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The authors present the case of a man in his 50s who arrived at the ED with palpitations and persistent tachycardia a month after undergoing catheter ablation (CA) for atrial fibrillation with rapid ventricular response, and a week after electrical cardioversion in our ED. He was once again successfully cardioverted in our ED. The unique aspect of this case is how refractory his case was. This case highlights the limitations of current AF management strategies in achieving durable rhythm control, particularly following ablation. It underscores the importance of timely follow-up, individualized treatment planning, and consideration of additional interventions such as repeat ablation or atrioventricular nodal ablation with pacemaker placement in refractory cases. Serial ECV can provide temporary relief but should be viewed as a bridge to more definitive therapy. Serial Electrical Cardioversion for Refractory Atrial Fibrillation with Rapid Ventricular Response Post Ablation.

Objective: Atrial structural remodeling has been suggested to contribute to atrial fibrillation (AF) recurrence following direct-current cardioversion (DCCV). The role of several inflammatory and extracellular matrix turnover markers in AF recurrence following DCCV has been investigated. However, data on the impact of galectin-3, which is known to play a role in various fibrotic conditions, including cardiac fibrosis are lacking. The aim of this study was to demonstrate the predictive role of serum galectin-3 levels in AF recurrence following successful DCCV. Methods: A total of 90 persistent AF patients who were sche-duled for DCCV were prospectively enrolled. Serum samples were assayed to determine pre-DCCV galectin-3 levels using the enzyme-linked immunosorbent assay method. Patients were followed up for 3 months for AF recurrence. Results: Of 90 persistent AF patients (mean age: 55.33+-7.94 years; 53.33% male) who underwent successful DCCV, 28 (31.11%) experienced early AF recurrence within 3 months. Patients with AF recurrence had a greater left atrial volume index (LAVI) (33.35+- 2.45 mL/m2 vs. 29.21+-3.08 mL/m2; p<0.001) and serum galectin-3 levels were higher (0.88 ng/mL [min-max: 0.52–1.32] vs. 0.60 ng/mL [min-max: 0.38–0.91]; p<0.001). In multivariate analysis, the number of DCCV attempts (hazard ratio [HR]: 1.879, 95% confidence interval [CI]: 1.052–3.355; p=0.033), LAVI (HR: 1.180, 95% CI: 1.028–1.354; p=0.018), and serum galectin-3 level (HR: 11.933, 95% CI: 1.220–116.701; p=0.033) were found to be independently associated with early AF recurrence following successful DCCV. Conclusion: Circulating levels of galectin-3 may have an association with early AF recurrence following DCCV.

IntroductionElectrical cardioversion (ECV) plays a key role in the management of symptomatic patients with persistent atrial fibrillation (AF) requiring a rhythm control strategy. Predictors for ECV to restore sinus rhythm in persistent AF are arrhythmia duration, patient age, presence of comorbidities and pre-treatment with antiarrhythmic drugs (AADs)1,2. The study’s primary aim was to determine the relationship between periprocedural use of AADs and the success of ECV in patients with persistent atrial fibrillation that have undergone ECV at University Hospital of North Tees. A successful outcome post-ECV was defined as the patient leaving the hospital on the day in sinus rhythm. By recording various patient characteristics, this study showcases predictors of both successful ECV, and subsequent maintenance of sinus rhythm in the studied population.MethodsOur service evaluation project comprised a retrospective case control study. 71 patients with symptomatic AF were included that were referred for elective ECV at our Cardiology Outpatient Day Unit, between November 2022 and November 2023. Data collection started November 2023 by reviewing patients’ notes, recording their ECV outcome on the day, and maintenance of sinus rhythm at 5 weeks (Fig 1).At each point, the prevalence of predictive factors for ECV success and maintenance of sinus rhythm was analysed, focusing on basic demographics, elements of past medical history, AAD use pre- and post-ECV, social history, pre-ECV echocardiography reports and biochemical investigations.ResultsThere were considerable differences in prevalence of some predictors between the successful and unsuccessful ECV groups, as shown in table 1.On the day, the main predictor for ECV restoring sinus rhythm was the pre-procedure use of AADs, in particular amiodarone. Predictors of an unsuccessful outcome included higher alcohol consumption, longer time spent in AF, a dilated LA and a history of HTN.The predictors of sinus rhythm maintenance at 5 weeks follow up are illustrated in table 2. Pre- and post-procedure amiodarone use seem to correlate with maintenance of sinus rhythm. Conversely, a dilated LA and the presence of hypertension were associated with the return of AF. ConclusionsAmiodarone administration before ECV appears to corelate with a successful outcome on the day of cardioversion.AAD continuation post-successful ECV, in particular amiodarone, represents a positive predictor for maintenance of sinus rhythm.Further research is required to determine the ability of amiodarone to improve ECV outcomes, and to what extent this represents a reasonable solution in clinical practice.Abstract 132 Table 1Immediate ECV outcome and identified significant discrepancies in ECV predictors Successful (94%) Predictors Unsuccessful (6%) 18 Alcohol (average units/week) 37 96% Pre-procedure AAD 75% 18% Pre-procedure amiodarone 0% 48% Dilated left atrium (LA) 75% 45% Hypertension (HTN) 75% 65 days DCCV waiting time 127 days Abstract 132 Table 25-week outcomes and identified significant discrepancies in sinus rhythm maintenance predictors Sinus rhythm (47%) Predictor AF (52%) Lost to follow up (1%) 100% Pre-procedure AAD 92% 21% Pre-procedure amiodarone 14% 97% Post-procedure AAD use 86% 24% Post-procedure amiodarone use 16% 45% Dilated LA 57% 45% HTN 49% Abstract 132 Figure 1ECV outcomes on the day, at 5 weeks and at 1 yearConflict of InterestNone

