- Email: [email protected]
Low energy biphasic cardioversion of atrial flutter: Results from a pilot trial
368
Letters to the Editor
dependent on the direction of myocardial motion and difficulty of exclusion of subendocardial ischemia. Nevertheless, it was clearly documented that because of the angle dependency, tissue Doppler-derivated methods have some limitations that are possibly important for the complete elimination of stressinduced abnormal myocardial tissue function in cardiac patients including those with ischemic or nonischemic LV functional abnormality [13,14]. Furthermore, it will be a big challenge to document preserved LV function completely despite the presence of a huge record of documentations of clear midapical region involvement compared to hypercontractile LV base in disease course in the future. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [15].
References [1] Sharkey SW, Lesser JR, Zenovich AG, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 2005;111:472–9. [2] Dorfman TA, Iskandrian AE. Takotsubo cardiomyopathy: state-of-the-art review. J Nucl Cardiol 2009;16:122–34. [3] Dundel M, Lehmkuhl H, Knosalla C, Hetzer R. Left ventricular wall motion abnormality and myocardial dysfunction in stress cardiomyopathy: new pathophysiological aspects suggested by echocardiography. Int J Cardiol 2009;135: e40–3. [4] Yalçin F, Muderrisoğlu H. Takotsubo cardiomyopathy may be associated with cardiac geometric features as observed in hypertensive heart disease. Int J Cardiol 2009;135:251–2.
[5] Yalçin F, Yigit F, Erol T, Baltali M, Korkmaz ME, Müderrisoglu H. Effect of dobutamine stress on basal septal tissue dynamics in hypertensive patients with basal septal hypertrophy. J Hum Hypertens 2006;20:628–30. [6] Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J 2006;27:1523–9. [7] Azzarelli S, Galassi AR, Amico F, Giacoppo M, Argentino V, Fiscella A. Intraventricular obstruction in a patient with tako-tsubo cardiomyopathy. Int J Cardiol 2007;121:22–4. [8] Dhoble A, Abdelmoneim SS, Bernier M, Oh JK, Mulvagh SL. Transient left ventricular apical ballooning and exercise induced hypertension during treadmill exercise testing: is there a common hypersympathetic mechanism? Cardiovasc Ultrasound 2008;6:37. [9] Yalçin F, Muderrisoglu H, Korkmaz ME, Ozin B, Baltali M, Yigit F. The effect of dobutamine stress on left ventricular outflow tract gradients in hypertensive patients with basal septal hypertrophy. Angiology 2004;55:295–301. [10] Yalçin F, Shiota T, Odabashian J, et al. Comparison by real-time three-dimensional echocardiography of left ventricular geometry in hypertrophic cardiomyopathy versus secondary left ventricular hypertrophy. Am J Cardiol 2000;85:1035–8. [11] Golbasi Z, Sakalli M, Cicek D, Aydogdu S. Dynamic left ventricular outflow tract obstruction in a patient with pheochromocytoma. Jpn Heart J 1999;40:831–5. [12] Takizawa M, Kobayakawa N, Uozumi H, et al. A case of transient left ventricular ballooning with pheochromocytoma, supporting pathogenetic role of catecholamines in stress-induced cardiomyopathy or takotsubo cardiomyopathy. Int J Cardiol 2007;114:15–7. [13] Edvardsen T, Helle-Valle T, Smiseth OA. Systolic dysfunction in heart failure with normal ejection fraction: speckle-tracking echocardiography. Prog Cardiovasc Dis 2006;49:207–14. [14] Yu CM, Fung JW, Zhang Q, et al. Tissue Doppler imaging is superior to strain rate imaging and postsystolic shortening on the prediction of reverse remodeling in both ischemic and nonischemic heart failure after cardiac resynchronization therapy. Circulation 2004;110:66–73. [15] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50.
0167-5273/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2010.02.041
Low energy biphasic cardioversion of atrial flutter: Results from a pilot trial Kai Mortensen a,⁎, Muhammet Ali Aydin b, Tjark F. Schwemer b, Rodolfo Ventura c, Michael Reppel a, Frank Bode a, Ralph Mletzko d, Heribert Schunkert a, Tim Risius d a
University Hospital Lübeck, Medizinische Klinik II, Lübeck, Germany University Hospital Hamburg-Eppendorf, Heart Center, Hamburg, Germany Electrophysiology Center Bremen, Bremen, Germany d Asklepios Klinik Nord-Heidberg, Dept. of Cardiology, Hamburg, Germany b c
a r t i c l e
i n f o
Article history: Received 30 December 2009 Accepted 14 February 2010 Available online 19 March 2010 Keywords: Atrial flutter Cardioversion Biphasic Low energy
⁎ Corresponding author. Dept. of Cardiology, Campus Lübeck University Hospital Schleswig Holstein Ratzeburger Alle 160 23538 Lübeck, Germany. Tel.: + 49 451 500 4859; fax: + 49 451 500 4951. E-mail address: [email protected] (K. Mortensen).
