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Randomized Controlled Trial
. 2024 Jul 1;9(7):641-648.
doi: 10.1001/jamacardio.2024.1091.

Dual vs Single Cardioversion of Atrial Fibrillation in Patients With Obesity: A Randomized Clinical Trial

Joshua D Aymond  1 , Alexandra M Sanchez  1 , Michael R Castine  2   3 , Michael L Bernard  1 , Sammy Khatib  1 , A Elise Hiltbold  1 , Glenn M Polin  1 , Paul A Rogers  1 , Paari S Dominic  4   5 , Cruz Velasco-Gonzalez  1 , Daniel P Morin  1   3
Affiliations
Randomized Controlled Trial

Dual vs Single Cardioversion of Atrial Fibrillation in Patients With Obesity: A Randomized Clinical Trial

Joshua D Aymond et al. JAMA Cardiol. .

Abstract

Importance: Atrial fibrillation and obesity are common, and both are increasing in prevalence. Obesity is associated with failure of cardioversion of atrial fibrillation using a standard single set of defibrillator pads, even at high output.

Objective: To compare the efficacy and safety of dual direct-current cardioversion (DCCV) using 2 sets of pads, with each pair simultaneously delivering 200 J, with traditional single 200-J DCCV using 1 set of pads in patients with obesity and atrial fibrillation.

Design, setting, and participants: This was a prospective, investigator-initiated, patient-blinded, randomized clinical trial spanning 3 years from August 2020 to 2023. As a multicenter trial, the setting included 3 sites in Louisiana. Eligibility criteria included body mass index (BMI) of 35 or higher (calculated as weight in kilograms divided by height in meters squared), age 18 years or older, and planned nonemergent electrical cardioversion for atrial fibrillation. Patients who met inclusion criteria were randomized 1:1. Exclusions occurred due to spontaneous cardioversion, instability, thrombus, or BMI below threshold.

Interventions: Dual DCCV vs single DCCV.

Main outcomes and measures: Return to sinus rhythm, regardless of duration, immediately after the first cardioversion attempt of atrial fibrillation, adverse cardiovascular events, and chest discomfort after the procedure.

Results: Of 2079 sequential patients undergoing cardioversion, 276 met inclusion criteria and were approached for participation. Of these, 210 participants were randomized 1:1. After exclusions, 200 patients (median [IQR] age, 67.6 [60.1-72.4] years; 127 male [63.5%]) completed the study. The mean (SD) BMI was 41.2 (6.5). Cardioversion was successful more often with dual DCCV compared with single DCCV (97 of 99 patients [98%] vs 87 of 101 patients [86%]; P = .002). Dual cardioversion predicted success (odds ratio, 6.7; 95% CI, 3.3-13.6; P = .01). Patients in the single cardioversion cohort whose first attempt failed underwent dual cardioversion with all subsequent attempts (up to 3 total), all of which were successful: 12 of 14 after second cardioversion and 2 of 14 after third cardioversion. There was no difference in the rating of postprocedure chest discomfort (median in both groups = 0 of 10; P = .40). There were no cardiovascular complications.

Conclusions and relevance: In patients with obesity (BMI ≥35) undergoing electrical cardioversion for atrial fibrillation, dual DCCV results in greater cardioversion success compared with single DCCV, without any increase in complications or patient discomfort.

Trial registration: ClinicalTrials.gov Identifier: NCT04539158.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Castine reported receiving speaker fees from ZOLL Medical outside the submitted work. Dr Khatib reported receiving personal fees from Medtronic Inc, Biotronik Medical, and Abbott Medical during the conduct of the study. Dr Morin reported receiving speaker fees from ZOLL Medical outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Defibrillation Pad Placement and Shock Vectors
This figure demonstrates the orientation of the 4 pads and indicates the set(s) of defibrillation pads used for cardioversion in the single and dual direct-current cardioversion (DCCV) cohorts, respectively. The numbers on the pads correspond to the pad pairs.
Figure 2.
Figure 2.. Consolidated Standards of Reporting Trials Flow Diagram
DCCV indicates direct-current cardioversion.
Figure 3.
Figure 3.. Efficacy of Cardioversion: Single Direct-Current Cardioversion (DCCV) vs Dual DCCV
Compared with single DCCV, cardioversion using the dual-DCCV strategy more often resulted in successful return to normal sinus rhythm.
See this image and copyright information in PMC

References

    1. Wang TJ, Parise H, Levy D, et al. . Obesity and the risk of new-onset atrial fibrillation. JAMA. 2004;292(20):2471-2477. doi:10.1001/jama.292.20.2471 - DOI - PubMed
    1. Chugh SS, Havmoeller R, Narayanan K, et al. . Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 study. Circulation. 2014;129(8):837-847. doi:10.1161/CIRCULATIONAHA.113.005119 - DOI - PMC - PubMed
    1. Miyasaka Y, Barnes ME, Gersh BJ, et al. . Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation. 2006;114(2):119-125. doi:10.1161/CIRCULATIONAHA.105.595140 - DOI - PubMed
    1. Go AS, Hylek EM, Phillips KA, et al. . Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study. JAMA. 2001;285(18):2370-2375. doi:10.1001/jama.285.18.2370 - DOI - PubMed
    1. Rogers PA, Bernard ML, Madias C, Thihalolipavan S, Mark Estes NA III, Morin DP. Current evidence-based understanding of the epidemiology, prevention, and treatment of atrial fibrillation. Curr Probl Cardiol. 2018;43(6):241-283. doi:10.1016/j.cpcardiol.2017.06.001 - DOI - PubMed

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