This study aims to determine the predictive value of the soluble suppression of tumorigenicity 2 (sST2) biomarker in atrial fibrillation (AF) recurrence. This prospective, observational study included patients with AF referred for electrical cardioversion (ECV) or pulmonary vein isolation (PVI) procedures. Baseline characteristics were collected, and sST2 was determined at baseline and at 3 and 6 months of follow-up. sST2 was determined at baseline in a matched control group. Left atrial voltage mapping was performed in patients undergoing PVI. The sST2 maximal predictive capacity of AF recurrence was at the 3-month FU in the cohort of patients undergoing ECV with respect to 6-month AF recurrence with an AUC of 0.669, a cut-off point of 15,511 pg/mL, a sensitivity of 60.97%, and a specificity of 69.81%. The ROC curve of the sST2 biomarker at baseline and 3 months in the cohort of patients undergoing PVI showed AUCs of 0.539 and 0.490, respectively. The logistic regression model identified the rhythm (AF) and the sST2 biomarker at 3 months as independent factors for recurrence at 6 months in the ECV cohort. In the logistic regression model, sST2 was not an independent factor for recurrence at 6 months of follow-up in the PVI cohort. In patients who underwent ECV, sST2 values at 3 months may provide utility to predict AF recurrence at 6 months of follow-up. In patients who underwent PVI, sST2 had no value in predicting AF recurrence at 6 months of follow-up.

Electrical cardioversion (ECV) a widely utilized intervention for persistent atrial fibrillation (AF) aimed at restoring sinus rhythm. However, ECV can be ineffective, raising questions about subsequent treatment options. This study aimed to compare the outcomes of non-ablation therapy versus ablation therapy following unsuccessful ECV. A total of 125 consecutive patients with persistent AF who underwent unsuccessful ECV between November 2017 and August 2023 was included in this retrospective analysis. Of these, 51.2% received only medical therapy (non-ablation therapy group, n  = 64), while 48.8% underwent AF ablation (ablation therapy group, n  = 61). Various ablation methods were employed, including catheter and thoracoscopic ablation. Ablation therapy was associated with significantly better AF-free survival compared to non-ablation therapy [hazard ratio (HR), 0.37; 95% confidence interval (CI) 0.22–0.61; p  < 0.01]. There was no difference of AF-free survival between catheter ablation and thoracoscopic ablation groups (HR 0.79, 95% CI 0.34–1.83; p  = 0.58). AF duration > 5 year (HR 1.51; 95% CI 0.930–2.437; p  = 0.10), BMI ≤ 25 kg/m 2 (HR 1.61; 95% CI 1.004–2.581; p  = 0.05) and diabetes (HR 2.38; 95% CI 0.902–6.266; p  = 0.08) were considerable as predictor of AF recurrence. Ablation therapy following unsuccessful ECV was associated with maintaining sinus rhythm, regardless of the specific ablation method utilized.

