Repeated Dual External Direct Cardioversions Using Two Simultaneous 360‐J Shocks for Refractory Atrial Fibrillation Are Safe and Effective

Abstract

Failure of cardioversion of atrial fibrillation (AF) to sinus rhythm (SR) by standard external direct current cardioversion (DCC) may be due to failure of delivery of enough defibrillating energy rather than to the true refractoriness of AF. Ninety-nine patients with persistent AF (76 male; age 63.7 +/- 0.4 years; weight 113.1 +/- 25.1 kg) who failed standard DCC were included in this report. Under anesthesia, QRS synchronous shocks were delivered across anteroposterior electrodes in the following sequence: (1) a single 360-J shock; (2) another single 360-J shock within 2 minutes; (3) 30 minutes of rest, reinduction of anesthesia and delivery of two simultaneous monophasic 360-J shocks. All patients underwent all three DCC steps. Sixty-six (67%) patients converted to SR following the first dual simultaneous shock. Fourteen patients (14%) required more than one dual shock to achieve SR. This increased the overall success rate of resuming SR to 81%. Except for minor skin burns in three patients there were no procedure related complications. On follow-up at 1 month, 55 (56%) patients were still in SR, whereas 50 (51%) patients maintained SR at 12 months. This was similar to our general DCC population (55% of the 1698 patients were in SR 6 months post-DCC, P = ns). In conclusion, dual external monophasic 360-J DCC is an effective rescue technique for restoration of SR in patients with AF refractory to standard DCC. AF in these patients seems to be as amenable to chronic suppression as AF in the general population of DCC patients.

Make it two: A case report of dual sequential external defibrillation

“…DSED has been previously reported to work for multiple etiologies of cardiac arrest. 6,8,[10][11][12][13][14][15][16] In one report of 2,990 consecutive patients undergoing treatment in the electrophysiology lab over a 3-year period, all 5 patients with VF refractory to standard defibrillation were successfully defibrillated with DSED. 10 A handful of prehospital and emergency department case reports and small case series in recent years describe DSED.…”

Double sequential cardioversion for refractory ventricular tachycardia: A case report

“…No thromboembolic, serious hypotension, or congestive heart failure events were reported. 12 To our knowledge, there have been no studies on the use of DSSC in VT patients with a pulse.…”

“…[4][5][6] Two retrospective cohort studies of patients with stable sustained VT revealed that 10.6% and 17% of patients developed hypotension during treatment, 7,8 findings that are consistent with a study of unstable VT. 9 In patients with unstable VT refractory to repeated shocks at standard doses, guidelines do not currently identify a rapid-acting low-risk therapy. Double sequential cardioversion, performed by delivering two shocks through two sets of pads as closely timed as possible, has been described for the management of patients with refractory atrial fibrillation (AF) [10][11][12][13] and VF. [14][15][16][17][18] Here we describe the successful use of double sequential synchronized cardioversion (DSSC) in a patient with unstable VT refractory to standard electrical cardioversion methods.…”

Cardiac Arrest Resuscitation

“…Since then, it has been attempted with some success in out-of-hospital VF. 41,42 Timing of Shock Delivery Historically, early defibrillation has been a key link in the chain of survival and is important to minimize the elapsed interval until ROSC. 43 However, observational data suggests that defibrillation of a myocardium depleted of high energy phosphates resulted in higher incidence of post-defibrillation asystole.…”