CARDIOVERSION AND

DEFIBRILLATION
Brook A. June/2016
UpToDate 20.3
OUTLINE
 Basic principles of cardioversion and
defibrillation

 Cardioversion for specific arrhythmias

INTRODUCTION
 Electrical cardioversion and defibrillation have
become routine procedures in the management
of patients with cardiac arrhythmias.
 Cardioversionis the delivery of energy that is
synchronized to the QRS complex

 Defibrillation
is the nonsynchronized delivery of a
shock randomly during the cardiac cycle
INTRODUCTION
 Most defibrillators are energy-based, meaning
that the devices charge a capacitor to a selected
voltage and then deliver a prespecified amount
of energy in joules.
 The amount of energy which arrives at the
myocardium is dependent upon the selected voltage
and the transthoracic impedance (which varies by
patient).
 Two other types (less commonly used)
 Impedance-based
 Current-based
INTRODUCTION
 Impedance-based defibrillators
 Allow selection of transthoracic current based upon the
transthoracic impedance;
 the latter is assessed initially with a test pulse with the
capacitor subsequently charged to the appropriate voltage
 Current-based defibrillation
A fixed dose of current is delivered
 Results in defibrillation thresholds that are independent of
transthoracic impedance and are invariant for the individual .
 Defibrillation success for a current-based method is
independent of both transthoracic impedance and body
weight
 Furthermore, this method achieves defibrillation with
considerably less energy than does the conventional energy-
based method.
INTRODUCTION
 Defibrillators can also deliver energy in a variety
of waveforms, broadly characterized as
monophasic or biphasic.

 Although monophasic defibrillation is highly

effective, biphasic defibrillation terminates
arrhythmias more consistently and at lower energy
levels
Initially defibrillators delivered only monophasic
waveforms.
While many monophasic defibrillators remain in use,
biphasic defibrillators are becoming increasingly
popular
ELECTROPHYSIOLOGY
 Cardioversion terminates arrhythmias by
delivering a synchronized shock that depolarizes
the tissue involved in a reentrant circuit
 By depolarizing all excitable tissue of the circuit and
making the tissue refractory, the circuit is no longer
able to propagate or sustain reentry.
 As a result, cardioversion terminates those
arrhythmias resulting from a single reentrant
circuit
 Such as atrial flutter, atrioventricular nodal
reentrant tachycardia, atrioventricular reentrant
tachycardia, or monomorphic ventricular tachycardia
ELECTROPHYSIOLOGY
 Despite its widespread clinical use, controversy
remains concerning the electrophysiologic
mechanisms by which electrical cardioversion or
defibrillation terminates atrial or ventricular
fibrillation, arrhythmias which involve multiple
microreentrant circuits.
 Fibrillation
involves the entire atrial or ventricular
myocardium and is considered to be a very persistent
rhythm
ELECTROPHYSIOLOGY
 Most investigators agree that defibrillation
occurs when a certain amount of current density
reaches the myocardium.
 However, it is unclear what amount of current
density is needed and what energy setting is
necessary to achieve a homogeneous current
density.
 At the cellular level, the delivered current flows
around and through the myocardial cells, resulting in
alteration of the transmembrane potentials
 At the organ level, the mechanisms responsible for
termination of fibrillation are still controversial
ELECTROPHYSIOLOGY
 Critical mass hypothesis
 There is general agreement that total elimination of
fibrillatory activity can be achieved with relatively
high defibrillation energy levels
 According to the critical mass hypothesis, a certain
amount of myocardium must be available to sustain
atrial or ventricular fibrillation and the entire
myocardium must be uniformly depolarized in order
to terminate the arrhythmia
 Electrophysiological evidence to support this theory has
been obtained using a computerized mapping system that
recorded simultaneous electrograms from 120 sites
 Defibrillation was successful only when fibrillatory activity

was annihilated at all sites.

