Effectiveness of dual external direct current cardioversion for initial cardioversion in atrial fibrillation

Abstract

Introduction Dual external direct current cardioversion (dual‐DCCV) is a rhythm control strategy for persistent atrial fibrillation (AF), involving simultaneous delivery of two shocks from two defibrillators. The long‐term effectiveness of this approach has not been studied in the biphasic cardioversion era. Methods Seventy‐seven consecutive patients at a single center were identified to receive dual‐DCCV at the time of their initial cardioversion for AF, when maximum output standard external direct current cardioversion failed in two vectors. Logistic regression was used to analyze risk factors for dual‐DCCV in a historical control group of 77 patients undergoing standard cardioversion and Cox proportional hazard models were used to compare time to AF recurrence. Results The dual‐DCCV group had a significantly larger body mass index (BMI), but similar AF duration and left atrial size as controls. Multivariable logistic regression revealed that BMI and absence of prior paroxysmal AF were risk factors for dual‐DCCV (P < 0.05). There was no difference observed between dual‐DCCV and control groups (adjusted hazard ratio = 0.57; P = .12) after adjusting for number of shocks and age. Transient hypoxia was the only acute complication in either group (P > .999). Conclusion Dual‐DCCV appears to be a safe and effective cardioversion strategy for patients with AF. The need for dual‐DCCV in the treatment of AF appears to be influenced more by body habitus than atrial substrate.

A stepwise external cardioversion protocol for atrial fibrillation to maximize acute success rate

“…Dual external cardioversion using biphasic shock is a safe and effective strategy in patients with large body habitus. 7 , 27 In our study, the mean BMI in a patient that required the use of two simultaneous defibrillators was 56.2 ± 9.51 while the remaining patients in Group B had a mean BMI of 35.9 ± 9.81 ( P < 0.0001).…”

Dual vs Single Cardioversion of Atrial Fibrillation in Patients With Obesity

“…The sample size was determined using assumptions based on prior published studies. 14,18,28 Using an expected efficacy of 75% for single DCCV and 90% for dual DCCV, we calculated that enrolling 200 patients and randomizing 1:1 would result in 80% power at a 2-sided α = .05. The statistical analysis was performed using the principle of intention to treat.…”

“…Dual DCCV, in contrast to the conventional approach using a single set of pads (single DCCV), uses 2 sets of defibrillator pads to administer simultaneous shocks, resulting in higher cumulative energy and current density delivered to the atrial myocardium . Dual DCCV has historically been used as salvage therapy for patients with AF refractory to maximum energy single DCCV, with previous case reports and retrospective analyses demonstrating this strategy to be potentially more effective and safe . In response to the notably elevated rate of cardioversion failure among patients with obesity, this study sought to evaluate the comparative effectiveness of dual DCCV vs single DCCV as an initial therapeutic approach for managing AF in this specific patient population.…”

“…23 Dual DCCV has historically been used as salvage therapy for patients with AF refractory to maximum energy single DCCV, with previous case reports and retrospective analyses demonstrating this strategy to be potentially more effective and safe. 18,[24][25][26][27][28][29][30] In response to the notably elevated rate of cardioversion failure among patients with obesity, this study sought to evaluate the comparative effectiveness of dual DCCV vs single DCCV as an initial therapeutic approach for managing AF in this specific patient population.…”

“…[10][11][12][13][14][15][16] This failure is often attributed to higher transthoracic impedance, atrial enlargement, and the dispersion of energy, which collectively lead to insufficient current density at the atrial myocardium. [17][18][19][20] Cardioversion failure may result in adverse patient outcomes related to multiple shocks and prolonged sedation duration, as well as a negative impact on quality of life and loss of cardiac benefit that would be expected from restoring sinus rhythm. 21,22 Patients with obesity may be particularly susceptible to such complications.…”