Common type atrial flutter is a highly prevalent atrial arrhythmia [1,2]. It has been demonstrated that cardioversion of atrial flutter is more effective with a biphasic waveform [3]. Furthermore the anterior–lateral electrode position (A–L) is superior in terms of success [4,5]. The present prospective pilot trial was initiated to evaluate whether a biphasic low energy step up protocol reveals further key benefits compared to existing recommendations or consensus of expert opinions [5–7]. This study was a prospective single-center pilot trial to assess the efficacy of low energy biphasic cardioversion with A–L electrode position in patients with common type atrial flutter. Patients were eligible for the study, if, according to current guidelines, electrical cardioversion of atrial flutter was indicated. Patients were ineligible for this trial, if they were less than 18 years of age, pregnant or planned for cardioversion of arrhythmias other than common type atrial flutter. All patients underwent diagnostic procedures and eventual treatment for the prevention of embolic stroke and systemic embolism according to actual guidelines [6] for the management of patients with atrial fibrillation or flutter. After cardioversion, all patients were required to be anticoagulated for at least 4 weeks [6].
Letters to the Editor Table 1 Variable
All (n = 40)
Low energy (n = 20)
Control (n = 20)
p-values
Age (years) Men Body mass index (kg/m2) Body surface area (m2) New York Heart Association Classification I II III IV Median Hypertension Coronary artery disease Valvular disease Atrial septal defect Cardiomyopathy [dilatative, ischemic, etc.] Left ventricular function Normal Mild dysfunction Moderate dysfunction Severe dysfunction Median
65 ± 10 28 (70%) 25 ± 4.12 2 ± 0.2
65 ± 10 14 (70%) 24 ± 4.34 2 ± 0.2
65 ± 11 14 (70%) 25 ± 3.94 1.9 ± 0.2
0.54 1.00 0.35 0.84
10 (25%) 15 (37.5%) 9 (22.5%) 6 (15%) II 15 (37.5%) 5 (12.5%) 5 (12.5%) 4 (10%) 9 (22.5%)
8 (40%) 7 (35%) 3 (15%) 2 (10%) II 11 (55%) 3 (15%) 3 (15%) 1 (5%) 7 (35%)
2 (10%) 8 (40%) 6 (30%) 4 (20%) II 4 (20%) 2 (10%) 2 (10%) 3 (15%) 2 (10%)
0.06 0.85 0.45 0.66
12 (30%) 13 (32.5%) 11 (27.5%) 4 (10%) Mild dysfunction
9 (45%) 6 (30%) 3 (15%) 2 (10%) Mild dysfunction
3 (15%) 7 (35%) 8 (40%) 2 (10%) Mild dysfunction
0.82 0.85 0.15 1.00
7 6 9 1
5 (25%) 3 (15%) 5 (25%) 0 (0%)
2 (10%) 3 (15%) 4 (20%) 1 (5%)
0.40 1.00 0.85 0.85
Antiarrhythmic drugs at cardioversion Amiodarone Flecainide ß-blocker Sotalol
(17.5%) (15%) (22.5%) (2.5%)
0.50 0.28 0.85 0.61 0.12
All continuous variables are given as mean ± standard error of the mean. There were no significant differences in the clinical characteristics between the groups.
The local ethics committee gave approval to the study, all patients gave written informed consent. The cardioversion procedure was performed as previously described [4] in A–L electrode position, starting energies were based upon previous trials [3–5,7]. All patients (n = 40) were randomized either for the low energy protocol (sequential shocks of increasing energy of 20, 30, 50, 75, 100, 150 or 200 J; n = 20) or the standard protocol (sequential shocks of increasing energy of 50, 75, 100, 150 or 200 J; n = 20). In case of cardioversion to atrial fibrillation, the next cardioversion step according to current guidelines was performed with 200 J. 40 patients (28 men, mean age 65 ± 10 years) were eligible and gave written informed consent for participation in the study. Clinical characteristics are listed in Table 1. Both groups showed no significant difference in anthropometrical data and underlying cardiac disease, e.g. hypertension or use of medications. All 40 patients could finally be successfully cardioverted to sinus rhythm. No major complications, adverse events or major skin irritations were reported in the two groups. The efficacy of the first shock with 20 J (Fig.1) in the low energy group (8/20 patients, 40%) was not significantly (p = n.s.) different to
Fig. 1. Success of first shock.