ELECTROPHYSIOLOGY
 Upper limit of vulnerability hypothesis
 Unsuccessful shocks are slightly weaker than necessary
for defibrillation
 Although they abolish small areas of localized reentry
during ventricular fibrillation, they stimulate other
regions of myocardium during their vulnerable period,
giving rise to new areas of local reentry that reinitiate
ventricular fibrillation
 To successfully defibrillate, therefore, the shock
strength must be greater than the largest shock that
reinitiates fibrillation (the upper limit of vulnerability).
 This hypothesis is supported by the observation that almost
identical changes in the upper limit of vulnerability and the
defibrillation threshold occur with changes in electrode
polarity and waveform duration
ELECTROPHYSIOLOGY
 Because the higher intensity shock selectively
extends the refractory period of the myocardium,
it may establish a zone of tissue in which
repolarization is delayed.
 This zone is always immediately in front of the
newly depolarized tissue, and the inability of the
depolarizing impulse to propagate across these
refractory zones may be the mechanism responsible
for terminating fibrillation.
 The size of these zones and the duration of increased
refractoriness both increase with increasing shock
intensity; this may account for the relatively high shock
energies required for defibrillation relative to the
intensities required to directly depolarize the tissue.
ELECTROPHYSIOLOGY
 An electrical shock will also induce different
degrees of action potential duration prolongation
and dispersion of ventricular repolarization,
depending upon shock strength and timing

 The creation of high dispersion of repolarization

facilitated reentry by creating functional blocks
and subsequently favored the induction of
ventricular fibrillation and the prevention of its
termination by a shock.
FACTORS AFFECTING SUCCESS OF
CARDIOVERSION & DEFIBRILLATION
Device Related Patient Related

 Electrode  Transthoracic impedance

 Position  Type of arrythmia
 Padsize  Duration of arrythmia
 Hand-held vs patch

 Monophasic vs biphasic
FACTORS AFFECTING …- DEVICE
RELATED
 Electrode Position
 Anterolateral orientation vs Anteroposterior
orientationa

 Electrode pad sizeb

A larger pad or paddle surface is associated with a
decrease in resistance and increase in current and
may cause less myocardial necrosis

 However, there appears to be an optimal electrode

size (approximately 12.8 cm) above which any further
increase in electrode area causes a decline in current
density
FACTORS AFFECTING …- DEVICE
RELATED
 Hand-held versus patch
 The use of hand-held paddle electrodes may be more
effective than self-adhesive patch electrodes
(especially for atrial fibrillation)a

 However, there are no published data comparing

hand-held paddle electrodes to self-adhesive patch
electrodes for other arrhythmias requiring
cardioversion
FACTORS AFFECTING …- DEVICE
RELATED
 Monophasic vs Biphasic waveforms
  Defibrillators can deliver energy in a variety of
waveforms that are broadly characterized as
monophasic or biphasic
 Monophasic: meaning that electrons flowed in a
single direction.

 Biphasic: meaning that during the shock, polarity and

electron flow reverse.
 In addition to reversing polarity, biphasic defibrillators
also deliver a more consistent magnitude of current
FACTORS AFFECTING …- DEVICE
RELATED
 Monophasic vs Biphasic ctd
 Biphasic waveforms defibrillate more effectively and
at lower energies than monophasic waveforms.
 This benefit has been demonstrated in both animals and
humans, and with both ventricular and atrial fibrillation

 However, monophasic defibrillation is still highly

effective in most situations, and it is not clear that
the superior efficacy of biphasic defibrillation
results in important clinical advantages
FACTORS AFFECTING …- DEVICE
RELATED
 Monophasic vs Biphasic- Ventricular fibrillation
 Several randomized trials have compared monophasic
and biphasic waveforms in the treatment of
ventricular fibrillationa

