetryoximetry, non, non--invasive invasive BPBPExternal defibrillation equipment availableExternal defibrillation equipment available

Alert CatheterAlert Catheter

Temporary Temporary transvenoustransvenous flowflow--directed directed multipurpose multipurpose AtrialAtrial Defibrillation/Pacing Defibrillation/Pacing devicedeviceDesigned temporary transmission of Designed temporary transmission of electrical impulseselectrical impulses

IntraIntra--cardiac Sensingcardiac SensingIntraIntra--cardiac Pacingcardiac PacingAtrialAtrial Defibrillation (Defibrillation (cardioversioncardioversion))

ALERT CatheterALERT Catheter

0.21 Guide wire, 0.21 Guide wire, teflon teflon coatedcoatedDefibrillation Array Defibrillation Array –– platinumplatinumCatheter marked 10 cm increments to Catheter marked 10 cm increments to allow depth of catheter in patient to be allow depth of catheter in patient to be seenseen

PlacementPlacement

XX--RayRayVenous access Venous access –– patients right of spinepatients right of spine

(on X(on X--Ray Ray –– left of spine)left of spine)

Balloon inflation Balloon inflation –– 2mls 2mls --RA level (air, check for RA level (air, check for leaks prior to insertion, flotation technique)leaks prior to insertion, flotation technique)Check Check VE’s VE’s or arrhythmias during placement or arrhythmias during placement Distal array Distal array –– Pulmonary arteryPulmonary arteryRV electrode RV electrode –– within RVwithin RVRa proximal array Ra proximal array –– within RA within RA

Catheter placementsCatheter placements

LPA RPA Bifurcation

Technical protocolTechnical protocol

Establish rhythm and record baselineEstablish rhythm and record baselineCompanion set up Companion set up

Appropriate gains for IEGMAppropriate gains for IEGMRate limit to 360ms (fastest Rate limit to 360ms (fastest bpm bpm allowed)allowed)Energy level 15J. Discuss with operator to Energy level 15J. Discuss with operator to increase this level to 30J if 15J increase this level to 30J if 15J –– failsfailsTilt 50/50%*Tilt 50/50%*Standby pacing Standby pacing –– OFF*OFF*

Technical protocolTechnical protocol

Connect alert catheterConnect alert catheterCheck IEGMCheck IEGMCheck synchronisation to R wavesCheck synchronisation to R waves

Change sensitivity if unacceptable*Change sensitivity if unacceptable*

Once patient is sedated Once patient is sedated Check rhythmCheck rhythmDeliver BiDeliver Bi--atrialatrial ShockShockConfirmConfirm

Check RhythmCheck Rhythm12 Lead ECG 1hour post procedure12 Lead ECG 1hour post procedure

If attempt fails discuss options;If attempt fails discuss options;increasing energy increasing energy –– max 30Jmax 30JChanging tilt 60/40%Changing tilt 60/40%Changing catheter positionChanging catheter positionIV IV flecainide flecainide (ERAF) (ERAF) 10

TiltTilt

Percentage decay of the initial voltagePercentage decay of the initial voltage

Monophasic Monophasic

ViVf

50% 75%

Tilt Vi(2) = Tilt Vi(2) = VfVf(1)(1)

BiphasicBiphasic 50/50%Vi(1)

Vf(1)

Vi(2) Vf(2)

Pulse width 1= Pulse width 2 60/40%

Tilt = (Vi Tilt = (Vi –– VfVf)/Vi x 100 !!)/Vi x 100 !!

SensitivitySensitivity

Sensitivity level Sensitivity level –– allows sensing of R wave allows sensing of R wave above a certain levelabove a certain levelrelates to ventricular size recorded from relates to ventricular size recorded from Ventricular electrodeVentricular electrodeNeeded to synchronize to R waveNeeded to synchronize to R wave3 screens satisfactory sensing should be 3 screens satisfactory sensing should be observed prior to shock deliveryobserved prior to shock deliveryIf sensing is not seenIf sensing is not seen-- increase sensitivity by increase sensitivity by lowering levellowering level

SensitivitySensitivity

ABCD

A = NO SENSING

B – INTERMITTENT SENSING

C – STABLE SENSING

D – SENSING OF MUSCLE NOISE

MUSCLE

CARDIAC

ERAFERAFEARLY REEARLY RE--INITIATION of AFINITIATION of AF

PV PV ectopics ectopics 11

RA conduction variation RA conduction variation 12

Atrial Atrial refractoriness (shorter in AF patients)refractoriness (shorter in AF patients)13

Relapse AF within 1 minute after at least 2 Relapse AF within 1 minute after at least 2 sinus beats sinus beats 14

Incidence Incidence -- 12% 12% 14

ERAF ERAF -- optionsoptions

FlecainideFlecainide 10 (normal LV function)(normal LV function)100mg + 50mg over 10100mg + 50mg over 10 minsminsImpaired LVF Impaired LVF –– IVIV amiodaroneamiodarone 300mg IV 300mg IV bolus over 15bolus over 15 minsmins

AtrialAtrial pacing post shockpacing post shockDue to post shockDue to post shock bradycardiabradycardiaTo reduceTo reduce atrialatrial premature depolarisation premature depolarisation ––42% success 42% success 15 (500ms)(500ms)

