title: Biphasic transoesophageal vs. transthoracic electrical cardioversion of persistent atrial fibrillation.
abstract: OBJECTIVE
  To compare the efficacy and safety of transoesophageal (TOC) vs. transthoracic (TTC) electrical cardioversion, both with biphasic shocks, for sinus rhythm (SR) restoration in patients with persistent atrial fibrillation (AF).
  
  
  METHODS
  We randomised 210 patients (151 male, 59 female, mean age 66 +/- 9 years) with persistent AF into two groups: group 1 (n = 104) undergoing TOC with a step-up protocol of 30, 50, 70 and 100 J, and group 2 (n = 106) undergoing TTC with a step-up protocol of 70, 100, 120 and 150 J.
  
  
  RESULTS
  The two groups were homogeneous as for clinical and instrumental characteristics, except for left ventricular ejection fraction (50.5 +/- 10% in group 1 vs. 53 +/- 8% in group 2, P < 0.05) and thoracic impedance (63 +/- 8 Omega in group 1 vs. 66 +/- 6 Omega in group 2, P < 0.005). SR was restored in 98 (94%) group 1 patients vs. 99 (93%) group 2 patients (P = NS). First shock was effective in 48 (46%) group 1 patients vs. 54 (51%) group 2 patients (P = NS). Mean delivered energy was 50.4 +/- 23.6 and 95.1 +/- 29.6 J; mean effective energy was 47.3 +/- 20.7 and 91.2 +/- 26.6 J in group 1 and group 2, respectively. Cross-over to the highest energy level was never effective. TOC tolerability was optimal (mean discomfort score 1.2 on a 1-4 grading scale). Markers of myocardial necrosis did not increase and no procedure-related complications occurred. On logistic regression analysis, the most predictive variables of unsuccessful cardioversion were AF duration (P = 0.0001) and low left atrial appendage emptying velocity (P = 0.02).
  
  
  CONCLUSIONS
  Both TOC and TTC with biphasic shocks are effective and safe for SR restoration in patients with persistent AF; however, the considerably lower levels of delivered and effective energies for SR restoration allow TOC to be performed during mild sedation with optimal tolerability, thus avoiding general anaesthesia.
authors.affiliation: 1st Cardiology Operative Unit, Cardiovascular Department, San Camillo-Forlanini Hospital, Rome, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Mazza
authors.forename: Maria Stella
authors.initials: MS
authors.lastname: Fera
authors.forename: Marco
authors.initials: M
authors.lastname: Pugliese
authors.forename: Massimo
authors.initials: M
authors.lastname: Leggio
authors.forename: Maria Grazia
authors.initials: MG
authors.lastname: Bendini
authors.forename: Valeria
authors.initials: V
authors.lastname: Poli
authors.forename: Carla
authors.initials: C
authors.lastname: Manzara
authors.forename: Giovanni
authors.initials: G
authors.lastname: Minardi
authors.forename: Paolo Giuseppe
authors.initials: PG
authors.lastname: Pino
authors.forename: Donato
authors.initials: D
authors.lastname: Pompa
authors.forename: Anna Teresa
authors.initials: AT
authors.lastname: Fiorella
authors.forename: Francesco
authors.initials: F
authors.lastname: De Santis
authors.forename: Ezio
authors.initials: E
authors.lastname: Giovannini
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000628:therapy*; D016009:Chi-Square Distribution; D018592:Cross-Over Studies; D004554:Electric Countershock / Q000379:methods*; D004947:Esophagus; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D018709:Statistics, Nonparametric; D013909:Thorax; D016896:Treatment Outcome