369
50 J used in the standard energy group (10/20, 50%). Three patients from the low energy were cardioverted to atrial fibrillation rather than sinus rhythm, using the lowest energy of 20 J in the first group. The cumulative cardioversion efficacy for the low energy group (20 J: 40%, 30 J: 70%, 50 J: 80%, 75 J: 85%) compared with the standard group (50 J 50%, 75 J: 85%, 100 J 85%, 150 J: 95%) showed also no significant difference (Fig. 2). Multivariate logistic regression of our data found only coronary artery disease as an independent predictor for cardioversion to atrial fibrillation. In our study the low energy protocol in A–L electrode position was not superior to a standard protocol. Multiple previous studies found an advantage of A–P electrode position [5,8,9] for electrical cardioversion of atrial fibrillation. We have recently shown that atrial flutter is best treated with biphasic energy and furthermore in A–L electrode position [3,4]. The current guidelines for treatment of atrial flutter are included in the guidelines for atrial fibrillation [6]. Atrial fibrillation requires large amounts of myocardial tissue as a substrate whereas atrial flutter only requires critical aspects of the right atrial isthmus to perpetuate, which may account for the different successful electrode positions. The superiority of A–L electrodes might be explained by electro-anatomical properties of the human thorax. For A–L electrode position it was shown that this electrode placement leads to a cardiac current flow entering at the frontal right atrial wall and leaving via inferior vena cava [10]. A–L electrodes might produce the peak cardiac current flow into the re-entry circuit of typical atrial flutter in the right atrium. In 1981, without knowing the pathomechanism of typical atrial flutter [11], Kerber found A–L electrode position preferable to A–P electrodes for cardioversion of atrial flutter [5]. Earlier studies found increasing success rates with increasing shock strengths [5,8], but high shock strengths might have a higher rate of complications and should be avoided [12]. Cumulative efficacy in the low energy group in this study showed no significant difference (Fig. 1). Additionally, no differences were shown also for First Shock Efficacy (Fig. 2). Three patients were cardioverted to atrial fibrillation rather than sinus rhythm. These patients were cardioverted according to the low energy protocol with the lowest energy of 20 J, but the statistic differences were not yet significant in this small group. Multivariate logistic regression of our data found coronary artery disease an independent predictor for cardioversion to atrial fibrillation. All three patients who were at first cardioverted to atrial fibrillation were successfully cardioverted to sinus rhythm thereafter. It is important to note that all patients could successfully be cardioverted to sinus rhythm in contrast to previous studies with atrial flutter [5,13]. Despite the use of the optimal electrode position (A–L) and the use of the biphasic waveform for cardioversion of atrial flutter we identified a threshold energy level of 30 J and higher in this pilot trial. For safety reasons we decided for self-adhesive patches. Further reduction of applied energy compared to standard energy schemes is not encouraged by our data. The limits of our small study cohort may motivate a study with a larger number of patients to
Fig. 2. Cumulative CV efficacy.
370
Letters to the Editor
finally establish a definite energy concept concerning the cardioversion protocol for patients with atrial flutter. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [14].
