E UROPACE 2003
IAl
2 2
RIGHT VENTRICULARREFRACTORINESS
REPOLARIZATION
IN SUCCESSFULLY
CARDIOVERTED
PERSISTENT ATRIAL
PATIENTS
AND
FIBRILLATION
E.G. Man&, E.M. Kmoupakis, E.M. Kallergis, H.E. Mavmkis,
H.K. Mouloudi, N.C. Klapsinos, P.E. Vardas. Cardiology Dept. Heraklion
University Hospital Heraklion, Crete, Greece
at
I
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EFFECT OF CARVEDILOL AND AMIODARONE
PRE-TREATMENT
ON PERSISTENT ATRIAL
FIBRILLATION
CONVERSION AND RECURRENCE
RATES
E.M. Kanoupakis, E.G. Mania, H.E. Maw&is, P.G. Tzerakis,
H.K. Mouloudi, E.M. Kallergis, D.C. Kambouraki, M. Homatidis, P.E. Vardas.
Cardiology Dept. Heraklion University Hospital Heraklion, Crete, Greece
Aim: Carvedilol is a multiple action cardiovascular drug with blocking effects on beta and alpha receptors, Ca+2-channels, Nat-channels and various
cardiac K’-channels. Such electrophysiological effects of carvedilol would be
beneficial for cardioversion outcome and prevention of recurrences in atria1
fibrillation (AF) patients.
In this prospective trial we examined the effects of carvedilol and amiodarone
on persistent AF conversion and recurrence rates and we measured several electrophysiological parameters of the pre- and post-electmversion period in order
to assess the possible effects of these drugs on atria1 electrical remodeling and
whether these actions have any clinical implications.
Methods: We evaluated 49 patients (66&9 years) with persistent AF (mean
duration 30&34 months). They randomly assigned to three treatment groups
over a period from 6 weeks before to 6 weeks after external biphasic cardioversion: group A (16 pts, Carvedilol, at a daily oral dose not less than 12,5
mg titrated up to a maximum of 50 mg), group B (17 patients, Amiodarone,
600 mg per day the first two weeks and subsequently 200 mg per day up
to the end of the study) and group C (13 patients, no ant&rhythmic drugs).
Several electrophysiological parameters were assessed 5 min and 24 h after
cardioversion. Relapses of AF were recorded after 24 hours and 7 days.
Results: All three groups had similar clinical and echocardiographical data.
Cardioversion rates were 14117 (87%) in group A, 16117 (94%) in group B and
9115 (69%) in group C. These rates differed signiiicantly between controls (C)
and groups A and B (F=5.848, p=O.OSO).Patients of groups A and B had longer
fibrillatory cycle length intervals in the immediate preconversion period than
patients of group C (X30&18 ms and X36&14 ms vs. 165&19 ms, p=O.OOl)
and longer atria1 effective refractory periods (211&22 ms and 208&16 ms vs.
X38&17 ms, p=O.O03) as assessed 5 min after conversion. There was a more
B18
Europace Supplements,
Vol. 4, December
2003
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CAN WE USE THE ENDOCARDIAL
SIGNALS FROM
ATRIAL DEFHLRILLATING
ELECTRODES JUST
BEFORE AND JUST AFTER SUCCESSFUL INTERNAL
CARDIOVERSION
TO PREDICT EARLY RECURRENCES
OF ATRIAL FIBRILLATION?
N. Shlevkov, A. Yang, J.O. Schwab, .I. Schrickel, A. Bitzen, H. Bielik,
B. Luederitz, T.H. Lewalter. Department of Cardiology, University of Bonn,
Bonn, Germany
Background: Unpredictable early reoccurrences of atria1 fibrillation (AF) after
successful internal cardioversion (ICV) remain as an important clinical problem. However, the possible predicting role of endocardial signals from right
atrium (RA) and distal coronary sinus (CS) both before and after successful
ICV have not been yet investigated.
Methods: Study population includes 44 consecutive patients (57&11 years,
32 males/l2 females) who underwent ICV due to unsuccessful external cardioversions of persistent AF (duration of AF: median=5 months, 25-75 percentiles: 2.14,5 months). The endocardial signals characteristics during AF 1
minute before the first ICV (monomorphic vs. at least temporally polymorphic
at each RA and distal CS electrodes) and atria1 activation time between RA
and distal CS signals in first 2 minutes of sinus rhythm after successful ICV
were analyzed according to AF recurrences during the first 3 months after the
ICV
Results: Twenty five patients (56%) have had AF recurrences within 3
months of follow-up after the ICV. Patients with constantly monomorphic signals at distal CS electrode before ICV (n=ll) demonstrated signiiicantly lower
AF recurrence rate within 3 months after the ICV (18% vs. 71%, p=O,OOl)
comparing with those with at least temporally polymorphic signals. RA signals
before the ICV as well as R/-distal CS atria1 activation time just after ICV
(83&34 vs. 82&27 ms, p=O,7) did not differed significantly between patients
with and without AF recurrences 3 months after the ICV
Conclusions: (1) The presence of at least temporally polymorphic atria1
activity at distal CS was associated with poor clinical outcome in patients
undergoing ICV of persistent AF. (2) Pre-procedural signals morphology at RA
electrode and post-procedural atria1 activation time between RA and distal CS
electrodes are of no clinical relevance.
