title: Transthoracic versus transesophageal cardioversion of atrial fibrillation under light sedation: a prospective randomized trial.
abstract: BACKGROUND
  Electrical cardioversion (ECV) of atrial fibrillation (AF) is limited by a 5-10% failure rate and by the expense arising from a perceived need for general anesthesia. A transesophageal approach using light sedation has been proposed as a means of augmenting the success rate and avoiding the need for general anesthesia. We hypothesized that the high rate of success and the lower energy requirement associated with biphasic cardioversion might eliminate any advantage of the transesophageal approach.
  
  
  METHODS
  We randomly assigned 60 patients attending for ECV of persistent AF to a transesophageal or a transthoracic approach. Sedation of moderate depth was achieved with intravenous midazolam. The dose of midazolam was titrated in the same manner in both groups.
  
  
  RESULTS
  Sinus rhythm was restored in 29/30 patients (97%) in each group using a similar number of shocks for both groups (1.3 +/- 0.6 transesophageal vs 1.4 +/- 0.7 transthoracic, P = NS) with a similar procedure duration (14.1 +/- 8.2 minutes vs 13.8 +/- 7.5 minutes, P = NS). Both groups received similar doses of midazolam (4.2 +/- 2.7 mg vs 4.4 +/- 2.8 mg, P = NS) and both reported a similar discomfort score in (0.9 +/- 1.3 vs 1.1 +/- 1.8, P = NS). No complication occurred in either group.
  
  
  CONCLUSIONS
  AF may be cardioverted safely and effectively by either a transthoracic or a transesophageal approach. The use of sedation of moderate depth renders cardioversion by either approach acceptable. As transesophageal ECV shows no clear advantage, transthoracic cardioversion should remain the approach of first choice.
authors: Department of Cardiology, Policlinico Tor Vergata, Rome, Italy.
authors: Luca
authors: L
authors: Santini
authors: Mark M
authors: MM
authors: Gallagher
authors: Lida P
authors: LP
authors: Papavasileiou
authors: Valentina
authors: V
authors: Romano
authors: Alessia
authors: A
authors: Topa
authors: Luciano
authors: L
authors: Di Battista
authors: Maurizio
authors: M
authors: Aracri
authors: Francesco
authors: F
authors: Romeo
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000503:physiopathology / Q000628:therapy*; D016009:Chi-Square Distribution; D016292:Procedural Sedation; D004554:Electric Countershock / Q000379:methods*; D004947:Esophagus; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D008297:Male; D008874:Midazolam / Q000627:therapeutic use; D011446:Prospective Studies; D012684:Sensory Thresholds; D018709:Statistics, Nonparametric; D013909:Thorax; D016896:Treatment Outcome
chemical_list: D006993:Hypnotics and Sedatives; D008874:Midazolam