[7] [8]
[9]
References [1] Wolf PA, et al. Secular trends in the prevalence of atrial fibrillation: the Framingham Study. Am Heart J 1996;131(4):790–5. [2] Feinberg WM, et al. Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications. Arch Intern Med 1995;155(5):469–73. [3] Mortensen K, et al. Biphasic versus monophasic shock for external cardioversion of atrial flutter: a prospective, randomized trial. Cardiology 2008;111(1):57–62. [4] Risius T, Mortensen K, Schwemer TF, et al. Comparison of antero-lateral versus antero-posterior electrode position for biphasic external cardioversion of atrial flutter. Am J Cardiol 2009;104(11)(Dec 1):1547–50. [5] Kerber RE, et al. Elective cardioversion: influence of paddle-electrode location and size on success rates and energy requirements. N Engl J Med 1981;305(12):658–62. [6] Fuster V, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and
[10] [11]
[12] [13]
[14]
the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol 2006;48(4):854–906. Kerber RE. Transthoracic cardioversion of atrial fibrillation and flutter: standard techniques and new advances. Am J Cardiol 1996;78(8A):22–6. Kirchhof P, et al. Anterior–posterior versus anterior–lateral electrode positions for external cardioversion of atrial fibrillation: a randomised trial. Lancet 2002;360 (9342):1275–9. Botto GL, et al. External cardioversion of atrial fibrillation: role of paddle position on technical efficacy and energy requirements. Heart 1999;82(6):726–30. Yoon RS, et al. Measurement of thoracic current flow in pigs for the study of defibrillation and cardioversion. IEEE Trans Biomed Eng 2003;50(10):1167–73. Kalman JM, et al. Activation and entrainment mapping defines the tricuspid annulus as the anterior barrier in typical atrial flutter. Circulation 1996;94 (3):398–406. Resnekov L. High-energy electrical current and myocardial damage. Med Instrum 1978;12(1):24–6. Niebauer MJ, et al. Comparison of the rectilinear biphasic waveform with the monophasic damped sine waveform for external cardioversion of atrial fibrillation and flutter. Am J Cardiol 2004;93(12):1495–9. Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131(2):149–50.
0167-5273/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2010.02.042
Accuracy of Doppler-derived pulmonary artery hypertension to predict heart failure with normal ejection fraction Stephane Arques ⁎, Marie-Perrine Jaubert, Laurent Bonello, Pascal Sbragia, Alexane Nicoud, Franck Paganelli Department of Cardiology, Centre hospitalo-universitaire Nord, Marseille, France
a r t i c l e
i n f o
Article history: Received 8 January 2010 Accepted 14 February 2010 Available online 6 March 2010 Keywords: Diastolic heart failure Pulmonary artery hypertension Doppler echocardiography
Recent advances have highlighted the clinical relevance of pulmonary artery hypertension in terms of diagnosis and risk stratification in patients with heart failure and normal ejection fraction (HFnlEF) [1,2]. Its diagnostic significance has not yet been addressed against international recommendations that include invasive hemodynamics, comprehensive Doppler echocardiography and natriuretic peptides [3]. The present study addressed the accuracy of Doppler-derived pulmonary artery systolic pressure (PASP) to predict HFnlEF in patients with isolated exertional dyspnea, using European diagnostic flow charts as the reference for the diagnosis [3]. After the written informed consent was obtained, diagnostic flow charts on “how to diagnose HFnlEF” and “how to exclude
⁎ Corresponding author. Department of Cardiology, Aubagne Hospital, Avenue des Soeurs Gastine, 13400 Aubagne, France. Tel.: +33 442 84 71 31; fax: +33 442 84 71 53. E-mail address: [email protected] (S. Arques).
HFnlEF” were applied to 40 consecutive patients in II to III NYHA class, with adequate recordings at transthoracic Doppler echocardiography and who were referred for clinically indicated catheterism. 25 patients fulfilled criteria for the diagnosis of HFnlEF according to the diagnostic flowchart on “how to diagnose HFnlEF”. Among the 15 patients who did not fulfill criteria for HFnlEF, the diagnostic flowchart “how to exclude HFnlEF” identified 12 controls. All the patients were in sinus rhythm, clinically stable and free of signs of pulmonary and peripheral congestion. Exclusion criteria were symptom of angina, acute coronary syndrome and acute myocardial infarction, severe left-sided valve disease and/or mild to moderate mitral stenosis. Laboratory, Doppler echocardiography and invasive data were collected on the same morning for each patient. B-type natriuretic peptide concentration was measured with a ADVIA Centaur system (Siemens healthcare Diagnostics Inc.; range of 5 to 5000 pg/ml). All the Doppler echocardiography studies were performed by the same experienced operator who was blinded to the data with an Acuson Sequoia ultrasound system (Siemens, Mountain View, California). All the measurements were performed according to the ASE recommendations [4,5] and validated by a second experienced operator. PASP was calculated as the tricuspid valve maximal gradient recorded by continuous-wave Doppler plus the estimated right atrial pressure. The maximal diameter of inferior vena cava was measured in the sub-costal view at end-expiration by 2-dimensional echocardiography. After the inferior vena cava was displayed in its longitudinal axis, the diameter was measured just proximal to the junction of the hepatic veins and the inferior vena cava. A value of 5, 10 and 15 mm Hg for right atrial pressure was arbitrarily given for diameters of b10 mm, 10 to 20 mm and N20 mm,
Letters to the Editor
dependent on the direction of myocardial motion and difficulty of exclusion of subendocardial ischemia. Nevertheless, it was clearly documented that because of the angle dependency, tissue Doppler-derivated methods have some limitations that are possibly important for the complete elimination of stressinduced abnormal myocardial tissue function in cardiac patients including those with ischemic or nonischemic LV functional abnormality [13,14]. Furthermore, it will be a big challenge to document preserved LV function completely despite the presence of a huge record of documentations of clear midapical region involvement compared to hypercontractile LV base in disease course in the future. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [15].
