Circulation, Vol 86, 1415-1420, Copyright © 1992 by American Heart Association
S Levy, P Lauribe, E Dolla, W Kou, A Kadish, H Calkins, F Pagannelli, C Moyal, M Bremondy and A Schork
BACKGROUND. Delivery of shocks within the right atrium has been reported to
be more effective than conventional external shocks in converting atrial
fibrillation (AF), but these two cardioversion techniques have never been
compared prospectively. The purpose of this study was to compare the
efficacies of external and internal cardioversion in patients with chronic
AF unresponsive to prior attempts at electrical and/or pharmacological
cardioversion. Low-dose amiodarone was used in all patients after
cardioversion to suppress recurrences of AF. METHODS AND RESULTS. One
hundred twelve patients with AF of at least 1 month in duration were
randomly assigned to undergo external cardioversion with 300-360-J shocks
or internal cardioversion with 200-300-J shocks delivered through a
standard electrode catheter within the right atrium. The patients were
treated with amiodarone (200 mg/day 5-7 days/week) for 1 month before
electrical cardioversion and afterward if the cardioversion was successful.
The patients were evaluated at regular intervals during 1 year of
follow-up. The efficacy of internal cardioversion was significantly greater
than that of external cardioversion (91% versus 67%, p = 0.002). The only
variable that was associated with the outcome of cardioversion was body
weight. Among patients in whom sinus rhythm was restored, AF recurred as
often after internal and external cardioversion; at 1 year of follow-up,
37% of patients in whom external or internal cardioversion had been
effective were still in sinus rhythm. Patients who had undergone an attempt
at electrical cardioversion before entry into this study were less likely
to remain in sinus rhythm after cardioversion. The only complications of
cardioversion were one instance of cerebral thromboembolism after external
cardioversion and one instance of transient pulmonary edema after internal
cardioversion. Therapy with amiodarone was discontinued because of an
adverse drug effect in only three patients. CONCLUSIONS. Internal
cardioversion is more effective than external cardioversion in restoring
sinus rhythm and is as safe as external cardioversion in patients with
chronic AF. The recurrence rate of AF is the same after both types of
cardioversion. If conventional electrical cardioversion is ineffective,
internal cardioversion should be attempted. The combination of low-dose
amiodarone and external or internal cardioversion may result in maintaining
sinus rhythm long-term in patients with refractory AF.
ARTICLES
A randomized comparison of external and internal cardioversion of chronic atrial fibrillation
University of Marseille, School of Medicine, France.
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