Cardioversia

The ESC Textbook of Cardiovascular
Medicine (3 edn)
A. John Camm (ed.) et al.
https://doi.org/10.1093/med/9780198784
906.001.0001
Published: 2018 Online ISBN:
9780191827143 Print ISBN:
9780198784906
Downloaded from https://academic.oup.com/esc/book/35489/chapter/312426068 by European Society of Cardiology user on 12 June 2023

CHAPTER
41.11 Restoration of sinus rhythm: direct current

cardioversion 
Riccardo Cappato
https://doi.org/10.1093/med/9780198784906.003.0504 Pages 2145–2147

Published: July 2018
Abstract
First introduced in 1962, electrical cardioversion represents an e ective and safe therapy to restore
sinus rhythm in patients with atrial brillation (AF). Consistent with the original description by Lown,
cardioversion is obtained through a ‘brief high-energy capacitor-stored electric shock … discharged
across the intact chest of the lightly anesthetized patient’, electronically programmed to fall outside of
the ‘vulnerable period’ of ventricular repolarization. Procedures performed according to the original
description di ered very little from those performed today, although a most remarkable advance was

represented by the upgrading from the initial monophasic to the actual biphasic shock waveform. With
this technique, atrial and ventricular de brillation thresholds and the probability of post-shock re-
initiation of brillating activity could be reduced. The anteroapical dual electrode con guration is the
most commonly used and self-adhesive paddles obviate the operator-dependent variability of
electrode location, pressure, and surface contact on the chest. Acute cardioversion is indicated in
subjects with new-onset AF, high-rate recurrent AF, or recurrent AF in the setting of severely impaired
left ventricular function with haemodynamic instability. In all other cases, elective cardioversion is
o ered under adequate anticoagulation using an early or a delayed approach. Pre-treatment with
antiarrhythmic drugs increases the likelihood of restoration of sinus rhythm and helps prevent
recurrent AF. Arrhythmia duration, cardiac size, P-wave duration, presence of rheumatic heart
disease, and previous cardioversion are predictors of AF recurrence. Post cardioversion,
antiarrhythmic drugs are mandatory. Patients receiving long-term treatment with antiarrhythmic
drugs have a larger probability of maintaining sinus rhythm during follow-up than patients receiving
short-term treatment.
Keywords: electrical, cardioversion, atrial fibrillation, direct current, shock

Collection: Oxford Medicine Online
This chapter provides the background information and detailed discussion of the data for the following
current ESC Guidelines on: atrial brillation - https://doi.org/10.1093/eurheartj/ehaa612
Summary
First introduced in 1962, electrical cardioversion represents an e ective and safe therapy to restore sinus
rhythm in patients with atrial brillation (AF). Consistent with the original description by Lown,
cardioversion is obtained through a ‘brief high-energy capacitor-stored electric shock … discharged across
the intact chest of the lightly anesthetized patient’, electronically programmed to fall outside of the
‘vulnerable period’ of ventricular repolarization. Procedures performed according to the original
description di ered very little from those performed today, although a most remarkable advance was
represented by the upgrading from the initial monophasic to the actual biphasic shock waveform. With this