References [1] Sharkey SW, Lesser JR, Zenovich AG, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 2005;111:472–9. [2] Dorfman TA, Iskandrian AE. Takotsubo cardiomyopathy: state-of-the-art review. J Nucl Cardiol 2009;16:122–34. [3] Dundel M, Lehmkuhl H, Knosalla C, Hetzer R. Left ventricular wall motion abnormality and myocardial dysfunction in stress cardiomyopathy: new pathophysiological aspects suggested by echocardiography. Int J Cardiol 2009;135: e40–3. [4] Yalçin F, Muderrisoğlu H. Takotsubo cardiomyopathy may be associated with cardiac geometric features as observed in hypertensive heart disease. Int J Cardiol 2009;135:251–2.
[5] Yalçin F, Yigit F, Erol T, Baltali M, Korkmaz ME, Müderrisoglu H. Effect of dobutamine stress on basal septal tissue dynamics in hypertensive patients with basal septal hypertrophy. J Hum Hypertens 2006;20:628–30. [6] Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J 2006;27:1523–9. [7] Azzarelli S, Galassi AR, Amico F, Giacoppo M, Argentino V, Fiscella A. Intraventricular obstruction in a patient with tako-tsubo cardiomyopathy. Int J Cardiol 2007;121:22–4. [8] Dhoble A, Abdelmoneim SS, Bernier M, Oh JK, Mulvagh SL. Transient left ventricular apical ballooning and exercise induced hypertension during treadmill exercise testing: is there a common hypersympathetic mechanism? Cardiovasc Ultrasound 2008;6:37. [9] Yalçin F, Muderrisoglu H, Korkmaz ME, Ozin B, Baltali M, Yigit F. The effect of dobutamine stress on left ventricular outflow tract gradients in hypertensive patients with basal septal hypertrophy. Angiology 2004;55:295–301. [10] Yalçin F, Shiota T, Odabashian J, et al. Comparison by real-time three-dimensional echocardiography of left ventricular geometry in hypertrophic cardiomyopathy versus secondary left ventricular hypertrophy. Am J Cardiol 2000;85:1035–8. [11] Golbasi Z, Sakalli M, Cicek D, Aydogdu S. Dynamic left ventricular outflow tract obstruction in a patient with pheochromocytoma. Jpn Heart J 1999;40:831–5. [12] Takizawa M, Kobayakawa N, Uozumi H, et al. A case of transient left ventricular ballooning with pheochromocytoma, supporting pathogenetic role of catecholamines in stress-induced cardiomyopathy or takotsubo cardiomyopathy. Int J Cardiol 2007;114:15–7. [13] Edvardsen T, Helle-Valle T, Smiseth OA. Systolic dysfunction in heart failure with normal ejection fraction: speckle-tracking echocardiography. Prog Cardiovasc Dis 2006;49:207–14. [14] Yu CM, Fung JW, Zhang Q, et al. Tissue Doppler imaging is superior to strain rate imaging and postsystolic shortening on the prediction of reverse remodeling in both ischemic and nonischemic heart failure after cardiac resynchronization therapy. Circulation 2004;110:66–73. [15] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50.
0167-5273/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2010.02.041
Low energy biphasic cardioversion of atrial flutter: Results from a pilot trial Kai Mortensen a,⁎, Muhammet Ali Aydin b, Tjark F. Schwemer b, Rodolfo Ventura c, Michael Reppel a, Frank Bode a, Ralph Mletzko d, Heribert Schunkert a, Tim Risius d a
University Hospital Lübeck, Medizinische Klinik II, Lübeck, Germany University Hospital Hamburg-Eppendorf, Heart Center, Hamburg, Germany Electrophysiology Center Bremen, Bremen, Germany d Asklepios Klinik Nord-Heidberg, Dept. of Cardiology, Hamburg, Germany b c
a r t i c l e
i n f o
Article history: Received 30 December 2009 Accepted 14 February 2010 Available online 19 March 2010 Keywords: Atrial flutter Cardioversion Biphasic Low energy
⁎ Corresponding author. Dept. of Cardiology, Campus Lübeck University Hospital Schleswig Holstein Ratzeburger Alle 160 23538 Lübeck, Germany. Tel.: + 49 451 500 4859; fax: + 49 451 500 4951. E-mail address: [email protected] (K. Mortensen).
