Internal low-energy cardioversion: A therapeutic option for restoring sinus rhythm in chronic atrial fibrillation after failure of external cardioversion

Abstract

Aims: Conventional external cardioversion remains the technique of choice for restoration of sinus rhythm in patients with chronic atrial fibrillation (AF). Recent reports have suggested that internal low-energy cardioversion is efficient and safe in terminating AF in patients with failed external cardioversion. Methods and Results: In 20 of 118 consecutive patients with spontaneous chronic AF (>7/days), who underwent low-energy cardioversion, one or more attempts at restoring sinus rhythm with external cardioversion had failed. Low-energy internal cardioversion was performed under light sedation. Shocks were delivered (using an external custom defibrillator) between two nonapolar catheters positioned in the right atrium (cathode) and in the coronary sinus (anode). Heart disease was present in 12 and absent in eight patients ('lone' atrial fibrillation). Atrial fibrillation was established for a period ranging from 12 days to 53 months. Low-energy internal cardioversion restored sinus rhythm in 15 of the 20 patients (75%) with a mean energy of 4·5 ± 1·2 J, a mean conversion voltage of 355 ± 53 V and a mean impedance of 63 ± 8 ohms. No complications were observed. With a mean follow-up of 6 ± 7 months, 11 patients (73%) were in stable sinus rhythm. Conclusions: This study provides evidence in support of low-energy internal cardioversion as a valuable therapeutic option in patients in whom conventional external cardioversion failed. This technique is safe and does not require general anaesthesia.