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(Circulation. 1997;96:253-259.)
© 1997 American Heart Association, Inc.
Articles |
Low-Energy Cardioversion of Spontaneous Atrial Fibrillation
Immediate and Long-term Results
From the Cardiology Division, School of Medicine, University of Marseilles, Marseilles, France.
Correspondence to Samuel Lévy, MD, University of Marseilles, School of Medicine, Cardiology Division, Hôpital Nord, 13015 Marseilles, France.
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Abstract |
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Background Recent studies have suggested that induced atrial fibrillation (AF) could be successfully terminated by using a two-catheter electrode system and low energy (<400 V). This study evaluated the efficacy and safety of low-energy cardioversion in spontaneous chronic and paroxysmal AF.
Methods and Results Forty-two consecutive patients with
spontaneous AF underwent low-energy electrical cardioversion. AF was
chronic (
1 month) with a mean duration of 9±19 months in 28 patients
(group I) or paroxysmal with a history of recurrent attacks and a mean
duration of the present episode of 7±16 days in 14 patients (group
II). An underlying heart disease was present in 28 patients. A
3/3-ms biphasic shock was delivered between catheters positioned in the
right atrium and the coronary sinus in 32 patients. In 10
patients, the left pulmonary artery branch was used. The
catheters were connected to a custom external defibrillator. The shocks
were synchronized to the R wave. Following a test shock of 60 V, the
energy was increased in 40-V steps until a maximum of 400 V or
restoration of sinus rhythm. Sinus rhythm was restored in 22 of the 28
patients (78%) of group I by using a mean leading-edge voltage of
297±57 V (mean energy, 3.3±1.3 J) and in 11 of 14 patients (78%) of
group II by using a mean leading-edge voltage of 223±41 V (mean
energy, 1.8±0.7 J). The energy required for terminating chronic AF was
significantly (P<.001) higher than that required for
terminating paroxysmal AF. Among the other variables studied, the
duration of AF significantly affected the successful voltage.
Ventricular proarrhythmia occurred in 1 patient
with atrial flutter due to an unsynchronized shock. Of the 22 patients
of group I in whom sinus rhythm was restored, 14 (63%) remained in
sinus rhythm with a mean follow-up of 9±3 months. Pain level showed a
good correlation with increasing voltage. However, a marked
interindividual variation was noted.
Conclusions Atrial defibrillation using low energy between two intracardiac catheters with an electrical field between the right and left atria and the protocol used is feasible in patients with persistent spontaneous AF. The technique is safe provided synchronization to the R wave is achieved. A low recurrence rate of AF was seen in patients in whom sinus rhythm was restored.
Key Words: arrhythmia • atrium • fibrillation • defibrillation • shock
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Atrial fibrillation is a common arrhythmia that has gained a renewed interest in recent years. A number of patients complain of disabling symptoms, and the arrhythmia is associated with hemodynamic impairment and a decreased life expectancy.1 Antiarrhythmic therapy remains the treatment of choice and is efficient in maintaining SR and preventing recurrences in a portion of patients. However, there is a group of patients in whom the use of antiarrhythmic agents is unsuccessful or associated with intolerable side effects. Moreover, recent reports2 3 have raised concern regarding the safety of antiarrhythmic agents, as their use may result in an increased mortality rate compared with placebo-treated subjects or with similar groups of patients not on antiarrhythmic therapy. Therefore, nonpharmacological therapy for AF has become appealing. Such options include catheter ablation or modification of the atrioventricular node with or without a permanent pacemaker and an IAD.4 One of the prerequisites for the use of an atrial defibrillator is the ability to safely and efficiently terminate recurrences of AF. Recent technological advances have allowed the development of defibrillation leads with a large surface area and of a prototype of an IAD capable of delivering R wave–synchronized shocks following a programmed minimum RR interval, with a voltage ranging from 0 to 400 V and providing a direct readout of energy and catheter system impedance. Furthermore, the considerable advances made in the implantable cardioverter defibrillator for ventricular tachyarrhythmias have also made possible the development of an IAD.