Common type atrial flutter is a highly prevalent atrial arrhythmia [1,2]. It has been demonstrated that cardioversion of atrial flutter is more effective with a biphasic waveform [3]. Furthermore the anterior–lateral electrode position (A–L) is superior in terms of success [4,5]. The present prospective pilot trial was initiated to evaluate whether a biphasic low energy step up protocol reveals further key benefits compared to existing recommendations or consensus of expert opinions [5–7]. This study was a prospective single-center pilot trial to assess the efficacy of low energy biphasic cardioversion with A–L electrode position in patients with common type atrial flutter. Patients were eligible for the study, if, according to current guidelines, electrical cardioversion of atrial flutter was indicated. Patients were ineligible for this trial, if they were less than 18 years of age, pregnant or planned for cardioversion of arrhythmias other than common type atrial flutter. All patients underwent diagnostic procedures and eventual treatment for the prevention of embolic stroke and systemic embolism according to actual guidelines [6] for the management of patients with atrial fibrillation or flutter. After cardioversion, all patients were required to be anticoagulated for at least 4 weeks [6].
Letters to the Editor Table 1 Variable
All (n = 40)
Low energy (n = 20)
Control (n = 20)
p-values
Age (years) Men Body mass index (kg/m2) Body surface area (m2) New York Heart Association Classification I II III IV Median Hypertension Coronary artery disease Valvular disease Atrial septal defect Cardiomyopathy [dilatative, ischemic, etc.] Left ventricular function Normal Mild dysfunction Moderate dysfunction Severe dysfunction Median
65 ± 10 28 (70%) 25 ± 4.12 2 ± 0.2
65 ± 10 14 (70%) 24 ± 4.34 2 ± 0.2
65 ± 11 14 (70%) 25 ± 3.94 1.9 ± 0.2
0.54 1.00 0.35 0.84
10 (25%) 15 (37.5%) 9 (22.5%) 6 (15%) II 15 (37.5%) 5 (12.5%) 5 (12.5%) 4 (10%) 9 (22.5%)
8 (40%) 7 (35%) 3 (15%) 2 (10%) II 11 (55%) 3 (15%) 3 (15%) 1 (5%) 7 (35%)
2 (10%) 8 (40%) 6 (30%) 4 (20%) II 4 (20%) 2 (10%) 2 (10%) 3 (15%) 2 (10%)
0.06 0.85 0.45 0.66
12 (30%) 13 (32.5%) 11 (27.5%) 4 (10%) Mild dysfunction
9 (45%) 6 (30%) 3 (15%) 2 (10%) Mild dysfunction
3 (15%) 7 (35%) 8 (40%) 2 (10%) Mild dysfunction
0.82 0.85 0.15 1.00
7 6 9 1
5 (25%) 3 (15%) 5 (25%) 0 (0%)
2 (10%) 3 (15%) 4 (20%) 1 (5%)
0.40 1.00 0.85 0.85
Antiarrhythmic drugs at cardioversion Amiodarone Flecainide ß-blocker Sotalol
(17.5%) (15%) (22.5%) (2.5%)
0.50 0.28 0.85 0.61 0.12
All continuous variables are given as mean ± standard error of the mean. There were no significant differences in the clinical characteristics between the groups.
The local ethics committee gave approval to the study, all patients gave written informed consent. The cardioversion procedure was performed as previously described [4] in A–L electrode position, starting energies were based upon previous trials [3–5,7]. All patients (n = 40) were randomized either for the low energy protocol (sequential shocks of increasing energy of 20, 30, 50, 75, 100, 150 or 200 J; n = 20) or the standard protocol (sequential shocks of increasing energy of 50, 75, 100, 150 or 200 J; n = 20). In case of cardioversion to atrial fibrillation, the next cardioversion step according to current guidelines was performed with 200 J. 40 patients (28 men, mean age 65 ± 10 years) were eligible and gave written informed consent for participation in the study. Clinical characteristics are listed in Table 1. Both groups showed no significant difference in anthropometrical data and underlying cardiac disease, e.g. hypertension or use of medications. All 40 patients could finally be successfully cardioverted to sinus rhythm. No major complications, adverse events or major skin irritations were reported in the two groups. The efficacy of the first shock with 20 J (Fig.1) in the low energy group (8/20 patients, 40%) was not significantly (p = n.s.) different to
Fig. 1. Success of first shock.