technique, atrial and ventricular de brillation thresholds and the probability of post-shock re-initiation of
brillating activity could be reduced. The anteroapical dual electrode con guration is the most commonly
used and self-adhesive paddles obviate the operator-dependent variability of electrode location, pressure,
and surface contact on the chest. Acute cardioversion is indicated in subjects with new-onset AF, high-rate
recurrent AF, or recurrent AF in the setting of severely impaired left ventricular function with
haemodynamic instability. In all other cases, elective cardioversion is o ered under adequate
anticoagulation using an early or a delayed approach. Pre-treatment with antiarrhythmic drugs increases
the likelihood of restoration of sinus rhythm and helps prevent recurrent AF. Arrhythmia duration, cardiac
size, P-wave duration, presence of rheumatic heart disease, and previous cardioversion are predictors of AF
recurrence. Post cardioversion, antiarrhythmic drugs are mandatory. Patients receiving long-term
treatment with antiarrhythmic drugs have a larger probability of maintaining sinus rhythm during follow-
up than patients receiving short-term treatment.
History
Electrical cardioversion for the treatment of atrial brillation was rst introduced at the 54th annual
1
meeting of the American Society for Clinical Investigation in 1962. It was originally described by Zoll and
2
colleagues in 1954 as a therapeutic technique to terminate ventricular brillation. In 1962 and 1963, Lown
and colleagues adopted electrical cardioversion for safer and more e cient termination of atrial
3,4
brillation. Prior to its introduction, the method of terminating atrial brillation had not changed since
5
Frey rst introduced quinidine in 1918. Quinidine administration had been somewhat discouraging due to a
complicated titration strategy, a not infrequent untoward reactions (including sudden death), and its
4
ine ciency in restoring sinus rhythm in many cases.
The original technique of electrical cardioversion consisted of a ‘brief high-energy capacitor-stored electric
4
shock … discharged across the intact chest of the lightly anesthetized patient’. In order to prevent the
danger of shock-induced ventricular brillation, discharge was programmed electronically to fall outside of
the ‘vulnerable period’ (a brief interval in the cardiac cycle during which the heart is susceptible to
electrically induced ventricular brillation). This fundamental requisite has been maintained over the years
and still represents a mandatory condition to obviate the risk of shock-induced life-threatening
arrhythmias (proarrhythmic complication).
The apparatus employed for electrical cardioversion originally consisted of four components: (1) a direct-
current (DC) depolarizer to provide the necessary electric energy; (2) a synchronizer to permit timely
discharge of the electric pulse during any preselected phase of the cardiac cycle; (3) a cardiometer to
monitor the heart rate and provide an R-wave signal as a reference for the synchronizer; and (4) a
4
cardioscope for continuous display of the patient’s electrocardiogram.
Procedures performed in 1962 di ered very little from those performed today. In those days, paddles were
placed in an anteroapical position with conductive paste between skin and paddle applied with rm
pressure. A 2.5 ms pulse of DC monophasic waveform energy was given timed to the R wave with energies
between 0 and 400 J. With this con guration, the e cacy of cardioversion (inclusive of absolute failure and
6
clinical failure) was about 70%.
A most relevant advance to improve cardioversion e cacy was the advent of biphasic shock. With this
7,8
technique, atrial and ventricular de brillation thresholds and the probability of post-shock re-initiation
6
of brillating activity could be reduced. Biphasic shock has contributed to signi cantly improve the
9
e ciency of electrical cardioversion. In addition, self-adhesive pads provided with anti-resistive paste are
nowadays positioned on the patient’s chest prior to the procedure to optimize the probability of success and

9
increase the patient’s comfort.
Indications and techniques
Electrical cardioversion is performed according to two clinical conditions: (1) acute cardioversion (i.e. within
48 h from documented onset of atrial brillation or atrial tachyarrhythmia), or (2) elective cardioversion
(i.e. 48 h or longer from documented onset of atrial brillation or atrial tachyarrhythmia, or of unknown
duration).
Acute cardioversion
Emergency electrical cardioversion, without delaying to achieve anticoagulation, is indicated in subjects
with life-threatening haemodynamic instability caused by new-onset atrial brillation, high-rate recurrent
atrial brillation, or recurrent atrial brillation in the setting of severely impaired left ventricular function.
A less emergent condition is represented by atrial brillation of recent new onset and with or without
haemodynamic instability. In this case, pharmacological cardioversion can be considered prior to electrical
cardioversion. Overall, the short procedure duration, the high success rate, and the low risk of
proarrhythmic e ects make acute cardioversion a most preferred option to enable a rapid in-hospital
patient course. When evaluating the indication for cardioversion, one should consider that (1) at least 50%
10
of atrial brillation episodes will spontaneously convert to sinus rhythm within 48 h ; and (2) when the
rst episode of atrial brillation spontaneously terminates, nearly 40% of patients will not have a
11
recurrence during the next 5 years.
Elective cardioversion
The electivity of cardioversion is intended for protecting patients from the risk of periprocedural stroke by
means of adequate anticoagulation. To this purpose, two strategies have been developed: (1) an ‘early’
cardioversion, according to which patients are cardioverted if a preliminary transoesophageal
echocardiogram has failed to show intra-atrial thrombi or if adequate anticoagulation has been e ciently
12
established during the 3 preceding weeks ; and (2) a ‘delayed’ cardioversion according to which
13
anticoagulation therapy is administered for at least 3 weeks before cardioversion. The choice of elective
cardioversion is usually left to the best judgement of the investigator. Delaying cardioversion may reduce
the probability of maintaining sinus rhythm at 45-day follow-up and the proportion of patients e ectively
14
undergoing cardioversion. Elective cardioversion is indicated in patents with atrial brillation of new
onset presenting 48 h after onset of symptoms or of unknown duration and in patients with symptomatic
persistent atrial brillation.
Pharmacological preparation
Antiarrhythmic drugs
Pre-treatment with antiarrhythmic drugs increases the likelihood of restoration of sinus rhythm and helps
15
prevent recurrent atrial brillation. Oral agents such as ecainide and dofetilide that are most e ective for
16
the pharmacological cardioversion of atrial brillation are probably to be preferred as an adjuvant therapy
at time of electrical cardioversion.