AsystoleAsystole

Emergency standby pacingEmergency standby pacing? Ensure ventricular capture ? Ensure ventricular capture –– ring ring electrodeelectrodeexternal pacing facility external pacing facility –– external external

defibrillatordefibrillator

WarningsWarnings

Long QT syndromeLong QT syndromeLBBBLBBBCO2 for balloon inflation CO2 for balloon inflation –– presence ofpresence ofintracardiacintracardiac shunts shunts

ContraContra--IndicationsIndications

Peripheral embolism or stroke (last 3 Peripheral embolism or stroke (last 3 months)months)Mechanical tricuspid/pulmonary valveMechanical tricuspid/pulmonary valveEvidence of digitalis toxicity (failed to Evidence of digitalis toxicity (failed to correct)correct)Evidence of sepsisEvidence of sepsisEvidence of Evidence of hypercoagulationhypercoagulation

Patient perceptionPatient perception

Effective and tolerable Effective and tolerable –– fully conscious fully conscious patients patients 16

Low satisfaction Low satisfaction –– high in ICV group high in ICV group compared to ECV group 4 hours post compared to ECV group 4 hours post procedure, but was lower 28 days post procedure, but was lower 28 days post procedure procedure 17

Anxiety, depression, heart related symptomsAnxiety, depression, heart related symptomsFailure to maintain SR Failure to maintain SR –– most powerful most powerful contributor to low satisfactioncontributor to low satisfaction

References References 1. Internal low energy 1. Internal low energy atrial cardioversionatrial cardioversion: efficacy and safety in older patients with chronic persistent : efficacy and safety in older patients with chronic persistent AF AF –– BorianiBoriani,G ,G (2001)(2001)2. Safety of electrical 2. Safety of electrical cardioversioncardioversion in patients with AF in patients with AF –– Gentile,F (2002)Gentile,F (2002)3. AF recurrence after internal 3. AF recurrence after internal cardioversioncardioversion: prognostic importance of electrophysiological parameters : prognostic importance of electrophysiological parameters -- BiffiBiffi,M (2002),M (2002)

4. 4. Transvenous Transvenous low energy internal low energy internal cardioversion cardioversion for AF: a review of clinical applications and future developmentfor AF: a review of clinical applications and future developments s ––BorianiBoriani,G (2001),G (2001)5. Electrical 5. Electrical Cardioversion Cardioversion of AF of AF –– JoglarJoglar,J (2004),J (2004)6. The effect of 6. The effect of cardioversion cardioversion on maximal exercise capacity in patients with chronic AF on maximal exercise capacity in patients with chronic AF –– Atwood, J (1989)Atwood, J (1989)7.A comparison of treatment of AF with low energy7.A comparison of treatment of AF with low energy intracardiac cardioversionintracardiac cardioversion and externaland external cardioversioncardioversion –– Alt,E Alt,E (1997)(1997)8. Internal 8. Internal CardioversionCardioversion: a worthwhile alternative after failed external : a worthwhile alternative after failed external cardioversion cardioversion in obese patients in obese patients –– De De RidderRidder,S ,S (2002)(2002)9.Role of prophylactic anticoagulation for DC9.Role of prophylactic anticoagulation for DC cardioversionincardioversionin patients with AF or AFL patients with AF or AFL –– Arnold,A (1992)Arnold,A (1992)10.10. FavorableFavorable effects ofeffects of flecainide intransvenousflecainide intransvenous internalinternal cardioversioncardioversion of AF of AF –– BorianiBoriani,G (1999),G (1999)11. Mechanism of immediate recurrences of AF after restoration o11. Mechanism of immediate recurrences of AF after restoration of sinus rhythm f sinus rhythm –– ChughChugh,A (2004),A (2004)12. Immediate recurrence of AF after internal 12. Immediate recurrence of AF after internal cardioversioncardioversion: importance of right : importance of right atrial atrial variation variation –– GorenekGorenek,B (2002),B (2002)13. Evaluation of 13. Evaluation of atrial atrial refractoriness and AF refractoriness and AF inducibility inducibility immediately after internal immediately after internal cardioversion cardioversion in patients with in patients with chronic persistent AF chronic persistent AF –– BorianiBoriani,G (1999),G (1999)14.Incidence & management of early recurrent AF (ERAF) after 14.Incidence & management of early recurrent AF (ERAF) after transthoracictransthoracic electrical electrical cardioversion cardioversion –– SiaplaourasSiaplaouras,S ,S (2004)(2004)15.15.Atrial Atrial Pacing for suppression of early Pacing for suppression of early reinitiation reinitiation of AF after successful internal of AF after successful internal cardioversion cardioversion –– TseTse,H (2000),H (2000)16. Efficacy & tolerability in fully conscious patients of 16. Efficacy & tolerability in fully conscious patients of transvenous transvenous low energy low energy atrial cardioversion atrial cardioversion for AF for AF –– BorianiBoriani,G ,G (1998)(1998)17.Treatment satisfaction of internal versus external 17.Treatment satisfaction of internal versus external cardioversioncardioversion in patients with chronic AF in patients with chronic AF –– a randomized, a randomized, prospective, 28 day followprospective, 28 day follow--up study up study