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Cardioversion of atrial fibrillation in 2014: practical issues

ESC Congress Report

  • Transesophagael echocardiogram (TEE) us a good alternative to adequate anticoagulation in patients undergoing early cardioversion to prevent from peri-operative thrombo-embolic risk
  • Some drugs available for pharmacological cardioversion are more rapidly effective than amiodarone when administered intravenously.
  • Possible cardiac and non-cardiac side effects should be considered and counterbalanced.
  • Post-cardioversion therapy primarily stems on anticoaugulation protection. Maintenance of sinus rhythm is best ensured with amiodarone, but high discontinuation rates over time
Atrial Fibrillation

View the Slides from this session in ESC Congress 365

This session was dedicated to the current strategies characterising  the preparation, treatment and follow-up of patients undergoing cardioversion.

In the first presentation, Dr. Ole-Alexander Breithardt (Leipzig, DE) reported on the use of transesophageal echo before cardioversion. He referred to the current guidelines of the European Society of Cardiology setting the pre-requisite for selecting between early and delayed cardioversion in patients with atrial fibrillation lasting > 48 hours or of unknown duration.
Transesophageal echocardiogram (TEE) is recommended in all patients undergoing early cardioversion where there is evidence for insufficient anticoagulation in the 3 weeks before planned cardioversion. In such cases, TEE helps to exclude the presence of intra-atrial thrombi and provides reassuring significance in terms of subsequent peri-operative efficacy and safety. Dr. Breithard also highlighted the value of TEE in specific conditions and as a monitoring tool in patients with intra-atrial thrombi at time of first examination.

The second speaker, Dr. Jean-Yves Le Heuzey, (Paris, FR) highlighted the role of old and new drugs used to convert atrial fibrillation. Using the data from AVRO, he addressed the different attitudes of the medical community to the use of pharmacological or electrical cardioversion, depending on the European country.
Pharmacological cardioversion requires careful clinical assessment, because selection of anti-arrhythmic drugs is highly dependent on the patient characteristics. Flecainide, Propafenone and Sotalol, preferably intravenously administered, continue to be the preferred drugs in patients presenting with no or mild underlying heart disease. 
Amiodarone is less effective in the acute setting, but is more valuable, and indeed, the only recommended drug in patients with significant heart disease. There was some discussion about  Vernakalant, as this drug provides an exceptionally rapid efficacy when administered intraveneously, usually enabling restoration of sinus rhythm within 8 to 14 min in about 50% of patients. Clearly, this drug suffers the same limitations as other class I or III drugs and patients should be selected with care.
The "pill-in-the-pocket" solution for out-of-hospital acute oral management of atrial fibrillation relapses should be applied to a very select population with adequate preparation and no heart disease or mild heart disease.

The third speaker, Dr. Helmut Puerefellner(Linz, AT), highlighted the practical issues when performing cardioversion of atrial fibrillation. Attention was given to the side effects that can be generated in response to administration of anti-arrhythmic drugs, especially intravenously. In addition to the commonly reported cardiac side-effects, he focused on general side effects, such as hypotension or respiratory impairment that may be associated with either anti-arrhythmic drugs or anesthetic drugs in the setting of sedation.
The presentation was enriched by the discussion in which different clinical scenarios were represented. In response to one question, Dr. Puerenfeller discouraged the performance of more than three consecutive unsuccessful attempts at electrical cardioversions because of possible failure to restore sinus rhythm.
In response to another question, he suggested that novel oral anticoagulants may be considered as a valuable alternative to vitamin K antagonist (VKA) therapy in naive patients presenting for cardioversion.

The Moderator, Dr. Riccardo Cappato (San Donato Milanese, IT), responded that initiation of a new drug for thrombo-embolic protection does not appear to be recommendable. He noted that, in the absence of solid clinical data, VKA should continue to represent the standard of care in this setting.
Dr. Puerenfeller reported recent data from a Finnish survey showing that female patients with heart failure, diabetes  and vascular disease independently correlate with perioperative thromboembolic rates between 2% and 9%. Despite the evidence from prospective controlled studies, Dr. Puerenfeller suggested that these patients may be candidate to peri-operative anticoagulation.

The final speaker, Dr. Lucas DE ROY (Wavre, BE), addressed the important field of what to do after cardioversion. His presentation was focused on anticoagulation therapy and anti-arrhythmic therapy. Anticoagulation therapy should be continued in all patients depending on their risk score. Patients at low risk, and specifically those with new onset atrial fibrillation (about 25% of all patients), may discontinue the anticoagulation therapy after 30 to 45 days from cardioversion, if he or she has a low risk profile and maintains a stable sinus rhythm. 
Novel anticoagulants clearly represent a valuable alternative to VKAs and can be used as a chronic therapy even after switching from peri-operative VKA treatment. Anti-arrhythmic drugs can be selected under the assumption that the probability of maintaining sinus rhythm will progressively decline with time. Oral sotalol and dofetilide are associated with one-year success rates between 50% and 60%, similar to acute cardioversion success rates. Although amiodarone appears superior to these drugs, its discontinuation rate over time is significant and counterbalances the anti-arrhythmic efficacy of the drug. 




Cardioversion of atrial fibrillation in 2014: practical issues

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.