Anticoagulation therapy
In early studies, the periprocedural risk of thromboembolic events associated with elective cardioversion
18,19,20
ranged between 5% and 7% in non-anticoagulated patients. The introduction of vitamin K
antagonists, although never validated in controlled trials, has reduced the periprocedural incidence of
12,20
events to between 0.6% and 1.6%. As a consequence, vitamin K antagonists have represented the
21,22,23,24
standard of care for many years until the recent introduction of novel oral anticoagulants. When
25
administered empirically or in post hoc analyses of randomized trials versus vitamin K antagonists,
26 27 28
dabigatran, rivaroxaban, and apixaban have proven rather safe and e ective during the periprocedural
phase of elective cardioversion. In a recent study, rivaroxaban showed similar of periprocedural
14
thromboembolic and bleeding e ects as vitamin K antagonists. Due to its predictable pharmacokinetics,
rivaroxaban and other novel oral anticoagulants may signi cantly reduce the time to delayed cardioversion
and increase the number of eligible patients that e ectively undergo this procedure. These characteristics
29
are also likely to reduce hospitalization costs and increase the number of patients in sinus rhythm during
30
follow-up.
Procedure execution
External cardioversion
Electrode con guration: an e cient electrical cardioversion requires that a su cient current density hits a
6
dominating part of the brillating atria mass. In humans, the atria are located to the left of the mid-sternal
line some 5 cm up to 17 cm away from the skin surface deep within the thoracic cage, with the left atrium
posterior to the right atrium. In light of these characteristics, it is possible that an anterior-to-posterior
(mid sternal-to-dorsal, opposite to the anterior location) de brillating paddle (serving as electrode)
con guration is slightly more e ective than an anterior-to-anterior (right upper subclavian-to-left lower
31,32
anterolateral—‘apical’—below the nipple) de brillating paddle con guration. This di erence, if
con rmed, may be related to the lower de brillation thresholds associated with the latter de brillation
6
paddle con guration and may be less relevant with biphasic than with monophasic shocks.
Originally, cardioversion paddles were positioned at the target sites and held rmly in the selected position
by the operator’s hands (manual technique). There is no conclusive evidence that applying active chest wall
pressure through the cardioversion paddles, as empirically performed in the early times, would decrease
de brillation threshold or increase e ectiveness. Conductive paste was applied to reduce conductive
resistance and prevent arching. More recently, self-adhesive paddles are applied passively to the patient’s
skin at target sites and shock energy is delivered without the need of the operator (automatic technique).
Due to its practicality, the anterior-to-anterior de brillating paddle con guration has been and still is the
one con guration which is more often used in daily practice. Usually, the left lower anterolateral (apical)
electrode serves as cathode, although evidence in favour of any preselected polarity to reduce de brillation
33,34
threshold or increase cardioversion probability is missing. Regardless of the selected putative dual
electrode polarity and location, alternative polarity and con guration should be considered as
complementary options if the rst attempts fail to restore sinus rhythm.
Energy application: although the risk of shock-related myocardial damage is limited for cardioversion of
6
atrial brillation, the initial shock energy should be adapted to the need of minimizing the risk of damage
while maximizing the probability of success at the rst attempt (which also is proportional to the energy
applied). E ective cardioversion of atrial brillation typically requires at least 200 J using monophasic

shock energy, and at least 100 J using biphasic shock energy. For both shock energy forms, the probability of
success increases as the applied energy is enhanced. More than 90% e ective conversion rates can be
35
achieved with 360 J and 200 J shock energies with the monophasic and the biphasic shock energy
36
techniques, respectively.
Internal cardioversion
Technique and energy application: with internal cardioversion, the shock is delivered via one electrode
catheter (and an indi erent plate positioned on the patient’s skin) or via two electrode catheters advanced
into the heart (usually one catheter in the right atrium and the other catheter either in the distal coronary
sinus or in the left pulmonary artery). Originally, high-energy internal shocks were found to be e ective in
37
cases of atrial brillation resistant to external cardioversion. The application of biphasic shock energy in
this setting contributed to substantially limit the safety concerns generated by the initial high-energy
38
intracardiac shock delivery pulses and to signi cantly reduce the amount of e ective energy required
37
(usually between 5 and 30 J). Consistent with the original ndings, more recent studies con rmed that
internal cardioversion is more e ective than external cardioversion and that it may e ectively revert to
39,40,41,42
sinus rhythm atrial brillation episodes that are refractory to external cardioversion. Despite these
advantages, a widespread use of internal cardioversion has been limited by the increasingly larger di usion
of e ective external cardioversion assisted by biphasic shock energy. In addition, patients with atrial
brillation refractory to external cardioversion are not likely to maintain sinus rhythm during follow-up
thus further limiting the indication of internal cardioversion in these patients.
Complications
Complications of cardioversion are those occurring in the periprocedural time period that usually includes
the time from eligibility up to the 30–45 days after cardioversion. They are infrequent and include the
4,12,15,20,43,44,45 15
following categories: thromboembolic, bleeding secondary to treatment with anticoagulants,
4,6,12,15,20
cardiovascular including proarrhythmic (tachyarrhythmias and bradyarrhythmias), associated with
6 6,15
general anaesthesia or sedation, and skin burns. A special condition is represented by device carriers, as
electrical cardioversion may lead to malfunctions related to interference with the electronic system of the
device. In these patients careful assessment of device technology should be performed after cardioversion to
6,15
limit the risk of malfunction post cardioversion.
Follow-up
Predictors of sinus rhythm

