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. 2020 Aug 1;22(8):1149-1161.
doi: 10.1093/europace/euaa057.

Cardioversion of atrial fibrillation and atrial flutter revisited: current evidence and practical guidance for a common procedure

Axel Brandes  1   2 , Harry J G M Crijns  3 , Michiel Rienstra  4 , Paulus Kirchhof  5 , Erik L Grove  6   7 , Kenneth Bruun Pedersen  1 , Isabelle C Van Gelder  1   2   4
Affiliations

Cardioversion of atrial fibrillation and atrial flutter revisited: current evidence and practical guidance for a common procedure

Axel Brandes et al. Europace. .

Abstract

Cardioversion is widely used in patients with atrial fibrillation (AF) and atrial flutter when a rhythm control strategy is pursued. We sought to summarize the current evidence on this important area of clinical management of patients with AF including electrical and pharmacological cardioversion, peri-procedural anticoagulation and thromboembolic complications, success rate, and risk factors for recurrence to give practical guidance.

Keywords: Anticoagulation; Atrial fibrillation; Atrial flutter; Electrical cardioversion; Pharmacological cardioversion; Thromboembolism.

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Figures

Figure 1
Figure 1
Antero-posterior electrode position for ECV. ECV, electrical cardioversion. Modified after Kirchhof et al., with permission.
Figure 2
Figure 2
The 1-1-1-1-1 pattern of recurrence after ECV of persistent AF. Modified after Van Gelder et al., with permission. AF, atrial fibrillation; ECV, electrical cardioversion; IRAF, immediate recurrence of atrial fibrillation.
Figure 3
Figure 3
Conversion to sinus rhythm over time after start of drug therapy for recent-onset AF. Class Ic AADs foreshorten time to sinus rhythm significantly. Amiodarone and non-AAD (rate control drugs) are associated with spontaneous conversion, with minimal conversion action of amiodarone discernable from 6 h on. At the end of the day around 60–70% of patients reached sinus rhythm. Modified after Crijns et al., with permission. AAD, antiarrhythmic drug; AF, atrial fibrillation.
Figure 4
Figure 4
Interval between cardioversion and thromboembolic events in 92 patients. From Berger and Schweitzer with permission.
Figure 5
Figure 5
Schematic approach for the TOE evaluation of the LAA before cardioversion. From Beigel et al., with permission. aSafe if no other contraindications exist for the patient. TOE refers to 2D TOE, but 3D TOE should be used, if available, to increase sensitivity and specificity of findings. 2D, 2-dimensional; 3D, 3-dimensional; LAA, left atrial appendage; TOE, transoesophageal echocardiography.
Figure 6
Figure 6
LAA thrombus (arrows) on cardiac CT. CT, computed tomography; LAA, left atrial appendage.
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References

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