Cooper et al5 report that AF may be cardioverted in an acute model of AF in sheep by using low-energy shocks and that the best electrode configuration is the use of two catheters, one in the RA and the other in the CS. Reports6 7 in a limited number of patients have shown that cardioversion of short-lived AF is possible in humans by using low-energy shocks. Alt et al8 report the termination of chronic AF in 10 of 13 patients, and Murgatroyd et al9 have shown the feasibility and safety of low-energy shock in terminating induced AF in 19 patients. The purpose of the present study was to evaluate the immediate and long-term results of low-energy atrial defibrillation in 42 patients with spontaneous chronic AF or long-lasting episodes of paroxysmal AF.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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This prospective study included 42 patients with spontaneous, non–self-terminating AF for whom cardioversion was indicated. In no patient was AF electrically or mechanically induced. Informed consent was obtained from all patients. AF was defined as chronic if it was present for
1 month; paroxysmal AF was defined as recurrent
attacks of arrhythmia.9 Only patients with
episodes of paroxysmal AF with a duration 24 hours were included.
Whenever possible, antiarrhythmic therapy was discontinued for five
half-lives. However, the presence of antiarrhythmic therapy was not an
exclusion criterion. All patients with paroxysmal or chronic AF
underwent a transesophageal echocardiogram to rule out
the presence of intracardiac thrombus and received subcutaneous heparin
until the coagulation time was twice or more that of control subjects.
All patients underwent a workup that included a history and physical
examination, 12-lead ECG, chest x-ray, 24-hour ambulatory monitoring,
M-mode and bidimensional echocardiogram, laboratory tests (including
creatinine, serum potassium, and red blood count), and
thyroid function evaluation. This study protocol received approval from
the ethics committee of the University of Marseilles.
The 42 patients included 26 men and 16 women aged 42 to 85 (mean,
67±10) years; weights ranged from 54 to 107 (mean, 74±14) kg. Mean
left atrial diameter was 44±7 (range, 26 to 62) mm. Underlying
heart disease was present in 28 patients, including
valvular heart disease (9), hypertension (13), dilated
cardiomyopathy (2), hypertrophic
cardiomyopathy (1), atrial septal defect (2, one of
whom had had surgery), and hemochromatosis (1). The patients were
subdivided into two groups: chronic AF (group I) and paroxysmal AF
(group II). The patients' clinical characteristics are shown in Table 1
. There were no significant differences between the two
groups except for the duration of the current episode of AF.
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Protocol
Defibrillator shocks were delivered through two 6F catheters
(Elecath), each with a surface area of 2.83 cm2. One of
these was introduced through the left subclavian vein and positioned in
the CS. The other catheter was introduced through the right femoral
vein and positioned in the RA such that the electrodes had contact with
the anterolateral wall. The RA catheter served as the cathode and the
left atrial catheter as the anode. When the CS could not be
successfully catheterized, the anodal catheter was positioned in the
left branch of the pulmonary artery. An additional catheter was
positioned in the right ventricular apex in order to obtain
satisfactory R wave synchronization and to provide postshock
ventricular pacing. Catheter locations are shown in Fig 1. The electrodes used for defibrillation were connected
to a custom external atrial defibrillator (XAD, In Control Inc) capable
of delivering a 3/3 biphasic shock waveform with a leading-edge voltage
that could be programmed between 10 and 400 V. The other programmable
parameter was the RR interval preceding the shock, which
was set to be 500 ms for safety reasons.10 After each
shock, the defibrillator displayed the measured voltage, energy, and
impedance. Cardioversion was performed under local
anesthesia (lidocaine, 1%) in the fasting state without
sedation and after informed consent. The patient was informed that
sedation would be provided at any time should shock delivery become
intolerable. At each voltage level, the patient was asked to rate the
pain level according to the following scale: (1) could not feel the
shock, (2) shock felt but described as not painful, (3) mildly painful
shock, (4) moderately painful shock, or (5) severely painful shock.
