PLANNED DC CARDIOVERSION: Tips and Trips Dr Vineet Sankhla

MD DM Cardiology (CMC Vellore)

Terminology
Defrillation electrical termination of VF x Cardioversion electrical termination of AF, AFL, SVT and VT
x

Planned CV Pharmcalogical vs Electrical

x DC CV can restore SR immediately

& safely

x Side effects of AAD avoided x Time consuming titration of AAD

avoided

Response to CV
x CV useful in Reentry Arrhythmias x Ectopic rhythms, automatic

arrhythmias, MAT and digoxin induced arrhythmias do not respond to CV (may be harmful)

Planned CV for whom ?

x AF / AFL with
y MS y LVH (AS, HTN, HCM) x

Diminished Myocardial reserve (CHF, MI, Ischemia) and Symptoms in these patients

Restoration of SR improves Cardiac Performance

Planned CV
x Immediate and Long term success

depends

y Duration of arrhythmias y Extent of atrial fibrosis y LA size y TTI y Biphasic waveforms

Topics
x Risk of Thrombo-embolism x Myocardial condition/factors x Techniques of CV
y Sedation y Synchronization y Electrodes y New Waveforms for CV

Thrombo-embolism
x

Traditional - Therapeutic Anticoagulation for 3 weeks prior to CV TEE guided CV TEE to r/o LAA thormbus, 2 days of heparin & then CV Mandatory 4 weeks of anticoagulation post CV

Cardioversion
x

Myocardial factors/conditions
x

Hypoxia, acidosis, hypothermia, electrolyte imbalance, drug toxicity impede CV Antiarrhythmics amiodarone facilitate CV and maintenance of SR Dig toxicity and not normal dig levels contraindication to CV ? ACE or ARB in AF planned for CV

CV - Procedure
x x x x x x x x

Oxygen, ECG monitor, IV Vitals monitoring, Pulse oximetry Fasting state, metabolically balanced Patient must be on leads to cardiovert Conscious sedation with iv midazalom (1-5mg), propofol (5mg/kg/hr) Dont make patient unresponsive Bag-valve ventilation without ET tube sufficient Anaesthetist presence - desired

Synchronization
x Synchronize the electric discharge on

R wave of QRS complex

Dangers of CV

x Failure to enable sync button x Insufficient height of R wave

Cardioversion
x Procedure
y Charge to desired energy setting y Depress buttons; Hold until discharge

occurs y If VF occurs, unsynchronize before defibrillating

How much energy ?

x

Minimum effective energy

y SVTs and stable MMVT 25 50 J, if

unsuccessful give second shock with higher energy y AF x Monophasic 100 J x Biphasic 25 J
x

Increased in steps to max 360 J

How much Energy ?

x

If 360 J fails
y

Repeated shocks at same energy may succeed due to decrease in TTI Changing pads position and polarity Drug Ibutilide in AF If still failure Consider internal CV or esophageal CV

y y y

Electrodes
x Placement

y All positions are effective y Apex-Ant commonly used y Change to alternate position if failure

Electrodes
x

Size larger paddles decrease TTI, increase current flow and termination, decrease burns y 8-12 cm diameter in adults y Adult sized paddles in children > 10 kg (~ 1 year) y Pediatric (small paddles usually < 1 yr) Children 8 cm Infants 4.5 cm Total area of both electrodes should be min 150 cm2.

Defibrillation
x Paddle-skin interface
y Cream, paste, saline pads, gelled pads y Decreases resistance to current flow y Avoid smearing or running: bridges

charge x NEVER use alcohol!!!

Electrodes
x

Gel or paste should not smeared in between electrodes In women electrodes placed underneath or lateral to breast

Defibrillation
x Paddle contact pressure
y Firm pressure of 25 pounds y Deflates lungs; Shortens current path y Do not lean on paddles; They slip

Electrodes - Placement

Avoid electrode placement directly over

pacemaker & ICD Electrode polarity not related to success

Self-adhesive Pads
x

Advantages
y

Continuous monitoring of rhythm before & after shock Better documentation Safety of the operator Less erythemia

Monophasic or Biphasic ?

x x

MDS Biphasic initially used in ICD, now in most of the ED since 1996

Biphasic - Advantages
x

Biphasic waveform shocks of 200 joules are safe & have equivalent or higher efficacy than monophasic shocks of 200 J or 350 J. Less damage to the myocardium and a reduced frequency of postshock contractility and dysrhythmias.

Biphasic BTE or RBW

THANK YOU for your Kind Attention