Successful synchronized direct current cardioversion (DCCV) requires adequate current delivery to the heart. However, adequate current for successful DCCV has not yet been established. Transmyocardial current depends on 2 factors: input energy and transthoracic impedance (TTI). Although factors affecting TTI have been studied in animal models, factors affecting TTI in humans have not been well established. Herein, we explored the potential factors that affect TTI in humans. A retrospective review of patients who underwent DCCV at a large quaternary medical center between October 2019 and August 2021 was conducted. Pertinent clinical information, including demographics, echocardiography findings, laboratory findings, and body characteristics, was collected. Cardioversion details, including joules delivered and TTI, were recorded by the defibrillator for each patient's first shock. Predictors of thoracic impedance were assessed using regression analysis. A total of 220 patients (29% women) were included in the analysis; 143 of the patients (65%) underwent DCCV for atrial fibrillation and 77 (35%) underwent DCCV for atrial flutter. The mean impedance in our population was 73 ± 18 Ω. In a regression model with high impedance defined as the upper quartile of our cohort, body mass index (BMI), female sex, obstructive sleep apnea, and chronic kidney disease (all p values <0.05) were significantly associated with high impedance. According to a receiver operating characteristic analysis, BMI has a high predictive value for high impedance, with an area under the curve of 0.76. In conclusion, our study reveals that elevated BMI, female sex, sleep apnea, and chronic kidney disease were predictors of higher TTI. These factors may help determine the appropriate initial shock energy in patients who underwent DCCV for atrial fibrillation and flutter.

Objective: To determine the predictors of short-term and long-term success of electrical cardioversion in persistent atrial fibrillation. Study Design: Prospective longitudinal study. Place and Duration of Study: Department of Cardiology, Electrophysiology Division, Armed Forces Institute of Cardiology andNational Institute of Heart Diseases (AFIC-NIHD), Rawalpindi Pakistan, from Sep 2024 to Apr 2025. Methodology: A total of 119 male and female patients aged 20 to 90 years diagnosed with persistent atrial fibrillation. Patients with valvular heart disease, prior history of electrical cardioversion, paroxysmal atrial fibrillation, and left atrial clot were excluded. Electrical cardioversion was performed, and short-term (sinus rhythm restoration after a week) and long-term (sinus rhythm restoration after three months) success was noted. Data analysis was carried out using Statistical Package for the Social Sciences (SPSS) version 26. Results: The mean age of the participants was 55.95±11.46 years, and the mean Atrial Fibrillation (AF) duration was 12.63±3.72 days. Patients aged more than 50 years were 77(64.7%), and 72(60.5%) patients were male. Successful cardioversion was recorded in 104 patients (87.4%). Short-term and long-term success was recorded in 92(77.3%) and 80(67.2%) patients, respectively. Acute successful cardioversion was more frequent when performed by a consultant with more than 12 years of experience (91.0% versus 76.7%, p-value 0.041). Conclusion: Electrical cardioversion was shown to be an effective and successful therapy for persistent atrial fibrillation. Although success rates inevitably declined over time, the promising early outcomes demonstrate that electrical cardioversion is a dependable first-line technique for restoring sinus rhythm.

•Racial and ethnic minoritized populations were less likely to be treated with catheter ablation.•Disparities exist in the utilization of direct current cardioversion and antiarrhythmic drugs.•Black patients had increased all-cause mortality, heart failure hospitalization, and stroke rates compared to White patients.•Future studies exploring the cause of these disparities are needed. Rhythm control strategies are a key component of atrial fibrillation (AF) therapy, with recent reports suggesting racial and ethnic disparities in their utilization. We aimed to determine differences in the utilization of catheter ablation (CA), direct current cardioversion (DCCV), and anti-arrhythmic drugs (AAD) among different racial and ethnic groups. We searched PubMed/MEDLINE, EMBASE, and Cochrane Library (from inception to January 31st, 2024) for studies including adults with AF and reporting CA, DCCV, or AAD utilization rates in at least 2 racial and ethnic groups. Our primary outcome was the likelihood of Black, Hispanic, and Asian individuals undergoing each rhythm control strategy compared to White patients. Pooled estimates were calculated with a random-effects model and were reported as odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs). Nineteen studies were included comprising 12,598,109 patients. The pooled ORs (95% CI) of undergoing CA for Black individuals was 0.68 (95% CI 0.56 to 0.83), for Hispanic individuals was 0.72 (95% CI 0.63 to 0.82), and for Asian individuals was 0.64 (95% CI 0.48 to 0.86), compared to White individuals. The likelihood of undergoing DCCV (OR [95% CI]) was lower in Black (0.69 [95% CI 0.57 to 0.82]), Hispanic (0.67 [95% CI 0.57 to 0.80]), Asian (0.68 [95% CI 0.64 to 0.72]) patients compared to White patients. Our results identified that racial and ethnic minoritized groups with AF are significantly less likely to undergo treatment with a rhythm control strategy. In conclusion, these findings highlight a significant gap in healthcare delivery that stakeholders, healthcare systems, and clinicians should address. [Display omitted]