When needed, sedation was provided with midazolam at an initial dose of
2.5 mg and a total dose of 0.10 mg/kg body wt. The defibrillation
protocol included a test shock of 20 V and a first shock of 60 V; the
energy was then increased in 40-V steps to a maximum of 400 V. The end
point was restoration of SR or completion of the defibrillation
protocol. After restoration of SR, oral anticoagulation was instituted
and continued for a minimum of 1 month. At the time of the study, 24
patients were admitted on antiarrhythmic therapy aimed at preventing
recurrences, including amioda-rone in 21 patients
and a class I agent (disopyramide or hydroquinidine) in 2
patients. One patient was on a ß-blocking agent. Eighteen patients
were on no antiarrhythmic treatment. Following cardioversion, all
patients were put on class I or III prophylactic
antiarrhythmic therapy. Patients were followed up, and a physical
examination and 12-lead ECG were obtained at 1, 3, 6, 9, and 12 months
or earlier if symptomatic AF recurred.
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Statistical analysis used Student's unpaired t test, and multivariate analysis used the Pearson correlation.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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At the time of cardioversion, 41 patients had AF and 1 had atrial flutter. This patient was reported in this series for reasons described in detail below. Of the 42 patients, atrial arrhythmia was terminated with low-energy shocks in 33 (78%). SR was obtained immediately following the shock in 24 patients (Fig 2
)
and following a short (<30 s) run of persisting AF in 9 patients. In
the remaining 9 patients, the complete defibrillation protocol failed
to terminate AF (8 patients) or atrial flutter (1 patient). A
successful termination of AF following a low-energy shock is shown in
Fig 2. The impedance, RR interval preceding shocks, leading-edge shock
voltage, and energy of the total number of shocks are presented
in Table 2. The data regarding leading-edge voltage and
energy of the successful shocks in the two groups are shown in Table 3. Although the total success rate was similar in the
two groups, the leading-edge voltage and the energy required were
significantly higher in the chronic AF group (P<.001).
Because the CS could not be catheterized in 10 patients, the catheter
was positioned in the left branch of the pulmonary artery. The
leading-edge voltage and the energy required to successfully terminate
AF were significantly (P<.02) higher when the anodal
electrode catheter was in the pulmonary artery rather than in
the CS (Table 4). Twenty of the 32 patients (62.5%) in
the CS group had chronic AF as opposed to 8 of the 10 patients (80%)
in the pulmonary artery group.
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Safety
A total of 334 shocks were delivered to the 42 patients. No
complications occurred following R wave–synchronized shocks. However,
in one 49-year-old woman with mitral valve disease who had a history of
paroxysmal AF and flutter, ventricular
tachycardia that rapidly degenerated into
ventricular fibrillation was induced following a
nonsynchronized shock. At the time of electrical cardioversion she was
on amiodarone (200 mg/d) and presented with paroxysmal
atrial flutter in the hemodynamic laboratory. Atrial
pacing failed to terminate atrial flutter or convert it to AF. This
patient was excluded from the protocol but was reported in order to
provide complete information regarding the technique. Low-energy
cardioversion was attempted to obtain an adequate
hemodynamic evaluation of the valvular disease
in SR. Synchronization on surface ECG was faulty, and shock occurred on
the T wave (Fig 3). As the RR was short (240 ms), the
programmed RR was reduced in order to trigger the external device. The
shock induced ventricular fibrillation that was immediately
and successfully terminated by a 300-J external shock, and the patient
did well.
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Cardiac enzymes including creatine phosphokinase and its myocardium-specific isoenzymes CK-MB measured before, immediately after, and 2 and 6 hours following the defibrillation protocol did not show any significant change (45±36, 46±31, 46±34, and 47±32 IU, respectively).
Shock-Related Pain
Data regarding shock-related pain are available for 30 patients
who agreed to undergo the protocol without sedation. The test shock (20
V) was well tolerated and rated a mean of 1.6±3.5 on the subjective
scale. Only 1 patient described the test shock as moderately painful.
At 60, 100, 140, 180, and 220 V, shock-related pain rated a mean of
2.1, 2.5, 3.1, 3.4, and 3.7, respectively (Table 5).