Many studies have been conducted to evaluate which conditions are most likely to protect cardioverted
46
patients from the risk of a recurrence of atrial brillation. Most studies were conducted on limited patient
47,48
series and based on retrospective analysis. Given these limitations, duration of atrial brillation, cardiac
49 49 50 51,52
size and function, P-wave duration, presence of rheumatic heart disease, left atrial enlargement,

53 54
older age, and previous cardioversion are among the most commonly recognized predictors of
arrhythmia recurrence post cardioversion.
Drug therapy
Antiarrhythmic agents administered prior to electrical cardioversion have been shown to increase the
55
probability of acute restoration of sinus rhythm and to favour its maintenance over long-term follow-up.
Class IA (disopyramide, quinidine), class IC ( ecainide, propafenone), and class III agents (amiodarone,
dofetilide, sotalol) have been shown to signi cantly reduce the probability of recurrence of atrial
brillation.
After cardioversion, antiarrhythmic drugs appear mandatory in the majority of patients as their absence can
17
be associated with a 71–84% 1-year incidence of atrial brillation recurrence. Amiodarone has proven the
16
most e ective agent to prevent such recurrences. Dofetilide, ecainide, propafenone, sotalol, and
quinidine can be used as a valuable alternative, especially due to the high risk of side e ects associated with
amiodarone administration. When administering these agents, one should consider that quinidine,
dofetilide, and sotalol are those most likely associated with proarrhythmic, sometimes life-threatening
16 17
e ects. Class IA antiarrhythmic drugs may be associated with an increase in adverse e ects or mortality.
Patients receiving post-cardioversion long-term treatment with antiarrhythmic drugs have a 15% higher
56
probability of maintaining sinus rhythm during follow-up than patients receiving short-term treatment.
References
1. Lown B, Amarasingham R, Neuman J, Berkowitz BV. Use of Synchronized Direct-Current. Fi y-fourth annual meeting of
American Society for Clinical Investigation, Atlantic City, New Jersey, 30 April 1962.
Google Scholar Google Preview WorldCat COPAC
2. Zoll PM, Linenthal AJ, Gibson W, Paul MH, Norman LR. Termination of ventricular fibrillation in man by externally applied
electrical countershock. N Engl J Med 1956;254:727. 10.1056/NEJM195604192541601
Google Scholar WorldCat Crossref PubMed

3. Lown B, Amarasingham R, Neuman J. New method for terminating cardiac arrhythmias. Use of synchronized capacitor
discharge. N Engl J Med 1962;182:548–55.
Google Scholar WorldCat PubMed
4. Lown B, Perlroth MG, Kaidbey S, Abe T, Harken DE. ʻCardioversionʼ of atrial fibrillation. A report on the treatment of 65
episodes in 50 patients. N Engl J Med 1963;269:325–31. 10.1056/NEJM196308152690701
5. Frey W. Ueber vorho limmern bei menschen und seine beseitigung durch chinidin. Berl Klin Wchnschr 1918:55:417–9,
450–2.
Google Scholar WorldCat
6. Gall NP, Murgatroyd FD. Electrical cardioversion of AF: the state of the art. PACE 2007;30:554–67. 10.1111/j.1540-
8159.2007.00709.x
Google Scholar WorldCat Crossref PubMed Web of Science
7. Schneider T, Martens PR, Paschen H, Kuisma M, Wolcke B, Gliner BE, Russell JK, Weaver WD, Bossaert L, Chamberlain D.
Multi-centre, randomized, controlled trial of 150-J monophasic biphasic shocks compared with 200- to 360-J monophasic
shocks in the resuscitation of out-of-hospital cardiac arrest victims. Circulation 2000;102:1780–7. 10.1161/01.CIR.102.15.1780
8. Cooper RA, Alferness CA, Smith WM, Ideker RE. Internal cardioverter of atrial fibrillation in sheep. Circulation
1993;87:1673–86. 10.1161/01.CIR.87.5.1673
9. Kirchhof P, Monnig G, Wasmer K, Heinecke A, Breithardt G, Eckhardt L, Bocker D. A trial of self-adhesive patch electrodes
and hand-held paddle electrodes for external cardioversion of atrial fibrillation (MOBIPAPA). Eur Heart J 2005;26:1292–
7. 10.1093/eurheartj/ehi160
10. DellʼOrfano JT, Patel H, Wobrette DL, Luck JC, Naccarelli GV. Acute treatment of atrial fibrillation: spontaneous conversion
rates and cost of care. Am J Cardiol 1999; 83: 788–90. 10.1016/S0002-9149(98)00993-X
11. Kerr CR, Humphries KH, Talajic M, Klein GJ, Connolly SJ, Green M, Boone J, Newman D. Progression to chronic atrial
fibrillation a er initial diagnosis of paroxysmal atrial fibrillation: results from Canadian Registry of Atrial Fibrillation. Am Heart J
2005;149:489–96.
Google Scholar WorldCat PubMed Web of Science
12. Klein AL, Grimm RA, Murray RD, Apperson-Hansen C, Asinger RW, Black IW, Davido R, Erbel R, Halperin JL, Orsinelli DA,
Porter TR, Stoddard MF, Assessment of Cardioversion Using Transesophageal Echocardiography Investigators. Use of
transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med 2001;344:1411–20.
13. Laupacis A, Albers G, Dalen J, Dunn MI, Jacobson AK, Singer DE. Antithrombotic therapy in atrial fibrillation. Chest
1998;114:(Suppl):579S–589S.
14. Cappato R, Ezekowitz ME, Klein AL, Camm AJ, Ma CS, Le Heuzey JY, Talajic M, Scanavacca M, Vardas PE, Kirchhof P,
Hemmrich M, Lanius V, Meng IL, Wildgoose P, van Eickels M, Hohnloser SH; X-VeRT Investigators. Rivaroxaban vs. vitamin K
antagonists for cardioversion in atrial fibrillation. Eur Heart J 2014;35:3346–55.
Google Scholar WorldCat Web of Science

15. Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B,
Heidbuchel H, Alfieri O, Angelini A, Atar D, Colonna P, De Caterina R, De Sutter J, Goette A, Gorenek B, Heldal M, Hohloser SH,
Kolh P, Le Heuzey JY, Ponikowski P, Rutten FH. Guidelines for the management of atrial fibrillation: the Task Force for the
Management of Atrial Fibrillation of the European Society of Cardiology. Eur Heart J 2010;31:2369–429.
16. Schilling RJ. Cardioversion of atrial fibrillation: the use of anti-arrhythmic drugs. Heart 2010;96:333–8.
17. Lafuente-Lafuente C, Mouly S, Longas-Tejero MA, Mahé I, Bergmann JF. Antiarrhythmic drugs for maintaining sinus
rhythm a er cardioversion of atrial fibrillation. Arch Int Med 2006;166:719–28.
18. Bjerkelund CJ, Orning OM. The e icacy of anticoagulant therapy in preventing embolism related to D.C. electrical
conversion of atrial fibrillation. Am J Cardiol 1969;23:208–16.
19. Arnold AZ, Mick MJ, Mazurek RP, Loop FD, Trohman RG. Role of prophylactic anticoagulation for direct current
cardioversion in patients with atrial fibrillation or atrial flutter. J Am Coll Cardiol 1992;19:851–5.
20. Stellbrink C, Nixdor U, Hofmann T, Lehmacher W, Daniel WG, Hanrath P, Geller C, Mugge A, Sehnert W, Schmidt-Lucke C,
Schmidt-Lucke JA. Safety and e icacy of enoxaparin compared with unfractionated heparin and oral anticoagulants for
prevention of thromboembolic complications in cardioversion of nonvalvular atrial fibrillation: the Anticoagulation in
Cardioversion using Enoxaparin (ACE) trial. Circulation 2004;109:997–1003.
21. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J, Wang S,
Alings M, Xavier D, Zhu J, Diaz R, Lewis BS, Darius H, Diener HC, Joyner CD, Wallentin L, RE-LY Steering Committee and
Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139–51.
22. Patel MR, Maha ey KW, Garg J, Pan G, Singer DE, Hacke W, Breithardt G, Halperin JL, Hankey GJ, Piccini JP, Becker RC,
Nessel CC, Paolini JF, Berkowitz SD, Fox KAA, Cali RM, ROCKET AF Investigators. Rivaroxaban versus warfarin in nonvalvular
atrial fibrillation. N Engl J Med 2011;365:883–91. 10.1056/NEJMoa1009638
Google Scholar WorldCat Crossref
23. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, Al Khalidi HR, Ansell J, Atar D, Avezum A, Bahit MC,
Diaz R, Easton JD, Ezekowitz JA, Flaker G, Garcia D, Geraldes M, Gersh BJ, Golitsyn S, Goto S, Hermosillo AG, Hohnloser SH,
Horowitz J, Mohan P, Jansky P, Lewis BS, Lopez-Sendon JL, Pais P, Parkhomenko A, Verheugt FW, Zhu J, Wallentin L, ARISTOTLE
Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011;365:981–
92. 10.1056/NEJMoa1107039
Google Scholar WorldCat Crossref Web of Science
24. Giugliano RP, Ru CT, Braunwald E, Murphy SA, Wiviott SD, Halperin JL, Waldo AL, Ezekowitz MD, Weitz JI, Špinar J,
Ruzyllo W, Ruda M, Koretsune Y, Betcher J, Shi M, Grip LT, Patel S.P., Patel I, Hanyok JJ, Mercuri M, Antman EM, ENGAGE AF-TIMI
48 Investigators. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013;369:2093–
104. 10.1056/NEJMoa1310907
25. Yadlapati A, Groh C, Passman R. Safety of short-term use of dabigatran or rivaroxaban for direct-current cardioversion in
patients with atrial fibrillation and atrial flutter. Am J Cardiol 2014;113:1362–3. 10.1016/j.amjcard.2013.12.044
26. Nagarakanti R, Ezekowitz MD, Oldgren J, Yang S, Chernick M, Aikens TH, Flaker G, Brugada J, Kamensky G, Parekh A,