369
50 J used in the standard energy group (10/20, 50%). Three patients from the low energy were cardioverted to atrial fibrillation rather than sinus rhythm, using the lowest energy of 20 J in the first group. The cumulative cardioversion efficacy for the low energy group (20 J: 40%, 30 J: 70%, 50 J: 80%, 75 J: 85%) compared with the standard group (50 J 50%, 75 J: 85%, 100 J 85%, 150 J: 95%) showed also no significant difference (Fig. 2). Multivariate logistic regression of our data found only coronary artery disease as an independent predictor for cardioversion to atrial fibrillation. In our study the low energy protocol in A–L electrode position was not superior to a standard protocol. Multiple previous studies found an advantage of A–P electrode position [5,8,9] for electrical cardioversion of atrial fibrillation. We have recently shown that atrial flutter is best treated with biphasic energy and furthermore in A–L electrode position [3,4]. The current guidelines for treatment of atrial flutter are included in the guidelines for atrial fibrillation [6]. Atrial fibrillation requires large amounts of myocardial tissue as a substrate whereas atrial flutter only requires critical aspects of the right atrial isthmus to perpetuate, which may account for the different successful electrode positions. The superiority of A–L electrodes might be explained by electro-anatomical properties of the human thorax. For A–L electrode position it was shown that this electrode placement leads to a cardiac current flow entering at the frontal right atrial wall and leaving via inferior vena cava [10]. A–L electrodes might produce the peak cardiac current flow into the re-entry circuit of typical atrial flutter in the right atrium. In 1981, without knowing the pathomechanism of typical atrial flutter [11], Kerber found A–L electrode position preferable to A–P electrodes for cardioversion of atrial flutter [5]. Earlier studies found increasing success rates with increasing shock strengths [5,8], but high shock strengths might have a higher rate of complications and should be avoided [12]. Cumulative efficacy in the low energy group in this study showed no significant difference (Fig. 1). Additionally, no differences were shown also for First Shock Efficacy (Fig. 2). Three patients were cardioverted to atrial fibrillation rather than sinus rhythm. These patients were cardioverted according to the low energy protocol with the lowest energy of 20 J, but the statistic differences were not yet significant in this small group. Multivariate logistic regression of our data found coronary artery disease an independent predictor for cardioversion to atrial fibrillation. All three patients who were at first cardioverted to atrial fibrillation were successfully cardioverted to sinus rhythm thereafter. It is important to note that all patients could successfully be cardioverted to sinus rhythm in contrast to previous studies with atrial flutter [5,13]. Despite the use of the optimal electrode position (A–L) and the use of the biphasic waveform for cardioversion of atrial flutter we identified a threshold energy level of 30 J and higher in this pilot trial. For safety reasons we decided for self-adhesive patches. Further reduction of applied energy compared to standard energy schemes is not encouraged by our data. The limits of our small study cohort may motivate a study with a larger number of patients to
Fig. 2. Cumulative CV efficacy.
370
Letters to the Editor
finally establish a definite energy concept concerning the cardioversion protocol for patients with atrial flutter. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [14].
