Aims Electrical cardioversion is commonly used to restore sinus rhythm in patients with atrial fibrillation (AF), but procedural technique and clinical success vary. We sought to identify techniques associated with electrical cardioversion success for AF patients. Methods and results We searched MEDLINE, EMBASE, CENTRAL, and the grey literature from inception to October 2022. We abstracted data on initial and cumulative cardioversion success. We pooled data using random-effects models. From 15 207 citations, we identified 45 randomized trials and 16 observational studies. In randomized trials, biphasic when compared with monophasic waveforms resulted in higher rates of initial [16 trials, risk ratio (RR) 1.71, 95% CI 1.29–2.28] and cumulative success (18 trials, RR 1.10, 95% CI 1.04–1.16). Fixed, high-energy (≥200 J) shocks when compared with escalating energy resulted in a higher rate of initial success (four trials, RR 1.62, 95% CI 1.33–1.98). Manual pressure when compared with no pressure resulted in higher rates of initial (two trials, RR 2.19, 95% CI 1.21–3.95) and cumulative success (two trials, RR 1.19, 95% CI 1.06–1.34). Cardioversion success did not differ significantly for other interventions, including: antero-apical/lateral vs. antero-posterior positioned pads (initial: 11 trials, RR 1.16, 95% CI 0.97–1.39; cumulative: 14 trials, RR 1.01, 95% CI 0.96–1.06); rectilinear/pulsed biphasic vs. biphasic truncated exponential waveform (initial: four trials, RR 1.11, 95% CI 0.91–1.34; cumulative: four trials, RR 0.98, 95% CI 0.89–1.08) and cathodal vs. anodal configuration (cumulative: two trials, RR 0.99, 95% CI 0.92–1.07). Conclusions Biphasic waveforms, high-energy shocks, and manual pressure increase the success of electrical cardioversion for AF. Other interventions, especially pad positioning, require further study.
Objective We conducted a meta‐analysis to estimate the risk of adverse events, life expectancy, and event‐free life expectancy after the Ross procedure in adults. Methods We searched databases for reports evaluating the Ross procedure in patients aged more than or equal to 16 years of age. A microsimulation model was used to evaluate age‐ and gender‐specific life expectancy for patients undergoing the Ross procedure. Results Data were pooled from 63 articles totaling 19 155 patients from 20 countries. Perioperative mortality was 2.5% (95% confidence interval [CI]: 1.9‐3.1; N = 9978). We found a mortality risk of 5.9% (95% CI: 4.8‐7.2) at a mean follow‐up of 7.2 years (N = 7573). The rate of perioperative clinically significant bleeding was 1.0% (95% CI: 0.1‐3.0); re‐exploration for bleeding 4.6% (95% CI: 3.1‐6.3); postoperative clinically significant bleeding from 30 days until a mean of 7.1 years was 0.5% (95% CI: 0.2‐1.0). At a mean of 6.9 years of follow‐up, reintervention rate of any operated valve was 7.9% (95% CI: 5.7‐10.3). The risk of valve thrombosis was 0.3% (95% CI: 0.2‐0.5) at 7.6 years; peripheral embolism 0.3% (95% CI: 0.2‐0.4) at 6.4 years; stroke 0.9% (95% CI: 0.7‐1.2) at 6.5 years; and endocarditis 2.1% (95% CI: 1.6‐2.6) at 8.0 years. Microsimulation reported a 40‐year‐old undergoing the Ross procedure to have a life expectancy of 35.4 years and event‐free life expectancy of 26.6 years. Conclusions Ross procedure in nonelderly adults is associated with low mortality and low risk of adverse events both at short‐ and long‐term follow‐up. The surgical community must prioritize a large, expertize‐based randomized controlled trial to definitively address the risks and benefits of the Ross procedure compared to conventional aortic valve replacement.
Background: Electrical cardioversion (ECV) is a common management strategy for atrial fibrillation (AF). ECV contains multiple modifiable components, including pad size and placement, shock energy, and waveform phases. Guidance on optimal technique, however, is limited. A comprehensive review of interventions used to increase ECV success will guide ideal clinical practice and identify techniques that could be studied in future randomized controlled trials. Methods: This review will include RCTs randomized controlled trial and observational studies that compare acute cardioversion success between 2 or more non-pharmacological interventions in patients with AF undergoing ECV. We will search CENTRAL, MEDLINE and EMBASE from inception to present and will also include the grey literature as part of our search. We will assess the risk of bias for each study and summarize the extracted data in a narrative report with a table of findings included. Results: Based on a full search strategy developed for MEDLINE along with findings from the grey literature search, the non-pharmacological interventions are expected to include pad placement, shock energy, waveform phases, and manual pressure, among others. Conclusions: The objective of this scoping review is to identify and examine the evidence on non-pharmacological interventions to improve electrical cardioversion in patients with AF. Registered on Open Science Framework: https://osf.io/gdh27/
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