Vol. 6, Issue 2, Part A (2024)

Background: Atrial fibrillation (AF) is common in the community and its incidence is rising. Attempting to restore sinus rhythm is mandatory to avoid the wide range of complications. Unfortunately, pharmacological cardioversion generally has poor outcome. Electrical cardioversion is often more effective in restoring sinus rhythm.
Aim of the study: Assessment of feasibility, safety and effectiveness of direct current cardioversion (DCCV) that is guided by transoesophageal echocardiography (TEE) in restoring sinus rhythm in patients with AF, to assess the rate of recurrence of AF in the intermediate term, and to determine the factors that predict failure to restore sinus rhythm or recurrence of AF in the intermediate term.
Patients and methods: All patients with persistent AF undergoing TEE-guided DCCV were included in this prospective study. After relevant clinical workup, a comprehensive transthoracic echocardiographic assessment preceded transesophageal echocardiography, which was primarily performed to rule out left atrial appendage thrombus, and also to perform a complete study. After optimization of treatment, all eligible patients received DC cardioversion. In patients who converted to sinus rhythm, follow-up was performed to assess recurrence and any change in left ventricle function or clinical status.
Results: 57 patients with AF were included, their ages ranged from (37 to 80 years), there were 31 males and 26 females. (13) were diabetics, (31) hypertensives. In (23) there was left ventricle dysfunction. Of the 57 patients studied, DC cardioversion could immediately restore sinus rhythm in 53 patients (immediate success rate of 93%). At completion of the study, 46 remained in sinus rhythm and 7 more patient had recurrence of AF (19%), amounting to an intermediate-term success rate of (80.7%). There was no statistical difference in age, body mass index, gender, history of alcohol intake, and smoking history between patients attaining sinus rhythm and atrial fibrillation persistence/recurrence. Longer duration of AF was weakly associated with higher risk of AF recurrence (104 vs. 23.5 weeks) but is was not statistically significant (p=0.067), left atrial size had fair ability to predict atrial fibrillation recurrence (AUC=0.766, p = 0.004) with optimal cut point of >41 mm, having 100% sensitivity, 58.7% specificity. Structural heart disease was present in (7) patients with successful DCCV and (5) patients with failure/recurrence. 
Conclusion: DC cardioversion for selected group of patients with persistent AF is a safe and highly effective method of rhythm conversion. Left atrial size, longer duration of AF and structural heart disease were fair predictors of failure/recurrence.