 Based upon the greater efficacy of biphasic

defibrillation demonstrated in other settings, the
lack of evidence of harm from biphasic defibrillation,
and the trends towards outcome benefits suggested
by clinical trials, the expanded use of biphasic
defibrillation for the treatment of ventricular
arrhythmias is supported
FACTORS AFFECTING …- DEVICE
RELATED
 Monophasic vs Biphasic- Atrial Fibrillation
 The benefit of the biphasic waveform for the
treatment of atrial fibrillation (AF) has been
illustrated in two randomized trialsa
 Successful first shock
 Less energy usage

 Fewer total shocks

 Less dermal injury

 More successful overall cardioversion

 Similar findings have been reported for patients

with atrial flutter, in whom cardioversion was
successful more frequently and at lower energy
levels when using biphasic waveforms
FACTORS AFFECTING …- DEVICE
RELATED
 Monophasic vs Biphasic- Dose
 Based upon the absence of adverse events and the
greater efficacy in patients requiring multiple
shocks, the use of escalating higher-energy shocks
with biphasic defibrillators in the treatment of
cardiac arrest due to a ventricular tachyarrhythmia
that does not respond to an initial lower energy
shock is advocated
FACTORS AFFECTING …- PATIENT
RELATED
 Transthoracic impedance
 Impedance results in the dissipation of energy due to
shunting to the lungs, the thoracic cage, and other
elements of the chest.
 In an animal study, 82 percent of the transthoracic current
was shunted to the thoracic cage, 14 percent to the lungs,
and only 4 percent passed through to the hear
 Transthoracic impedance is determined by multiple
factors including:
 Energy levela
 Electrode-to-skin interface

 Interelectrode distance

 Electrode pressure (with hand-held electrodes)

 Phase of ventilation

 Myocardial tissue and blood conductive properties

FACTORS AFFECTING …- PATIENT
RELATED
 Transthoracic impedance ctd
 To compensate for transthoracic impedance during
transthoracic defibrillation, a considerably larger
current must be delivered to the thorax than is
required for internal defibrillation

 With repeated shocks, impedance decreased by as

much as 8 percent and the peak current increased by
4 percent.
 Therefore, despite only a minimally larger amount of
energy being delivered to the heart, an unsuccessful shock
should be followed promptly by a higher energy shock.
FACTORS AFFECTING …- PATIENT
RELATED
 Transthoracic impedance ctd
 An observationa suggests that tissue edema
contributes to the DC shock-induced decline in
transthoracic impedance

 Transthoracic impedance decreased after

sternotomy and remained below preoperative
measurements even after wound healing was
complete, suggesting that the hyperemia,
inflammation, tissue edema, and pleural effusion
associated with sternotomy were the major
contributors to the reduction in impedance.
FACTORS AFFECTING …- PATIENT
RELATED
 Transthoracic impedance ctd
 The phase of ventilation is another factor that
alters transthoracic impedance.
 Inspiration (and the increased volume of air within the
lungs) is associated with a 13 percent higher transthoracic
impedance than expiration

 The composition of the gel used during cardioversion

also affects the transthoracic impedance.
 In a study comparing a non-salt-containing gel to a salt-
containing gel, transthoracic impedance was 20 percent
higher with the non-salt-containing gel
FACTORS AFFECTING …- PATIENT
RELATED
 Type of arrythmia
 Eg. patients with ventricular fibrillation as the
primary event are easier to defibrillate than patients
with secondary ventricular fibrillation resulting from
uncompensated congestive heart failure and
hypotension.
 Organized arrhythmias, such as sustained monomorphic
ventricular tachycardia, arise from a discrete reentrant
circuit which is easily depolarized by smaller amounts of
current
 Non-organized rhythms such as polymorphic ventricular

tachycardia and ventricular fibrillation, the wavefronts are

multiple and involve more myocardial mass, thereby
requiring more energy for termination
FACTORS AFFECTING …- PATIENT
RELATED
 Type of arrythmia ctd
 The electrical current and energy required to
terminate ventricular tachyarrhythmias vary by
arrhythmia.
 VT generally requires less energy than ventricular
fibrillation.
 In one studya transthoracic termination of monomorphic VT

