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J Am Coll Cardiol. 2019 Nov 5;74(18):2267-2274. doi: 10.1016/j.jacc.2019.08.1045.

Direct Current Cardioversion of Atrial Fibrillation in Patients With Left Atrial Appendage Occlusion Devices.

Author information

1
Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, Kansas.
2
Icahn School of Medicine at Mount Sinai, New York, New York.
3
Cedars-Sinai Medical Center, Los Angeles, California.
4
Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas.
5
Texas Heart Institute, St. Luke's Hospital, Houston, Texas.
6
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
7
The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
8
Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, Kansas. Electronic address: dlakkireddy@gmail.com.

Abstract

BACKGROUND:

Direct current cardioversion (DCCV) is a common rhythm control strategy in patients with symptomatic atrial fibrillation or flutter. There is no long-term data regarding the safety of DCCV in patients with endocardial left atrial appendage occlusion (LAAO) devices.

OBJECTIVES:

The purpose of this study was to assess the feasibility and safety of DCCV in patients with an LAAO device.

METHODS:

This multicenter retrospective study included 148 patients with an LAAO device who underwent DCCV for symptomatic atrial fibrillation or atrial flutter.

RESULTS:

The average age of the included patients was 72 ± 7 years and 59% were men. All patients (100%) had a transesophageal echocardiogram prior to DCCV. Device-related thrombus was seen in 2.7%. They were all successfully treated with oral anticoagulation (OAC) and were able to undergo DCCV after 6 to 8 weeks. DCCV restored sinus rhythm in all patients. None of the patients had DCCV-related thromboembolic complications. A total of 22% of patients were newly started on OAC after DCCV. There was no difference in DCCV-related complications between patients treated with or without OAC post-DCCV. Patients receiving OAC post-DCCV were found to undergo cardioversion at an earlier time after implantation (3.6 months [interquartile range (IQR): 0.7 to 8.6 months] vs. 8.6 months [IQR: 2.5 to 13.3 months]; p = 0.003). Three transient ischemic attacks, unrelated to DCCV, were found during follow-up. During a median follow-up of 12.8 months (IQR: 11.8 to 14.2 months), no device or left atrial thrombosis, device dislodgement, or a new device leak were observed. One patient died during follow-up due to noncardiac cause.

CONCLUSIONS:

DCCV is feasible in high-risk AF patients with an LAAO device without the need for oral anticoagulation if pre-procedural transesophageal echocardiography shows good device position, absence of device-related thrombus, and peridevice leak of ≤5 mm. The preliminary results are encouraging, but further large studies are warranted to establish safety.

KEYWORDS:

Watchman; direct current cardioversion; left atrial appendage occlusion; oral anticoagulation

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