[7] [8]
[9]
References [1] Wolf PA, et al. Secular trends in the prevalence of atrial fibrillation: the Framingham Study. Am Heart J 1996;131(4):790–5. [2] Feinberg WM, et al. Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications. Arch Intern Med 1995;155(5):469–73. [3] Mortensen K, et al. Biphasic versus monophasic shock for external cardioversion of atrial flutter: a prospective, randomized trial. Cardiology 2008;111(1):57–62. [4] Risius T, Mortensen K, Schwemer TF, et al. Comparison of antero-lateral versus antero-posterior electrode position for biphasic external cardioversion of atrial flutter. Am J Cardiol 2009;104(11)(Dec 1):1547–50. [5] Kerber RE, et al. Elective cardioversion: influence of paddle-electrode location and size on success rates and energy requirements. N Engl J Med 1981;305(12):658–62. [6] Fuster V, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and
[10] [11]
[12] [13]
[14]
the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol 2006;48(4):854–906. Kerber RE. Transthoracic cardioversion of atrial fibrillation and flutter: standard techniques and new advances. Am J Cardiol 1996;78(8A):22–6. Kirchhof P, et al. Anterior–posterior versus anterior–lateral electrode positions for external cardioversion of atrial fibrillation: a randomised trial. Lancet 2002;360 (9342):1275–9. Botto GL, et al. External cardioversion of atrial fibrillation: role of paddle position on technical efficacy and energy requirements. Heart 1999;82(6):726–30. Yoon RS, et al. Measurement of thoracic current flow in pigs for the study of defibrillation and cardioversion. IEEE Trans Biomed Eng 2003;50(10):1167–73. Kalman JM, et al. Activation and entrainment mapping defines the tricuspid annulus as the anterior barrier in typical atrial flutter. Circulation 1996;94 (3):398–406. Resnekov L. High-energy electrical current and myocardial damage. Med Instrum 1978;12(1):24–6. Niebauer MJ, et al. Comparison of the rectilinear biphasic waveform with the monophasic damped sine waveform for external cardioversion of atrial fibrillation and flutter. Am J Cardiol 2004;93(12):1495–9. Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131(2):149–50.
0167-5273/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2010.02.042
Accuracy of Doppler-derived pulmonary artery hypertension to predict heart failure with normal ejection fraction Stephane Arques ⁎, Marie-Perrine Jaubert, Laurent Bonello, Pascal Sbragia, Alexane Nicoud, Franck Paganelli Department of Cardiology, Centre hospitalo-universitaire Nord, Marseille, France
a r t i c l e
i n f o
Article history: Received 8 January 2010 Accepted 14 February 2010 Available online 6 March 2010 Keywords: Diastolic heart failure Pulmonary artery hypertension Doppler echocardiography
Recent advances have highlighted the clinical relevance of pulmonary artery hypertension in terms of diagnosis and risk stratification in patients with heart failure and normal ejection fraction (HFnlEF) [1,2]. Its diagnostic significance has not yet been addressed against international recommendations that include invasive hemodynamics, comprehensive Doppler echocardiography and natriuretic peptides [3]. The present study addressed the accuracy of Doppler-derived pulmonary artery systolic pressure (PASP) to predict HFnlEF in patients with isolated exertional dyspnea, using European diagnostic flow charts as the reference for the diagnosis [3]. After the written informed consent was obtained, diagnostic flow charts on “how to diagnose HFnlEF” and “how to exclude
⁎ Corresponding author. Department of Cardiology, Aubagne Hospital, Avenue des Soeurs Gastine, 13400 Aubagne, France. Tel.: +33 442 84 71 31; fax: +33 442 84 71 53. E-mail address: [email protected] (S. Arques).
HFnlEF” were applied to 40 consecutive patients in II to III NYHA class, with adequate recordings at transthoracic Doppler echocardiography and who were referred for clinically indicated catheterism. 25 patients fulfilled criteria for the diagnosis of HFnlEF according to the diagnostic flowchart on “how to diagnose HFnlEF”. Among the 15 patients who did not fulfill criteria for HFnlEF, the diagnostic flowchart “how to exclude HFnlEF” identified 12 controls. All the patients were in sinus rhythm, clinically stable and free of signs of pulmonary and peripheral congestion. Exclusion criteria were symptom of angina, acute coronary syndrome and acute myocardial infarction, severe left-sided valve disease and/or mild to moderate mitral stenosis. Laboratory, Doppler echocardiography and invasive data were collected on the same morning for each patient. B-type natriuretic peptide concentration was measured with a ADVIA Centaur system (Siemens healthcare Diagnostics Inc.; range of 5 to 5000 pg/ml). All the Doppler echocardiography studies were performed by the same experienced operator who was blinded to the data with an Acuson Sequoia ultrasound system (Siemens, Mountain View, California). All the measurements were performed according to the ASE recommendations [4,5] and validated by a second experienced operator. PASP was calculated as the tricuspid valve maximal gradient recorded by continuous-wave Doppler plus the estimated right atrial pressure. The maximal diameter of inferior vena cava was measured in the sub-costal view at end-expiration by 2-dimensional echocardiography. After the inferior vena cava was displayed in its longitudinal axis, the diameter was measured just proximal to the junction of the hepatic veins and the inferior vena cava. A value of 5, 10 and 15 mm Hg for right atrial pressure was arbitrarily given for diameters of b10 mm, 10 to 20 mm and N20 mm,