Reilly PA, Yusuf S, Connolly SJ. Dabigatran versus warfarin in patients with atrial fibrillation: an analysis of patients undergoing
cardioversion. Circulation 2011;123:131–6 10.1161/CIRCULATIONAHA.110.977546
27. Piccini JP, Stevens SR, Lokhnygina Y, Patel MR, Halperin JL, Singer DE, Hankey GJ, Hacke W, Becker RC, Nessel CC,
Maha ey KW, Fox KA, Cali RM, Breithardt G. Outcomes following cardioversion and atrial fibrillation ablation in patients
treated with rivaroxaban and warfarin in the ROCKET AF trial. J Am Coll Cardiol 2013;61:1998–2006. 10.1016/j.jacc.2013.02.025
28. Flaker G, Lopes RD, Al Khatib SM, Hermosillo AG, Hohnloser SH, tinga B, Zhu J, Mohan P, Garcia D, Bartunek J, Vinereanu D
, Husted S, Harjola VP, Rosenqvist M, Alexander JH, Granger CB. E icacy and safety of apixaban in patients a er cardioversion
for atrial fibrillation: insights from the ARISTOTLE Trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in
Atrial Fibrillation). J Am Coll Cardiol 2014;63:1082–7. 10.1016/j.jacc.2013.09.062
29. Honhloser S, Cappato R, Ezekowitz MD, Evers T, Sahin K, Kirchhoh P, Meng IL, van Eickels M , Camm AJ. Patient-reported
treatment satisfaction and budget impact with rivaroxaban vs standard therapy in elective cardioversion of atrial fibrillation: a
post-hoc analysis of the x-vert trial. Europace 2016;18:184–90 . 10.1093/europace/euv294
30. Ezekowitz MD, Cappato R, Klein A, Ming IL, Hemmrich M, van Eickels M, Hohnloser SH. Factors predicting sinus rhythm in
patients cardioverted in the X-VERT study. Circulation 2014;130:A19504.
31. Dalzell GW, Anderson J, Adgey AA. Factors determining success and energy requirements for cardioversion of atrial
fibrillation. Q J Med 1990;76:903–13.
32. Mathew TP, Moore A, McIntyre M, Harbinson MT, Campbell NP, Adgey AA, Dalzell GW. Randomized comparison of
electrode positions for cardioversion of atrial fibrillation. Heart 1999;81:576–9. 10.1136/hrt.81.6.576
33. Oral H, Brinkman K, Pelosi F, Flemming M, Tse HF, Kim MH, Michaud GF, Knight BP, Goyal R, Strickberger SA, Morady F.
E ect of electrode polarity on the energy required for transthoracic atrial defibrillation. Am J Cardiol 1999;84:228–
30. 10.1016/S0002-9149(99)00241-6
34. Rashba EJ, Bouhouch R, MacMurdy KA, Shorofsky SR, Peters RW, Gold MR. E ect of shock polarity on the e icacy of
transthoracic atrial defibrillation Am Heart J 2002;143:541–5. 10.1067/mhj.2002.120155
35. Kirchhof P, Eckardt L, Loh P, Weber K, Fischer RJ, Seidl KH, Böcker D, Breithardt G, Haverkamp W, Borggrefe M. Anterior-
posterior versus antero-lateral electrode positions for external cardioversion of atrial fibrillation: a randomized trial. Lancet
2002;360:1275–9. 10.1016/S0140-6736(02)11315-8
36. Walsh SJ, McCarty D, McClelland AJJ, Owens CG, Trouton TG, Harbinson MT, O'Mullan S, McAllister A, McClements BM,
Stevenson M, Dalzell GW, Adgey AA. Impedance compensated biphasic waveforms for transthoracic cardioversion of atrial
fibrillation. A multi-centre comparison of antero-apical and antero-posterior pad positions. Eur Heart J
2005;26:1298. 10.1093/eurheartj/ehi196
37. Levy S, Lacombe P, Cointe R, Bru P. High energy transcatheter cardioversion of chronic atrial fibrillation. J Am Coll Cardiol
1988;12:524–18. 10.1016/0735-1097(88)90428-7