OBJECTIVEDirect current electrical cardioversion (DCCV) is an effective rhythm-control option for patients with atrial fibrillation (AF). Despite initial success, a high recurrence rate remains a significant challenge. There is limited data on the genetic predictors of AF recurrence following successful DCCV. In this study, we aimed to evaluate whether 11 single nucleotide polymorphisms (SNPs) previously associated with AF are also linked to recurrence after DCCV in the Turkish population.METHODSSeventy-five patients with persistent AF, who achieved stable sinus rhythm following DCCV, were included in the study. The patients were prospectively monitored for the onset of AF recurrence. Clinical characteristics and SNPs were analyzed and compared between patients who experienced recurrence and those who did not.RESULTSThe average age of the patients was 61.9 ± 11.5, and 33 (44%) were female. Over an average follow-up period of 17.0 (11.0-25.0) months, AF recurrence was observed in 38 patients (50.7%). A SNP in the PITX2 gene (rs17570669) (OR: 9.00, 95% Confidence Interval (CI): 1.28-63.02) and another in the ZFHX3 gene (rs2106261) (OR: 8.96, 95% CI: 1.03-77.66) were notably associated with AF recurrence in the additive model (P = 0.027 and 0.047, respectively). Multivariate Cox regression analysis revealed that the rs17570669 SNP was the sole independent predictor of AF recurrence (Hazard Ratio (HR): 3.59, 95% CI: 1.05-12.21, P = 0.040).CONCLUSIONThe SNP in the paired-like homeodomain 2 (PITX2) gene (rs17570669) emerges as an independent predictor for AF recurrence after successful electrical cardioversion.

Background: The integrated approach to electrical cardioversion (EC) in atrial fibrillation (AF) is complex; candidates can resolve spontaneously while waiting for EC, and post-cardioversion recurrence is high. Thus, it is especially interesting to avoid the programming of EC in patients who would restore sinus rhythm (SR) spontaneously or present early recurrence. We have analyzed the whole elective EC of the AF process using machine-learning (ML) in order to enable a more realistic and detailed simulation of the patient flow for decision making purposes. Methods: The dataset consisted of electronic health records (EHRs) from 429 consecutive AF patients referred for EC. For analysis of the patient outcome, we considered five pathways according to restoring and maintaining SR: (i) spontaneous SR restoration, (ii) pharmacologic-cardioversion, (iii) direct-current cardioversion, (iv) 6-month AF recurrence, and (v) 6-month rhythm control. We applied ML classifiers for predicting outcomes at each pathway and compared them with the CHA2DS2-VASc and HATCH scores. Results: With the exception of pathway (iii), all ML models achieved improvements in comparison with CHA2DS2-VASc or HATCH scores (p < 0.01). Compared to the most competitive score, the area under the ROC curve (AUC-ROC) was: 0.80 vs. 0.66 for predicting (i); 0.71 vs. 0.55 for (ii); 0.64 vs. 0.52 for (iv); and 0.66 vs. 0.51 for (v). For a threshold considered optimal, the empirical net reclassification index was: +7.8%, +47.2%, +28.2%, and +34.3% in favor of our ML models for predicting outcomes for pathways (i), (ii), (iv), and (v), respectively. As an example tool of generalizability of ML models, we deployed our algorithms in an open-source calculator, where the model would personalize predictions. Conclusions: An ML model improves the accuracy of restoring and maintaining SR predictions over current discriminators. The proposed approach enables a detailed simulation of the patient flow through personalized predictions.