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