| Are there any circumstances where you would prefer Propafenone over Flecainide for the maintance of SR? | There is no magic in any of the antiarrhythmic drugs and preferring one over another will depend on tolerance, effectiveness and side effects. Most doctors end-up developing a better knwledge of one or the other, which dictates de order (preference) of use. But failure of one does not rule out success of the other.
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| Should we discourage people form engaging in sport activities like long distance running due the risk of AF or whom should we advice not to participate in such an activity | The proportion of sportsmen developing AF is probably small and the "sports culture" of our times makes such a recommendation difficult to implement. Perhaps it is time, however, to instruct sport fans on the possible side-effects of extreme sports. "Fine tunning" this sports "craze" may be better than trying to swimm against a tide that has some other health advantages. |
| How does CRT with 3 leads and atrial pacing influence the natural history of a persistent AF after electrical cardioversion? | Cardiac resynchronization therapy has been reported to decrease the incidence of AF. This may be due to atrial pacing, but it could also be due to the improved hemodynamics decreasing atrial stretch. Atrial pacing by itself has not been very useful for the treatment of AF except in patients with bradicardia-tachycardia syndrome. The effect of CRT is encouraging because it might support the reversibility of some of the arrhythmogenic factors leading to AF (AF risk factors). |
| How strong is the evidence for the 48 h time limit? How safe is electrical cardioversion compared to pharmacologic? | Not very strong. In fact there are very few studies looking at the natural history of AF from the very first clinical episode, in detail. The safety of pharmacologic vs electrical CV is difficult to compare, because they are generally used in different clinical settings. I would stress that electrical CV is very safe if you can control your sedation well. Pharmacological CV can lead to arrhythmogenesis (flutter with 1:1 AV conduction, ventricular tachycardia) or extreme sinus bradycardia and low output state in a few patients. In the end it will depend on your indication and your local resources. From the thromboembolism standpoint there are no significant differences. |
| How long must be course of antiarrhitmic drugs (amiodaron for example) after successful electric cardiovertion? | I don't think we have firm data. Based on reversibility of the electrical and mechanical remodelling caused by AF itself I would recommend stabilization of sinus rhythm for 3 months after successful cardioversion. After this time all reversible atrial dilatation and ventricular dysfunction should be back to baseline and other risk factors should be controled and an attempt at withdrawing the antiarrhythmic drug would appear reasonable. A different question would arise if AF was very poorly tolerated the first time. |
| What about IV novocainamide? Is it a good option for converting AF? | Procainamide may be less effective than flecainide, but y can recover sinus rhythm in 65% of cases of recent onset AF (European Heart Journal 1993;14:1127) |
| Is it mandatory to mantane SR after cardioversion and which AAD is the best? | In my view the AAD to use depends on which one you know best and use most comfortably and on possible contraindications in the clinical picture. It depends also in your long-term plan. If you are planning to maintain AAD post-CV for only 3 months, amiodarone would be a good first line choice, because in this short time the side effects are improbable and amiodarone would be the most effective AAD in maintaining sinus rhythm. |
| What do you think about TEE before cardioversion in AF> 48 hour without apprpriate INR? | Fine to cardiovert after ruling out thrombi, however, keep in mind that thrombi may appear during post-cardioversion atrial stunning, therefore you do need effective anticoagulation for 3-4 weeks after cardioversion |
| When the patient is with one of antyarythmic drugs and he has new atrialfibrillation,WHO is treatment of choise | AF recurrence while on an antiarrhythmic drug (AAD) is frequent and underlines the need for a long-term plan. A second AAD trial is reasonable. Also the association of verapamil or diltiazem with previously failed propafenone or flecainde may be useful. If you are thinking of long-term amiodarone you could consider rate control or AF ablation as possible alternatives. |
| My question is about a young man with permanent AF and unsuccesful cardioversion with CHA2DS2VASC=0, could we don't give any OAC for him, without remorse? | No remorse at all! Let's always think of the risk of hemorrhage and strike the right balance. Even with CHADS ≤ 2 anticoagulation may not offer a "net benefit", considering the clinical severity of intracranial hemorrage. |
| How about spontaneous echo-contrast and risk of embolism peri-cardioversion? does it contraindicated | Only the detection of actual thrombi in the left atrium contraindicate cardioversion. |
| Are you expecting rivaroxaban and apixaban to be approved for preparation for cardioversion in persistent >48h AF? | At this time we can only hope so. There are some studies running that should clarify this important question. |
| A question not about cardioversion, but about OAC... Should we continue lifelong anticoagulation in patients, who have high Chads2vasc score and AFib due to potentially reversible causes - for example thyrotoxicosis - could we stop OAC after euthyrosis? | Excellent question. We sorely need data along this line. The long-term risk of hemorrhage has to be considered also in order to strike the right risk/benefit balance. How much monitoring is necessary? It is not only thyrotoxicosis, but also postoperative AF and others. Long-term follow-up (1-2 years?) with repeat Holter or even implantable Holter could help make a sensible clinical decision. |
| Flecainide is the drug of choice for fetal supraventricular tachycardio, causing fetal hydrops. So it is relatively save in pragnant women! | This comment agrees with statements in the ESC guidelines. Experience is however short. |
| Do you have any experience with Ranolazin or Chinidin for CV or SR maintance in your daily practice? | Ranolazin is a fascinating drug for AF on paper. I can't offer any personal experience to guide you, I'm sorry |
| ECV as a Bridge to AF ablation? I mean, patients with persistent symptomatic AF, is there a place for the CV to see the response and if the patients has more chances of being in SR after the ablation? | This is a very significant question. Early recognition of PERSISTENT AF should lead to an early decission toward rate or rhythm control. If rhythm control appears preferable CV could prevent further AF-induced remodelling and could be a step toward more effective AF ablation later on [if so decided]. This could be most applicable in young patients (<60 y/l) without organic heart disease. |
