Cardioversion of atrial fibrillation in obese patients: Results from the Cardioversion‐BMI randomized controlled trial

Aims Obesity is associated with higher electrical cardioversion (ECV) failure in persistent atrial fibrillation (PeAF). For ease‐of‐use, many centers prefer patches over paddles. We assessed the optimum modality and shock vector, as well as the safety and efficacy of the Manual Pressure Augmentation...

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Published in:Journal of cardiovascular electrophysiology Vol. 30; no. 2; pp. 155 - 161
Main Authors: Voskoboinik, Aleksandr, Moskovitch, Jeremy, Plunkett, George, Bloom, Jason, Wong, Geoffrey, Nalliah, Chrishan, Prabhu, Sandeep, Sugumar, Hariharan, Paramasweran, Ramanathan, McLellan, Alex, Ling, Liang‐Han, Goh, Cheng‐Yee, Noaman, Samer, Fernando, Himawan, Wong, Michael, Taylor, Andrew J., Kalman, Jonathan M., Kistler, Peter M.
Format: Journal Article
Language:English
Published: United States Wiley Subscription Services, Inc 01.02.2019
Subjects:
Aged
atrial fibrillation
Atrial Fibrillation - complications
Atrial Fibrillation - diagnosis
Atrial Fibrillation - physiopathology
Atrial Fibrillation - therapy
Body Mass Index
Cardiac arrhythmia
Cross-Over Studies
Defibrillators
direct current cardioversion
Electric Countershock - adverse effects
Electric Countershock - instrumentation
Electric Countershock - methods
Equipment Design
Female
Fibrillation
Humans
left atrium
Male
Middle Aged
Obesity
Obesity - complications
Obesity - diagnosis
Obesity - physiopathology
Prospective Studies
Retreatment
Shock
Success
transthoracic impedance
Treatment Failure
Victoria
Victoria
transthoracic impedance
atrial fibrillation
direct current cardioversion
left atrium
obesity
ISSN:1045-3873, 1540-8167, 1540-8167
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Summary:Aims Obesity is associated with higher electrical cardioversion (ECV) failure in persistent atrial fibrillation (PeAF). For ease‐of‐use, many centers prefer patches over paddles. We assessed the optimum modality and shock vector, as well as the safety and efficacy of the Manual Pressure Augmentation (MPA) technique. Methods Patients with obesity (BMI ≥ 30) and PeAF undergoing ECV using a biphasic defibrillator were randomized into one of four arms by modality (adhesive patches or handheld paddles) and shock vector (anteroposterior [AP] or anteroapical [AA]). If the first two shocks (100 and 200 J) failed, then patients received a 200‐J shock using the alternative modality (patch or paddle). Shock vector remained unchanged. In an observational substudy, 20 patients with BMI of 35 or more, and who failed ECV at 200 J using both patches/paddles underwent a trial of MPA. Results In total, 125 patients were randomized between July 2016 and March 2018. First or second shock success was 43 of 63 (68.2%) for patches and 56 of 62 (90.3%) for paddles (P = 0.002). There were 20 crossovers from patches to paddles (12 of 20 third shock success with paddles) and six crossovers from paddles to patches (three of six third shock success with patches). Paddles successfully cardioverted 68 of 82 patients compared with 46 of 69 using patches (82.9% vs 66.7%; P = 0.02). Shock vector did not influence first or second shock success rates (82.0% AP vs 76.6% AA; P = 0.46). MPA was successful in 16 of 20 (80%) who failed in both (patches/paddles), with 360 J required in six of seven cases. Conclusion Routine use of adhesive patches at 200 J is inadequate in obesity. Strategies that improve success include the use of paddles, MPA, and escalation to 360 J.
Bibliography:Dr Voskoboinik is supported by cofunded NHMRC/NHF postgraduate scholarships and Baker IDI Bright Sparks scholarships. Professor Kalman is supported by a NHMRC practitioner fellowship. This study is supported in part by the Victorian Government’s Operational Infrastructure Funding. Other authors: No disclosures.
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ISSN:1045-3873
1540-8167
1540-8167
DOI:10.1111/jce.13786