required relatively low energy (70 to 100 joules) while

polymorphic VT required more energy (150 to 200 joules).
 The varying energy requirements for cardioversion
for ventricular tachyarrhythmias are analogous to
those of atrial tachyarrhythmias.
 Atrial flutter, a more organized rhythm than atrial
fibrillation, generally terminates with lower electrical
doses.
FACTORS AFFECTING …- PATIENT
RELATED
 Duration of arrythmia
 VF-the effectiveness of defibrillation is reduced
when the arrhythmia is of longer duration
 The more recent the onset of ventricular fibrillation, the
coarser are the fibrillatory waves and the greater the
success with defibrillation.
 As the arrhythmia persists (ie, more than 10 to 30

seconds), the fibrillatory waves become finer and the

likelihood of successful termination decreases

 AF- similar effect with success vs durationb

 98% vs 62% with <24hours & >24hours, respectively
 90% vs 50% with <1 year & >5 years, respectively
CARDIOVERSION FOR SPECIFIC
ARRHYTHMIAS
 The amount of energy selected for initial attempts
of defibrillation has been controversial.

 The energy selected should be sufficient to

accomplish prompt defibrillation because repeated
failures expose the heart to damage from prolonged
ischemia and multiple shocks.

 On the other hand, excessive energy should be

avoided, since myocardial damage from high-energy
shocks has been demonstrated in experimental
studies, although the frequency with which this
occurs in humans is not known
ENERGY SELECTION
 The following are suggested initial energy
requirements for monophasic and biphasic
waveforms:
 For atrial fibrillation, 120 to 200 joules for biphasic
devices and 200 joules for monophasic devices
 For atrial flutter, 50 to 100 joules for biphasic
devices and 100 joules for monophasic devices.
 For ventricular tachycardia with a pulse, 100 joules
for biphasic devices and 200 joules for monophasic
devices.
 For ventricular fibrillation or pulseless ventricular
tachycardia, 120 to 200 joules for biphasic devices
and 360 joules for monophasic devices
ENERGY SELECTION
 Cardioversion with higher energy levels may be
effective when prior cardioversion attempts
using a maximal energy of 360 joules have failed
to restore sinus rhythm- like 720joulesa

 As another option besides high-energy

cardioversion, pretreatment with an
antiarrhythmic drug can facilitate cardioversion
at lower energy levels.
 Ibulitideb, Amiodarone, sotalol, quinidine, and
procainamide have been shown to increase the
likelihood of successful cardioversion or lower the
energy threshold required for cardioversion
 a- In one study, 55 patients who did not have sinus
rhythm restored after at least two attempts of
external cardioversion with 360 joules underwent
cardioversion with 720 joules, which was performed by
using two external cardioverters, each connected to
its own pair of patches  Sinus rhythm was restored in
84 percent of these patients with no major
complications, hemodynamic compromise, or strokes
occurring after the procedure.
 b-Pretreatment with ibutilide prior to electrical

cardioversion has been shown to significantly improve

the rate of successful cardioversion to sinus rhythm
and was also associated with the use of significantly
lower energy levels to achieve cardioversion
ATRIAL FIBRILLATION
 To reduce the risk of thromboembolism following
cardioversion, anticoagulation is generally
recommended for three to four weeks before
and after cardioversion.