However, 2 patients at 180 V and 4 at 220 V described the shock as
severely painful and were sedated. At 260 V and above, the shocks
reached a score ranging from a mean of 3.9 to a mean of 4.5 at 340 V
and 400 V, respectively. t test analysis showed a
good correlation between the level of discomfort and increasing
voltage. The difference was significant between 140- and 220-V shocks
(P<.02) and 220- and 300-V shocks (P<.01). A
marked interindividual variation was noted, eg, 5 patients found the
60-V shock mildly painful while 5 patients felt no discomfort with a
180-V shock. Fig 4 shows the distribution of patients
according to leading-edge voltages and shock-related pain levels.
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Outcome of Patients and Follow-up
Of the 6 patients with chronic AF who failed low-energy
cardioversion, SR was restored during the same session in 4 patients
after external cardioversion in 1 and high-energy internal
cardioversion in 3. The remaining 2 patients failed high-energy
internal cardioversion. Of the 22 patients in group I (chronic AF) who
were successfully cardioverted with low-energy shocks, AF
recurred within the first 24 hours in 1 patient and in 2
patients on days 2 and 3, respectively. At hospital discharge, 19 of
the 22 patients were in SR. With a mean follow-up of 9±3 (range, 7 to
13) months, 14 patients (63%) remained in SR. Recurrence of AF
was observed in 5 patients, within 1 week in 3 and after 1 month and 13
months after discharge in the 2 remaining patients. All 19 patients
discharged in SR were on class I or III antiarrhythmic drugs. Among
group II (paroxysmal AF) patients who failed low-energy internal
cardioversion, SR was restored in 2 by using external cardioversion
(260 J) and in 1 by using high-energy internal cardioversion (300 J).
Thus, using the three modalities for cardioversion, SR was restored in
40 of 42 (95%) patients.
Antiarrhythmic Therapy
Of the 24 patients who were on antiarrhythmic therapy at the time
of the procedure, low-energy cardioversion resulted in 22 successful
results (91%) compared with 11 in the 18 patients (61%) who were not
on antiarrhythmic therapy. This was also the case for each of the two
groups (chronic and paroxysmal) studied separately.
Variables and Successful Voltage
An attempt was made to correlate the voltage resulting in
successful cardioversion with variables such as type of AF
(paroxysmal versus chronic), age, gender, weight, duration of current
episode of AF, left atrial size, tested defibrillation impedance,
creatine phosphokinase and potassium levels, and presence or absence
and type of underlying heart disease. Among these, only the type and
duration of AF predicted the successful voltage level. The latter was
lower when AF was paroxysmal (P<.001) as opposed to chronic
and when the duration (in days) was shorter (P<.004). There
was no significant difference between patients with chronic and
paroxysmal AF regarding defibrillation shock impedance.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Background
Restoring SR is a desirable end point in patients with chronic or paroxysmal non–self-terminating AF. It eliminates symptoms when AF is poorly tolerated, prevents left ventricular dysfunction, improves exercise capacity, and may reduce the risk of embolic complications. Electrical external cardioversion is the technique of choice for the restoration of SR. However, the energy required to terminate AF is high, and the technique is not always successful. We have reported11 a catheter technique that can terminate chronic AF in patients who failed external cardioversion. The technique uses the proximal electrode of a quadripolar catheter as the cathode and a backplate as the anode. The energy is 200- or 300-J monophasic shocks. In another study, we showed12 that internal cardioversion is superior to external cardioversion and that the recurrence rate of AF is not higher following internal cardioversion. Thus, the use of internal high-energy cardioversion after failure of external cardioversion results in a higher number of patients in SR at 1 year. Other reports have confirmed the high success rates of high-energy internal cardioversion.13 14 Unfortunately, both external and internal cardioversion techniques use high-energy shocks and require general anesthesia. In an elegant work, Cooper et al5 studied different electrode configurations and waveforms to convert AF in sheep. They found that the electrode configuration that resulted in the lowest defibrillation threshold comprised catheters in the RA appendage and the CS. They also found that biphasic waveform shocks resulted in lower atrial defibrillation thresholds than monophasic ones.