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ELECTRICAL
CARDIOVERSION
OF ATRIAL
FIBRILLATION:
COMPARISON OF MONOPHASIC
BIPHASIC SHOCK WAVEFORMS
AND
S. Siaplaouras, A. Buob, C. Rotter, M. Bohm, .I. Jung. Internal Medicine III,
Cardiology University Hospital HomburglSaal; Germany
In a prospective study we compared the efficacy of electrical cardioversion
(Cv) of atria1 fibrillation with a biphasic (Bi) versus a monophasic (MO) shock
wavefoml.
Methods: Consecutive patients (P) (n=216) underwent CV with Bi or MO
in a random fashion. Energies used were 120-150-200 Ws (Bi, Zoll M-series
biphasic, Zoll Medical) or 200-300-360 Ws (MO, Lifepak 9, Physio-Control).
Results: Patient characteristics: mean age 66 years, 71% male, 88% underlying cardiovascular disease or hypertension. The 2 study groups (Bi, MO)
did not differ concerning age, sex, body rims index, underlying cardiovascular
disease, left atria1 diameter, duration of atria1 fibrillation and a&rhythmic
therapy. CV was successful in 95.4% of the P. The success rate was comparable
in both groups (Bi: 94.3% vs. MO 96.8%; p = ns). First shock efficacy did not
differ between Bi and MO (76.4% vs. 67.7%; p = ns). The early relapse rate
(AF-relapse < 1 minute after successful Cv) was 8.9% (Bi 8.1% vs. MO 9.7%,
p = ns). Mean number of shocks was 1.4 shocks/P in both groups. The mean
delivered energy was significantly lower in the Bi-group (Bi 186 Ws vs. MO
324 Ws; p < 0.001).
Conclusion: Biphasic and monophasic shock waveforms used in this trial
are comparable concerning the first shock and the cumulative shock efficacy.
Biphasic cardioversion allows comparable SUCCESS
rates with signiiicmtly lower
energies.
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Introduction:
Very rapid ventricular rates in certain animal species and in
humans can result in stmchml and electrophysiological remodeling. So far it
is largely unknown if the irregular and the transiently rapid ventricular rhythms
during persistent or permanent atria1 fibrillation (AF) can result in changes
of ventricular electrical properties. The aim of this study was to detect if
restoration of sinus rhythm in persistent AF patients is associated with changes
in ventricular refractoriness and repolarization and to explore their time course.
Methods: In 33 persistent AF patients (64&S years old) who underwent
successful cardioversion, right ventricular effective refractory period (VERP)
at three basic cycle lengths (600,500,400 ms), as well as monophasic action
potential duration (MAPdgo) at a drive cycle length of 500 ms, were measured
just before, 20 min and 24 h after conversion. RR variability, an index of rhythm
irregularity, was assessedin terms of SDRR and RMSSD obtained from Halter
recordings 3 hours before cardioversion.
Results: VERP
600 ms changed from 241&19 ms to 249&21 ms to
253&24 ms @<O.OOl), VERP at 500 ms changed from 234&19 ms to 242&22
ms to 246&23 ms (p<O.OOl) and VERP at 400 ms changed from 224&20 ms
to 232&23 ms to 236&24 ms @<O.OOl). MAPdso changed from 247&16 ms
preconversion to 252&17 ms 20 min postconversion to 253&19 ms after 24
hours (p< 0.05).
Mean RR interval before cardioversion was 730&112 ms and 20 min after
cardioversion it changed to 885&108 ms (p<O.OOl). A further, non-significant
increase to 902&94 ms was observed 24 hours later (p=O.41).
Change in refractoriness at 500 ms correlated with change of mean RR
interval before and 20 min after conversion (R= 0.616, p<O.OOl) suggesting
that those patients in whom sinus mean RR after conversion was longer than
that of AF, exhibit prolongation of refractoriness, whereas those in whom sinus
RR was shorter responded with a shortening of refractoriness. There was no
correlation between RR variability and VERP before cardioversion.
Conclusion: Restoration of sinus rhythm in persistent AF patients is associated with changes in ventricular refractoriness and repolatiation that depend on
ventricular cycle length change. No relation of VERP during AF with rhythm
irregularity was found.
marked trend towards a higher incidence of AF relapses after 7 days in group
C (419 44%) than in groups A (4114, 29%) and B (3116, 19%).
Conclusions: Carvedilol seems to have similar effects with amiodarone
regarding the conversion rates, prolongation of fibrillatory cycle length and
atria1 effective refractory period in AF patients. These preliminary results of
OUTstudy provide the first clinical and electrophysiological evidence suggesting
that carvedilol may have a beneficial effect on cardioversion outcome and
preservation of sinus rhythm after cardioversion of persistent AF.