 Alternatively, the presence of existing

intracardiac thrombus should be excluded using
transesophageal echocardiography prior to
cardioversion if therapeutic anticoagulation has
not been achieved.
ATRIAL FIBRILLATION
 The energy requirement for successful
cardioversion of AF varies according to the type
of electrical waveform and chronicity of AF
 Monophasic-100 to 200 joules is often adequate to
restore sinus rhythm, although >200 joules may be
required, particularly for AF of long duration.
 The overall success rate (at any level of energy) of
electrical cardioversion for AF is 75 to 95 percent and is
related inversely both to the duration of AF and to left
atrial size
 Biphasic-the energy requirements are less (generally
50 percent of that required with monophasic
waveforms) and efficacy is highera
ATRIAL FIBRILLATION
 Although it had been hoped that cardioversion to and
maintenance of sinus rhythm would improve the
prognosis of and reduce embolic risk in patients with AF,
this concept was not confirmed in the two largest
randomized trials comparing rate control plus
anticoagulation versus rhythm control for AF (the
AFFIRM and RACE trials)
 Both studies showed a trend toward a lower incidence of the
primary endpoint with rate control and anticoagulation
 In addition, embolization occurred with equal frequency
regardless of whether a rhythm control or a rate
control strategy was adopted.
 In both groups, embolization primarily occurred after
warfarin had been stopped or when the INR was
subtherapeutic.
ATRIAL FLUTTER
 Many patients with type I (typical)atrial flutter can
be cardioverted with 50 to 100 joules or less,
particularly with biphasic defibrillators

 In contrast, atypical (type II) atrial flutter may

result from reentrant circuits in various locations
and tends to require higher energy levels for
cardioversion, but in most cases sinus rhythm can be
successfully restored.
 While starting at 50 to 100 joules may be effective for
cardioversion of atypical (type II) atrial flutter,
particularly with biphasic defibrillators, this approach
has the potential adverse effect of requiring additional
shocks
SUPRAVENTRICULAR TACHYCARDIA
 The most common mechanisms for SVT are AVNRT and AVRT
 Often terminate with vagal maneuvers or IV antiarrhythmic
therapy with adenosine or verapamil; as such, electrical
cardioversion is usually not required.
 However, if these arrhythmias persist and electrical
cardioversion is attempted, cardioversion is usually successful
but may require relatively high energy levels, probably due to
the deep location of the reentrant pathway.
 If sinus rhythm is not restored following an initial 50 to 100
joule shock, subsequent shocks should be at higher energy
levels.
 Althoughenergy requirements with biphasic waveforms have not
been reported, they are likely to be lower than for monophasic
waveforms based upon experience with other arrhythmias
VENTRICULAR TACHCARDIA
 If a distinct QRS and T wave are identified,
allowing the delivery of energy to be
synchronized to the QRS complex, monomorphic
VT can often be terminated with a low-energy
shock.
 Despite the potential for terminating VT with
very low-energy shocks, one must consider the
seriousness of the arrhythmia and the desire to
avoid repeated shocks.
 As a result, the initial synchronized shock in
these circumstances is recommended to be 100
joules with a biphasic waveform and 200 joules
with a monophasic waveform
VENTRICULAR TACHCARDIA
 In contrast, synchronized cardioversion may be
impossible or hazardous if
 The VT is rapid and distinct QRS complexes are not
identified,
 The QRS complexes are wide and bizarre, or
 The VT is polymorphic.

 In these settings, there is a potential for delivery

of a discharge on the T wave, possibly provoking
ventricular fibrillation.
 Under these circumstances, nonsynchronized
defibrillation should be performed starting with
120 to 200 joules for a biphasic device or 360
joules for a monophasic device.
VENTRICULAR FIBRILLATION
 The only definitive treatment for VF is
defibrillation.
 If done promptly, the success rate for terminating
ventricular fibrillation can be as high as 95 percent
 However, the success rate falls substantially as the
duration of ventricular fibrillation increases,
probably due to myocardial ischemia, acidosis, and
other metabolic changes.
 These cellular changes are associated with an
electrophysiologic deterioration of ventricular
fibrillation, leading to an increase in fibrillation
cycle length and prolonged diastolic duration
between fibrillation action potentials
VENTRICULAR FIBRILLATION
 Some studies suggest that when VF has been
present for longer than four to five minutes,
outcomes are better if cardiopulmonary
resuscitation is performed prior to
defibrillationa,b