Preliminary Comparison With Previous Studies
Reports in humans6 9 have confirmed that low-energy
cardioversion using the electrode configuration found to be most
effective in sheep, ie, RA and CS,5 is effective. Most of
the data appear in abstracts and concern particular subsets of
patients. Keane et al6 successfully restored SR in 8 of 9
patients with chronic AF by using spring-coil electrodes with a mean
energy of 6.7±2.2 J. Successful cardioversion of electrically induced
AF was obtained by Johnson et al7 in 6 patients with a
mean of 2.5±1.4 J by using biphasic shocks. Alt et al8
report successful atrial defibrillation in 10 of 13 patients with
chronic AF with a mean energy of 3.7±1.7 J. Murgatroyd et
al9 have recently reported on 19 patients with stable AF
lasting >5 minutes, in all of whom SR was restored with a leading-edge
voltage ranging from 140 to 340 V (0.7 to 4.4 J). AF was spontaneous in
only 4 of these patients; in the remaining 15, AF was induced by
catheter manipulation or electrical stimulation.9
Therefore, the data available on catheter-based atrial defibrillation
using low energy in humans are limited. The present series
represents the largest group of catheter-based, low-energy
cardioversion of AF in humans. It included only patients with
spontaneous non–self-terminating AF and confirms that low-energy
atrial defibrillation may be achieved in 78% of patients. Although the
success rate was similar in patients with chronic or paroxysmal AF, the
leading-edge voltage required was significantly (P<.001)
lower with paroxysmal (223±41 V) than chronic (297±57 V) AF. This
represents an important new finding in light of consideration
of the automatic atrial defibrillator as a therapeutic alternative.
Safety
No ventricular proarrhythmia was observed with
synchronized shock. Ventricular fibrillation was induced
with an unsynchronized shock in a flutter patient. Although this
patient represents a protocol violation in several respects,
ie, flutter as opposed to fibrillation and preceding RR interval
programmed <500 ms, we included her in our series. Unlike the 41 other
patients of our series in whom the technique was performed in the
electrophysiological laboratory, this
patient was in the hemodynamic laboratory, and a
display of the synchronization signal to the QRS complex could not be
obtained. Synchronization occurred on the T wave instead of the R wave,
which explains the proarrhythmia.
The importance of R wave synchronization is emphasized and requires a
lead in the right ventricle. Ayers et al10 have also
studied in sheep the conditions under which ventricular
fibrillation might be induced during synchronized shocks delivered
during AF. They found that short (<300 ms) RR intervals preceding the
shock were associated with a low but definite risk of
ventricular fibrillation. Shocks delivered following RR
intervals >300 ms were not associated with proarrhythmia.
Based on these findings, the shocks were delivered after an RR interval
of 500 ms. However, this represents a limitation in patients
with AF and rapid ventricular response.
Pain
Pain related to shocks is an important issue both regarding
patients' tolerance of low-energy cardioversion with an external
device or an automatic implantable defibrillator. The protocol used in
this study showed a correlation between energy delivered and
pain-related shocks. However, an important interindividual variation
was noted. It is likely that the discomfort is increased when the
defibrillation protocol includes shocks at increasing energy levels,
which may generate anxiety in the patients. The termination of AF with
energy levels <1 J was associated with little if any discomfort by
Murgatroyd et al.9 Such a correlation could not be
established in our study. Further studies with a specially adapted
protocol will be needed to evaluate discomfort related to low-energy
shocks.
Clinical Implications
Low-energy cardioversion of AF may have a number of clinical
implications. Using temporary electrode catheters and an external
device, this technique may be useful in terminating mechanically or
electrically induced AF during
electrophysiological studies, thereby
allowing completion of the study. Internal cardioversion may also be
useful in patients who fail external cardioversion. It may be of
particular value in patients with severe obstructive lung disease, as
the technique does not require general anesthesia.
Low-energy cardioversion provides information that is necessary to
study the feasibility of an IAD, which may be an interesting
nonpharmacological therapy for AF. The present study showed that
with the RA-CS configuration, patients with non–self-terminating
paroxysmal AF require a mean energy of <2 J, and for selected patients
of this group an atrial defibrillator may be an
option.15
Study Limitations
The energy required to terminate AF in a patient
represents the minimum energy required to restore SR.
