Europace Advance Access originally published online on February 28, 2008
Europace 2008 10(4):451-452; doi:10.1093/europace/eun046
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NOVEL NONPHARMACOLOGICAL THERAPIES FOR AF
Electrical cardioversion of atrial fibrillation using four defibrillation patches
Department of Cardiology, University of Ioannina, 1 Stavrou Niarxou Avenue, 45110 Ioannina, Greece
Manuscript submitted 28 November 2007. Accepted after revision 8 February 2008.
* Corresponding author. Tel: +30 265 1097227; fax: +30 265 1097053. E-mail address: thkolet{at}cc.uoi.gr
Key Words: Atrial fibrillation, Electrical cardioversion, Thoracic impedance, Patch configuration
A 73-year-old female patient with hypertrophic cardiomyopathy presented with angina. During catheterization, she developed atrial fibrillation with a rapid ventricular response, associated with severe haemodynamic compromise. Two transthoracic patches (pro-padz, Zoll Medical Corporation, USA) were positioned in the anterior–posterior position, but a rectilinear biphasic 200-J shock (M-series defibrillator, Zoll Medical Corporation, USA) was unsuccessful. Four further shocks using hand-held paddles were also unsuccessful, despite manual pressure applied to improve contact, as were six shocks at various patch positions. Amiodarone (450 mg) was administered, but five additional 200-J biphasic shocks were ineffective.
An increased thoracic electrical impedance was implicated as the cause of failure, because of the patient's body habitus (height, 160 cm; weight, 75 kg; body surface area, 1.75 m2). Prior to contemplating internal defibrillation, the impedance was decreased by increasing the defibrillation area with the use of four patches. Two patches were placed on the precordium; the insulation was stripped, and the two wires were connected together and then to the defibrillator output. A similar connection was made for the patches placed on the midscapular and the left subscapular position. Using this configuration, a 200-J biphasic shock restored sinus rhythm, with immediate haemodynamic improvement.
A number of techniques have been reported to increase cardioversion success rates using monophasic shocks, such as the sequential double shock configuration. The use of biphasic shocks increases cardioversion rates, minimizing the importance of thoracic electrical impedance. Our experience indicates that this factor should be accounted for in unsuccessful cases; a custom four-patch configuration can be easily applied and may prove useful (Figure 1A and B).
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Conflict of interest: none declared.
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