38. Mansourati J, Larlet JM, Salaun J, Maheu B, Blanc JJ. Safety of high energy internal cardioversion of paroxysmal atrial
fibrillation in humans. J Am Coll Cardiol 1997;20:1919–23.
39. Lévy S, Ricard P, Lau CP, Lok NS, Camm AJ, Murgatroyd FD, Jordaens LJ, Kappenberger LJ, Brugada P, Ripley KL. Multi-
center low energy transvenous atrial defibrillation (XAD) trial results in di erent subsets of atrial fibrillation. J Am Coll Cardiol
1997;29:750–5. 10.1016/S0735-1097(96)00583-9
40. Lévy S, Ricard P, Gueunoun M, Yapo F, Trigano J, Mansouri C, Paganelli F. Low-energy cardioversion of spontaneous atrial
fibrillation: immediate and long-term results. Circulation 1997;96:253–9. 10.1161/01.CIR.96.1.253
41. Alt E, Ammer R, Schmitt C, Evans F, Lehmann G, Pasquantonio J, Schömig A. A comparison of treatment of atrial
fibrillation with low-energy intracardiac cardioversion and conventional external cardioversion. Eur Heart J 1997;18:1796–
804. 10.1093/oxfordjournals.eurheartj.a015175
42. Schmitt C, Alt E, Plewan A, Ammer R, Leibig M, Karch M, Schömig A. Low energy intracardiac cardioversion a er failed
external cardioversion of atrial fibrillation. J Am Coll Cardiol 1996;28:994–9. 10.1016/S0735-1097(96)00274-4
43. Resnekov L, McDonald L. Complications in 220 patients with cardiac dysrhythmias treated by phased direct current shock,
and indications for electroconversion. Br Heart J 1967;29:926–35. 10.1136/hrt.29.6.926
44. Bjerkelund CJ, Orning OM. The e icacy of anticoagulant therapy in preventing embolism related to D.C. electrical
conversion of atrial fibrillation. Am J Cardiol 1969;23:208–16. 10.1016/0002-9149(69)90068-X
45. Arnold AZ, Mick MJ, Mazurek RP, Loop FD, Trohman RG. Role of prophylactic anticoagulation for direct current
cardioversion in patients with atrial fibrillation or atrial flutter. J Am Coll Cardiol 1992;19:851–5. 10.1016/0735-1097(92)90530-Z
46. Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermans AJ, Tijssen JG,
Crijns HJ; Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group. A comparison of rate control
and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002;347:1834–
40. 10.1056/NEJMoa021375
47. Dittrich HC, Erickson JS, Schneiderman T, Blacky AR, Savides T, Nicod PH. Echocardiographic and clinical predictors for
outcome of elective cardioversion of atrial fibrillation. Am J Cardiol 1898;63:193–7. 10.1016/0002-9149(89)90284-1
48. Dalzell GW, Anderson J, Adgey AA. Factors determining success and energy requirements for cardioversion of atrial
fibrillation. Q J Med 1990;76:903–13.
49. Raitt MH, Volgman AS, Zoble RG, Charbonneau L, Padder FA, O'Hara GE, Kerr D, AFFIRM Investigators. AFFIRM
Investigators. Prediction of the recurrence of atrial fibrillation a er cardioversion in the Atrial Fibrillation Follow-up Investigation
of Rhythm Management (AFFIRM) study. Am Heart J 2006;151:390–6. 10.1016/j.ahj.2005.03.019
50. Van Gelder IC, Crijns HJ, Val Gilst WH, Verwer R, Lie KI. Prediction of uneventful cardioversion and maintenance of sinus
rhythm from direct-current electrical cardioversion of chronic atrial fibrillation. Am J Cardiol 1991;68:41–6. 10.1016/0002-