Reproducibility was not tested because it would have required induction
of AF after the first successful shock, and the latter could not be
performed because the ethics committee of our university would not
allow the intentional induction of AF in this study. An important issue
for the use of an IAD is the pain possibly associated with the shock.
The step-up defibrillation protocol generated anxiety in the nonsedated
patients that impaired the appropriate evaluation of the shock-related
discomfort. A specially designed protocol to address this issue may be
required.
Conclusion
This study, using biphasic shocks and two catheter electrodes in
the RA and the CS or the left pulmonary artery, showed that
low-energy cardioversion is feasible in patients with chronic and
persistent non–self-terminating AF of both long and short duration.
The energy required to terminate paroxysmal AF was lower than that
needed to terminate chronic AF. The technique is safe provided
consistent synchronization to the R wave is achieved. This new
technique of internal cardioversion may be useful in patients who fail
external cardioversion and in a subset of patients with persistent AF
in whom general anesthesia may be hazardous. It paves the
way for an IAD. Further studies are required to test the safety and
tolerability of the implanted device.
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Selected Abbreviations and Acronyms |
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Acknowledgments |
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This work was supported in part by a grant from the Ministry of Health, Paris, France, and by a grant from In Control Inc, Redmond, Wash. We would like to thank Dr Jerry Griffin for his constructive criticisms, Steve Adler for his help with the statistical analysis, and Patricia Herpe for preparing this manuscript.
Received December 28, 1995; revision received January 13, 1997; accepted January 15, 1997.
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V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, 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 the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society Circulation, August 15, 2006; 114(7): 700 - 752. [Full Text] [PDF]
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J.C. Geller, S. Reek, C. Timmermans, T. Kayser, H.-F. Tse, C. Wolpert, W. Jung, A.J. Camm, C.-P. Lau, H. J.J. Wellens, et al. Treatment of atrial fibrillation with an implantable atrial defibrillator -- long term results Eur. Heart J., December 1, 2003; 24(23): 2083 - 2089. [Abstract] [Full Text] [PDF]
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A. A. Lotto, R. Ascione, M. Caputo, A. J. Bryan, G. D. Angelini, and M-S. Suleiman Myocardial protection with intermittent cold blood during aortic valve operation: antegrade versus retrograde delivery Ann. Thorac. Surg., October 1, 2003; 76(4): 1227 - 1233. [Abstract] [Full Text] [PDF]
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G. Manoharan, N. Evans, B. Kidwai, D. Allen, J. Anderson, and J. Adgey Novel Passive Implantable Atrial Defibrillator Using Transcutaneous Radiofrequency Energy Transmission Successfully Cardioverts Atrial Fibrillation Circulation, September 16, 2003; 108(11): 1382 - 1388. [Abstract] [Full Text] [PDF]
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H.-Y. Li, S. Wu, G.-W. He, and T.-M. Wong Aprikalim reduces the Na+-Ca2+ exchange outward current enhanced by hyperkalemia in rat ventricular myocytes Ann. Thorac. Surg., April 1, 2002; 73(4): 1253 - 1259. [Abstract] [Full Text] [PDF]
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Guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology Eur. Heart J., October 2, 2001; 22(20): 1852 - 1923. [PDF]
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V. Fuster, L. E. Ryden, R. W. Asinger, D. S. Cannom, H. J. Crijns, R. L. Frye, J. L. Halperin, G. N. Kay, W. W. Klein, S. Levy, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology J. Am. Coll. Cardiol., October 1, 2001; 38(4): 1266 - 1266. [Full Text] [PDF]