 The recommended starting energy to effectively

defibrillate VF is 360 joules when monophasic
waveforms are used and 120 to 200 joules with
biphasic waveforms
VENTRICULAR FIBRILLATION
 There is no reported benefit to using more than
360 joules, and there may be harm since high-
energy shocks may be associated with myocardial
damage and the risk for developing new
arrhythmias.
SPECIAL POPULATION
 Cardioversion during pregnancy 
 Cardioversioncan be performed during pregnancy
without affecting the rhythm of the fetus

 It is recommended, however, that the fetal heart

rate be monitored during the procedure using
standard fetal monitoring techniques
SPECIAL POPULATION
 Cardioversion in patients with permanent
pacemakers/ICDs
 Defibrillation in these patients can damage the pulse
generator, the lead system, or the myocardial tissue,
resulting in device dysfunction
 Precautions before external electrical cardioversion
or defibrillation
 The electrode paddle (or patch) should be at least 12 cm
from the pulse generator and
 An anteroposterior paddle position is recommended

 Elective cardioversion should be initiated with the lowest

indicated energy (which will vary depending on the

arrhythmia) in order to avoid damage to the device
circuitry and the electrode-myocardial interface.
SPECIAL POPULATION
 Cardioversion in patients with permanent
pacemakers/ICDs ctd
 After cardioversion, the pacemaker should be
interrogated and evaluated to ensure normal
pacemaker function. When these precautions have
been used, cardioversion with either monophasic or
biphasic shocks is safe and effective in patients with
an implantable device

 Alternatively, in patients with an ICD, internal

cardioversion can be attempted by a cardiologist
using the device programmer to deliver the shock
SPECIAL POPULATION
 Cardioversion in patients with digitalis toxicity
 Ventricular arrhythmias (including VF) are more likely to
occur in patients who have digitalis toxicity, especially if
the patient is also hypokalemic.
 There is a relative contraindication to cardioversion in the
setting of digitalis toxicity since digitalis sensitizes the
heart to the electrical stimulus and, hence, cardioversion
could trigger additional arrhythmias, most importantly
ventricular fibrillation.
 However, if cardioversion must be performed for a life-
threatening ventricular arrhythmia, prophylactic lidocaine
 (1 mg/kg up to a maximum dose of 100 mg IV push)
should be given and the lowest indicated energy levels
used.
 Hypokalemia should be corrected prior to cardioversion.
COMPLICATIONS
 ST- T wave changesa
 Arrythmias & conduction abnormalities

 Thromboembolism

 Myocardial necrosis

 Myocardial dysfunction

 Pulmonary edema

 Transient hypotension

 Cutaneous burns
COMPLICATIONS
 Arrhythmia and conduction abnormalities
 Arrhythmias are frequently observed after
cardioversion
 In many cases these arrhythmias are benign (eg, sinus
tachycardia, nonsustained ventricular tachycardia [VT]),
but in other cases the arrhythmias can be clinically and/or
hemodynamically significant (eg, ventricular fibrillation
[VF], sustained VT).
A transient left bundle branch block is occasionally
seen after cardioversion, but high-degree
atrioventricular block is more common.
 Patients receiving antiarrhythmic drugs are more prone to
develop bradycardia and asystole and an external
pacemaker should be readily available in such patients
COMPLICATIONS
 Thromboembolization
 Pulmonary or systemic thromboembolization.

 Thromboembolization after the return of

synchronous atrial contraction has classically been
attributed to the dislodgement of left atrial thrombi
present at the time of cardioversion.

