INTERNAL CARDIOVERSION. Lancashire & South Cumbria Cardiac Network

Transcription

1 INTERNAL CARDIOVERSION Lancashire & South Cumbria Cardiac Network

2 DC Cardioversion AF & AFL safe 1,2 efficacious 3,4 (60-94%) 5 SR - Increases exercise tolerance 6 Maintainence SR unlikely in patients in AF > 3years duration 3

3 Indications internal CV Failed external (on amiodarone) 7 High thoracic impedance (obesity & COPD) 8 Contra-indication to GA

4 Protocol Patients anticoagulated INR ,2 Normal electrolytes ECG recorded on admission Patient prepped as for femoral approach (usually) 8F sheath femoral vein (or right internal jugular) Single pass electrode placed in left Pulmonary artery Supplemental O2, pulse oximetry,, non-invasive BP External defibrillation equipment available

5 Alert Catheter Temporary transvenous flow-directed multipurpose Atrial Defibrillation/Pacing device Designed temporary transmission of electrical impulses Intra-cardiac Sensing Intra-cardiac Pacing Atrial Defibrillation (cardioversion( cardioversion)

6 ALERT Catheter

7 0.21 Guide wire, teflon coated Defibrillation Array platinum Catheter marked 10 cm increments to allow depth of catheter in patient to be seen

8 Placement X-Ray Venous access patients right of spine (on X-Ray X left of spine) Balloon inflation 2mls -RA level (air, check for leaks prior to insertion, flotation technique) Check VE s or arrhythmias during placement Distal array Pulmonary artery RV electrode within RV Ra proximal array within RA

9 Catheter placements LPA RPA Bifurcation

10 Technical protocol Establish rhythm and record baseline Companion set up Appropriate gains for IEGM Rate limit to 360ms (fastest bpm allowed) Energy level 15J. Discuss with operator to increase this level to 30J if 15J fails Tilt 50/50%* Standby pacing OFF*

11 Technical protocol Connect alert catheter Check IEGM Check synchronisation to R waves Change sensitivity if unacceptable* Once patient is sedated Check rhythm Deliver Bi-atrial Shock Confirm Check Rhythm 12 Lead ECG 1hour post procedure

12 If attempt fails discuss options; increasing energy max 30J Changing tilt 60/40% Changing catheter position IV flecainide (ERAF) 10

13 Tilt Percentage decay of the initial voltage Monophasic 50% 75% Vi Vf

14 Tilt Vi(2) = Vf(1) Biphasic 50/50% Vi(1) Vf(1) Vi(2) Vf(2) 60/40% Pulse width 1= Pulse width 2

15 Tilt = (Vi Vf)/Vi x 100!!

16 Sensitivity Sensitivity level allows sensing of R wave above a certain level relates to ventricular size recorded from Ventricular electrode Needed to synchronize to R wave 3 screens satisfactory sensing should be observed prior to shock delivery If sensing is not seen- increase sensitivity by lowering level

17 Sensitivity A B C D A = NO SENSING B INTERMITTENT SENSING C STABLE SENSING D SENSING OF MUSCLE NOISE MUSCLE CARDIAC

18 ERAF EARLY RE-INITIATION of AF PV ectopics 11 RA conduction variation 12 Atrial refractoriness (shorter in AF patients) 13 Relapse AF within 1 minute after at least 2 sinus beats 14 Incidence - 12% 14

19 ERAF - options Flecainide 10 (normal LV function) 100mg + 50mg over 10 mins Impaired LVF IV amiodarone 300mg IV bolus over 15 mins Atrial pacing post shock Due to post shock bradycardia To reduce atrial premature depolarisation 42% success 15 (500ms)

20 Asystole Emergency standby pacing? Ensure ventricular capture ring electrode external pacing facility external defibrillator

21 Warnings Long QT syndrome LBBB CO2 for balloon inflation presence of intracardiac shunts

22 Contra-Indications Peripheral embolism or stroke (last 3 months) Mechanical tricuspid/pulmonary valve Evidence of digitalis toxicity (failed to correct) Evidence of sepsis Evidence of hypercoagulation

23 Patient perception Effective and tolerable fully conscious patients 16 Low satisfaction high in ICV group compared to ECV group 4 hours post procedure, but was lower 28 days post procedure 17 Anxiety, depression, heart related symptoms Failure to maintain SR most powerful contributor to low satisfaction

24 References 1. Internal low energy atrial cardioversion: : efficacy and safety in older patients with chronic persistent AF Boriani,G (2001) 2. Safety of electrical cardioversion in patients with AF Gentile,F (2002) 3. AF recurrence after internal cardioversion: : prognostic importance of electrophysiological parameters - Biffi,M (2002) 4. Transvenous low energy internal cardioversion for AF: a review of clinical applications and future developments Boriani,G (2001) 5. Electrical Cardioversion of AF Joglar,J (2004) 6. The effect of cardioversion on maximal exercise capacity in patients with chronic AF Atwood, J (1989) 7.A comparison of treatment of AF with low energy intracardiac cardioversion and external cardioversion Alt,E (1997) 8. Internal Cardioversion: : a worthwhile alternative after failed external cardioversion in obese patients De Ridder,S (2002) 9.Role of prophylactic anticoagulation for DC cardioversionin patients with AF or AFL Arnold,A (1992) 10. Favorable effects of flecainide intransvenous internal cardioversion of AF Boriani,G (1999) 11. Mechanism of immediate recurrences of AF after restoration of sinus rhythm Chugh,A (2004) 12. Immediate recurrence of AF after internal cardioversion: : importance of right atrial variation Gorenek,B (2002) 13. Evaluation of atrial refractoriness and AF inducibility immediately after internal cardioversion in patients with chronic persistent AF Boriani,G (1999) 14.Incidence & management of early recurrent AF (ERAF) after transthoracic electrical cardioversion Siaplaouras,S (2004) 15.Atrial Pacing for suppression of early reinitiation of AF after successful internal cardioversion Tse,H (2000) 16. Efficacy & tolerability in fully conscious patients of transvenous low energy atrial cardioversion for AF Boriani,G (1998) 17.Treatment satisfaction of internal versus external cardioversion in patients with chronic AF a randomized, prospective, 28 day follow-up study