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X. Zheng, M. E. Benser, G. P. Walcott, and R. E. Ideker Right Atrial Septal Electrode for Reducing the Atrial Defibrillation Threshold Circulation, August 28, 2001; 104(9): 1066 - 1070. [Abstract] [Full Text] [PDF]
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G. Gasparini, A. Bonso, S. Themistoclakis, F. Giada, and A. Raviele Low-energy internal cardioversion in patients with long-lasting atrial fibrillation refractory to external electrical cardioversion: results and long-term follow-up Europace, January 1, 2001; 3(2): 90 - 95. [Abstract] [PDF]
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X. Zheng, M. E. Benser, G. P. Walcott, S. D. Girouard, D. L. Rollins, W. M. Smith, and R. E. Ideker Reduction of Atrial Defibrillation Threshold With an Interatrial Septal Electrode Circulation, November 21, 2000; 102(21): 2659 - 2664. [Abstract] [Full Text] [PDF]
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G. Boriani, M. Biffi, V. Cervi, G. Bronzetti, G. Magagnoli, R. Zannoli, and A. Branzi Evaluation of Myocardial Injury Following Repeated Internal Atrial Shocks by Monitoring Serum Cardiac Troponin I Levels Chest, August 1, 2000; 118(2): 342 - 347. [Abstract] [Full Text] [PDF]
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M. Santini, C. Pandozi, F. Colivicchi, F. Ammirati, M. Carmela Scianaro, A. Castro, F. Lamberti, and G. Gentilucci Transoesophageal low-energy cardioversion of atrial fibrillation. Results with the oesophageal-right atrial lead configuration Eur. Heart J., May 2, 2000; 21(10): 848 - 855. [Abstract] [PDF]
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C. W. Hogue Jr and M. L. Hyder Atrial fibrillation after cardiac operation: risks, mechanisms, and treatment Ann. Thorac. Surg., January 1, 2000; 69(1): 300 - 306. [Abstract] [Full Text] [PDF]
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H.-F. Tse, C.-P. Lau, B. M. Yomtov, and G. M. Ayers Implantable atrial defibrillator with a single-pass dual-electrode lead J. Am. Coll. Cardiol., June 1, 1999; 33(7): 1974 - 1980. [Abstract] [Full Text] [PDF]
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M. Kirsch, S. Bertrand, J.-P. Garnier, C. Fernandez, C. Baufreton, A. Astier, and D. Loisance Pretreatment with a potassium-channel opener before prolonged cardiac storage: an evaluation in an experimental brain death model Ann. Thorac. Surg., June 1, 1999; 67(6): 1623 - 1629. [Abstract] [Full Text] [PDF]
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C. Timmermans, L.-M. Rodriguez, G. M. Ayers, H. Lambert, J. L. R. M. Smeets, J. W. S. Vlaeyen, A. Albert, and H. J. J. Wellens Effect of Butorphanol Tartrate on Shock-Related Discomfort During Internal Atrial Defibrillation Circulation, April 13, 1999; 99(14): 1837 - 1842. [Abstract] [Full Text] [PDF]
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H.-F. Tse, C.-P. Lau, J. S. Sra, H. J. G. M. Crijns, N. Edvardsson, S. Kacet, and D. G. Wyse Atrial Fibrillation Detection and R-Wave Synchronization by Metrix Implantable Atrial Defibrillator : Implications for Long-Term Efficacy and Safety Circulation, March 23, 1999; 99(11): 1446 - 1451. [Abstract] [Full Text] [PDF]
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V. Taramasco, A. Socas, P. Ricard, and S. Levy Internal low-energy cardioversion: A therapeutic option for restoring sinus rhythm in chronic atrial fibrillation after failure of external cardioversion Europace, January 1, 1999; 1(3): 179 - 182. [Abstract] [PDF]
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R. A. S. Cooper, V. J. Plumb, A. E. Epstein, G. N. Kay, and R. E. Ideker Marked Reduction in Internal Atrial Defibrillation Thresholds With Dual-Current Pathways and Sequential Shocks in Humans Circulation, June 30, 1998; 97(25): 2527 - 2535. [Abstract] [Full Text] [PDF]
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R. A. Gray and J. Jalife Effects of Atrial Defibrillation Shocks on the Ventricles in Isolated Sheep Hearts Circulation, April 28, 1998; 97(16): 1613 - 1622. [Abstract] [Full Text] [PDF]
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