Velázquez Rodríguez Enrique, Martínez Enríquez Agustín, Cancino Rodríguez Carlos, Olvera Morales Gabriel, Rangel Rojo Javier, Arias Estrada Sergio
Departamento de Electrofisiología del Hospital de Cardiología, Centro Médico Nacional Siglo XXI, IMSS.
Arch Cardiol Mex. 2005 Jul-Sep;75 Suppl 3:S3-69-80.
Clinical studies have shown that transthoracic cardioversion of atrial fibrillation is dependent on achieving adequate current flow to the heart, which is dependent on transthoracic impedance. When multiple standard cardioversion fails to restore sinus rhythm in patients with atrial fibrillation the double sequential transthoracic shock may be an alternative.
Twenty one consecutive patients with paroxysmal or persistent atrial fibrillation refractory to at least two initial high energy 360 J or 200-300 and 360 J monophasic shocks underwent double sequential shocks with 720 J by means two defibrillators. Mean age was 64 +/- 11 years and mean weight 97 +/- 19 kg (range, 49 to 112). Duration of atrial fibrillation was present < or = 3 months in 76%. Arterial hypertension was present in 38% and lone atrial fibrillation in 33%. Mean left atrial size was 4.5 +/- 0.7 cm (range, 3.5 to 6.0). Sinus rhythm was achieved in 19 (90.4%). Two refractory to biphasic shocks with a median 1,050 J (range, 660 to 1,440 J) without major complications. Multivariate analysis identified duration of atrial fibrillation, > 90 days (RR 0.96, CI 0.95-0.98 p = 0.02) and body weight, 101 +/- 11 kg (RR 0.64, CI 0.46-0.90 p = 0.01) variables independently associated with cardioversion unsuccessful. Patient weight, p = 0.002 was the univariate predictor of unsuccessful cardioversion. High energy cardioversion does not cause cardiac damage evidenced from cardiac troponin T estimation.
For refractory atrial fibrillation to conventional cardioversion double sequential transthoracic shocks represents a safe and highly efficacious alternative and may have a general applicability.
临床研究表明，心房颤动的经胸心脏复律取决于能否实现足够的电流流向心脏，而这又取决于经胸阻抗。当多次标准复律未能使心房颤动患者恢复窦性心律时，双序列经胸电击可能是一种替代方法。
连续21例阵发性或持续性心房颤动患者，至少对两次初始高能量360J或200 - 300J及360J单相电击无效，采用两台除颤器进行720J双序列电击。平均年龄为64±11岁，平均体重97±19kg（范围49至112kg）。76%的患者心房颤动持续时间≤3个月。38%的患者存在动脉高血压，33%为孤立性心房颤动。平均左心房大小为4.5±0.7cm（范围3.5至6.0cm）。19例（90.4%）恢复窦性心律。2例对双相电击无效，中位能量为1050J（范围660至1440J），无重大并发症。多因素分析确定心房颤动持续时间>90天（RR 0.96，CI 0.95 - 0.98，p = 0.02）和体重101±11kg（RR 0.64，CI 0.46 - 0.90，p = 0.01）是与复律失败独立相关的变量。患者体重（p = 0.002）是复律失败的单因素预测指标。从心肌肌钙蛋白T评估结果来看，高能量复律不会导致心脏损伤。
对于传统复律难治的心房颤动，双序列经胸电击是一种安全且高效的替代方法，可能具有广泛的适用性。