9149(91)90707-R
51. Olshansky B, Heller EN, Mitchell LB, Chandler M, Slater W, Green M, Brodsky M, Barrell P, Greene HL. Are transthoracic
echocardiographic parameters associated with atrial fibrillation recurrence or stroke? Results from the Atrial Fibrillation Follow-
up Investigation of Rhythm Management (AFFIRM) study. J Am Coll Cardiol 2005;45:2025–33. 10.1016/j.jacc.2005.03.020
52. Akdemir B, Altekin RE, Küçük M, Yanikoğlu A, Karakaş MS, Aktaş A, Demir İ, Ermiş C. The significance of the le atrial
volume index in cardioversion success and its relationship with recurrence in patients with non-valvular atrial fibrillation
subjected to electrical cardioversion: a study on diagnostic accuracy. Anadolu Kardiyol Derg 2013;13:18–25.
Google Scholar WorldCat Web of Science
53. Van Gelder IC, Crijns HJ, Tieleman RG, Brügemann J, De Kam PJ, Gosselink AT, Verheugt FW, Lie KI. Chronic atrial
fibrillation. Success of serial cardioversion therapy and safety of oral anticoagulation. Arch Intern Med 1996;156:2585–92.
54. Abu-El-Haija B, Giudici MC. Predictors of long-term maintenance of normal sinus rhythm a er successful electrical
cardioversion. Clin Cardiol 2014;37:381–5. 10.1002/clc.22276
55. Naccarelli GV, DellʼOriano JT, Wolbrette DL, Patel HM, Luck JC. Cost-e ective management of acute atrial fibrillation: role
of rate control, spontaneous conversion, medical and direct-current cardioversion, transesophageal echocardiography and
antiembolic therapy. Am J Cardiol 2000;85:36D–45D 10.1016/S0002-9149(00)00905-X
56. Kirchhof P, Andresen D, Bosch R, Borggrefe M, Meinertz T, Parade U, Samol A, Steinbeck G, Trezl A, Wegscheider K,
Breithardt G. Short-term versus long-term antiarrhythmic drug treatment a er cardioversion of atrial fibrillation (Flec-SL): a
prospective, randomized, open-label, blinded endpoint assessment trial. Lancet 2012;380:238–45. 10.1016/S0140-
6736(12)60570-4
Further reading
Klein AL, Grimm RA, Murray RD, Apperson-Hansen C, Asinger RW, Black IW, Davido R, Erbel R, Halperin JL, Orsinelli DA,
Porter TR, Stoddard MF, Assessment of Cardioversion Using Transesophageal Echocardiography Investigators. Use of
transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med 2001;344:1411–
20. 10.1056/NEJM200105103441901
Cappato R, Ezekowitz ME, Klein AL, Camm AJ, Ma CS, Le Heuzey JY, Talajic M, Scanavacca M, Vardas PE, Kirchhof P, Hemmrich M,

Lanius V, Meng IL, Wildgoose P, van Eickels M, Hohnloser SH; X-VeRT Investigators. Rivaroxaban vs. vitamin K antagonists for
cardioversion in atrial fibrillation. Eur Heart J 2014;35:3346–55. 10.1093/eurheartj/ehu367
Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermans AJ, Tijssen JG,
Crijns HJ; Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group. A comparison of rate control
and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002;347:1834–
40. 10.1056/NEJMoa021375
Olshansky B, Heller EN, Mitchell LB, Chandler M, Slater W, Green M, Brodsky M, Barrell P, Greene HL. Are transthoracic
echocardiographic parameters associated with atrial fibrillation recurrence or stroke? Results from the Atrial Fibrillation Follow-
up Investigation of Rhythm Management (AFFIRM) study. J Am Coll Cardiol 2005;45:2025–33. 10.1016/j.jacc.2005.03.020
Kirchhof P, Andresen D, Bosch R, Borggrefe M, Meinertz T, Parade U, Samol A, Steinbeck G, Trezl A, Wegscheider K, Breithardt G.
Short-term versus long-term antiarrhythmic drug treatment a er cardioversion of atrial fibrillation (Flec-SL): a prospective,
randomized, open-label, blinded endpoint assessment trial. Lancet 2012;380:238–45. 10.1016/S0140-6736(12)60570-4
© European Society of Cardiology

Cardioversia

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cardioversia

Uploaded by

Copyright:

Available Formats

The ESC Textbook of Cardiovascular

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312426068 by European Society of Cardiology user on 12 June 2023

41.11 Restoration of sinus rhythm: direct current

https://doi.org/10.1093/med/9780198784906.003.0504 Pages 2145–2147

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312426068 by European Society of Cardiology user on 12 June 2023

Keywords: electrical, cardioversion, atrial fibrillation, direct current, shock

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312426068 by European Society of Cardiology user on 12 June 2023

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312426068 by European Society of Cardiology user on 12 June 2023

Indications and techniques

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312426068 by European Society of Cardiology user on 12 June 2023

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312426068 by European Society of Cardiology user on 12 June 2023

Predictors of sinus rhythm

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312426068 by European Society of Cardiology user on 12 June 2023

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312426068 by European Society of Cardiology user on 12 June 2023

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312426068 by European Society of Cardiology user on 12 June 2023

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312426068 by European Society of Cardiology user on 12 June 2023

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312426068 by European Society of Cardiology user on 12 June 2023

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312426068 by European Society of Cardiology user on 12 June 2023

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312426068 by European Society of Cardiology user on 12 June 2023

© European Society of Cardiology

You might also like