 This complication is more likely to occur in patients

with atrial fibrillation (AF) who have not been
anticoagulated prior to cardioversion.
 5.3% vs 0.8%
COMPLICATIONS
 Myocardial necrosis
 Myocardial necrosis, particularly of the epicardium, may
occur as a result of high-energy shocks and is manifested
by relatively small rises in serum CK-MB and troponin
levels.
 In contrast, substantial elevations of either CK-MB or
troponin following electrical cardioversion suggest the
presence of myocardial injury from causes unrelated to
the procedure.
 Although the cause is unknown, it has been suggested that
myocardial necrosis may be due to the sustained
depolarization of a critical mass of myocardial cells
 The risk of myocardial necrosis appears related to the amount of
energy delivered with each shock rather than to the number of
shocks, although many repeated shocks may lead to myocardial
damage and scarring.
COMPLICATIONS
 Myocardial dysfunction
 Global left ventricular dysfunction due to myocardial
stunning may be seen in patients with cardiac arrest who
have undergone successful cardiopulmonary resuscitation.
 This is related in part to defibrillation, but is also a
result of the arrhythmia itself and due to the absence of
cardiac output and coronary blood flow during the period
of arrest with resultant ischemia.
 Myocardial dysfunction due to stunning may reverse
within the first 24 to 48 hours after cardiac arrest.
 Thus, baseline evaluation of left ventricular function in
such patients should be delayed for at least 48 hours
after resuscitation
 The process of electrical cardioversion may transiently
injure or "stun" the atria as well
COMPLICATIONS
 Pulmonary edema 
 Pulmonary edema is a rare complication of
cardioversion which is probably due to transient left
atrial standstill or left ventricular dysfunction.
 It is unrelated to the amount of energy used.
 Pulmonary edema may be more common in patients
with AF associated with valvular heart disease or
left ventricular dysfunction.
 In this setting, the return of atrial systole after
cardioversion can result in a significant elevation in
left atrial pressure and pulmonary edema
COMPLICATIONS
 Transient hypotension
 Transient hypotension can occur for several hours
after cardioversion.

 Most patients require no therapy; if necessary, the

fall in blood pressure usually responds to fluid
replacement

 Although the mechanism is not certain, the

hypotension may be related to vasodilation or the use
of sedation during the procedure.
COMPLICATIONS
 Cutaneous burns
 ollowing cardioversion or defibrillation, skin burns
occur in 20 to 25 percent of patients and are more
likely with improper technique and placement of
electrodes

 The risk of burns is less with the use of biphasic

waveforms and the use of gel-based pads

 The prophylactic use of steroid cream or topical

ibuprofen prior to cardioversion reduces the pain and
inflammation
INTERNAL
CARDIOVERSION/DEFIBRILLATION
 Internal or intracardiac cardioversion is an
effective technique for patients in whom
external cardioversion has failed to restore
sinus rhythm
 However, the need for internal cardioversion has
been greatly diminished due to the efficacy of
biphasic waveform defibrillators in restoring
sinus rhythm
INTERNAL
CARDIOVERSION/DEFIBRILLATION
 Internal cardioversion can be performed in
various ways:
 Using a pre-existing implantable cardioverter
defibrillator (ICD) to deliver a clinician-directed
shock.
 Using epicardial wires placed during surgery or
internal paddles applied directly to the epicardium in
a patient with a sternotomy
 Two defibrillation electrodes are placed in the right
atrium and coronary sinus or in the right atrium and
left pulmonary artery, respectively, and then
intracardiac shocks are delivered by an external
defibrillator
INTERNAL
CARDIOVERSION/DEFIBRILLATION
 Internal cardioversion appears more effective
for the restoration of sinus rhythm in patients
with atrial fibrillation (AF) who have failed
conventional external cardioversiona
INTERNAL
CARDIOVERSION/DEFIBRILLATION
 Complications
 One study reported that
 Complications occurred in 19 percent of patients
 Includes

 Low cardiac output from ventricular stunning,

 Pericardial effusion, and

 A brief period of ventricular asystole requiring

ventricular pacing
REFERENCE
 UpToDate v. 20.1, Basic principles and technique
of cardioversion and defibrillation &
Cardioversion for specific arrhythmias
THANK YOU!