Electrical vs Chemical vs Mg Infusion for Cardioversion

I have had a number of ECV's, I have been reading that some places they do CV by Drugs (chemical) in the Hospital.
Also in places they normally try Drugs 1st, then if not Converted within several hours, then proceed to an ECV.

I'm wondering if in Canada and they EU, they are more likely to do a combined Protocol, whereas in the States, they are more apt to just Zap away with ECV.


Also I found this link to an article that discusses Conversion by Mg Infusion. Mg has only been used on a very limited basis. But I am going to try it at my next opportunity.

[emcrit.org]


Any Input from anyone on the risks of Chemical vs Electric CV?? Or about Mg infusion?



Edited 1 time(s). Last edit at 11/20/2016 10:21PM by The Anti-Fib.

AF,

My thoughts.

First, I've never had an ECV. I've got 12 years experience using chemical cardioversion in the form of 300 mg flecainide chewed and swallowed as soon as possible after I realize I'm in afib (which many times was upon waking at 3 AM - generally I know it almost instantly if I'm not asleep). My very first time using flec was to convert a 2 1/2 month episode. It took 20 hours. So did the next, 1 month later (I think atrial stunning may still have been present). After that, most episodes generally took between 1 to 2 hours to convert. During my divorce, when I was eating excess calcium, as it turns out, I did have a 4 hour conversion. Subsequent to figuring out the calcium issue, 3 1/2 years ago, I've only had two episodes. The first converted in about an hour. The second in 8 minutes. What did I do different? I took around 400 mg magnesium in the form of Natural Calm mag citrate powder immediately after chewing the flec. I have the time difference documented on my AliveCor.

Some years ago (8-10?), Jackie posted an article about using mag (I think as citrate liquid - sold in the drugstore for bowel cleanout) to convert. I think I tried it a few times, but without success.

I recently had a discussion about mag and afib with a young pediatrician friend. Turns out she dealt with rhythm issues frequently in the hospital during residency (even had to prescribe amio to a 3 month old because nothing else would work - issue wan't afib but another rhythm issue). She said one issue is how much mag to use. There isn't a standard protocol. At least that was her perspective. Another friend, an ER doc, said they did use in IV form commonly. A third friend said his 92 year old mother presented at the ER with afib and they gave her IV mag to convert.

George

Most ER docs who have been trained in the last 15 years or so, and many older ones who keep up, will often include hanging a bag of saline with 2 grams of Magnesium Sulfate inside to drip an in IV over 30 minutes either before an ECV ... (and then in those cases where the person converts to NSR with the magnesium sulfate that does the trick) .. but often the Mag Sulfate is used as a preloading dose prior to the ECV when the person does not convert solely with the Magnesium drip alone.

I shared an article some years ago here on a study showing definite improvement in both lowering the total number of joules needed to achieve ECV and also a consistent increase in duration of sustained NSR after the ECV when preloaded with the 2 grams of Mag Sulfate.

Some ER docs will just hang the 2 gram bag of Mag Sulfate after the ECV during the recovery phase from the Propofol and thus help to keep the heart calm and steady, and it helps the durability of the NSR as well.

A similar impact in helping to lower total joule level needed to achieve a long lasting NSR from an ECV is also achieved by preloading with Sotalol and, no doubt, other AAR drugs, but the beta blocker portion of Sotalol no doubt helps in this effort and perhaps with Rhythmol as well, that are similar to the same effect noted above achieved with the 2 grams of Mag Sulfate.

Also, I have had three chemical cardioversions in hospital ERs in my life (two in Hawaii in the later 1990s and one in Holland in 2008 three months prior to my index ablation in Austin with Dr Natale shortly after he moved to Austin and St Davids) and have had a total of 16 ECVs ranging from Hawaii, Holland, Texas, California and Arizona.

Most places follow a roughly similar protocol, but it helps to be an educated patient, and one who will help direct their own care to a degree too along with the main decision-making by he attending MD. Most ER docs are willing to listen when they realize you are an old hand at it and have been around the block ... so knowing the usual joule level you tend to convert with and the dose of Propofol typically that puts you out with no awareness at all of the shock is good to know to pass along are both handy things to know ... assuming one has been somewhat of a frequent flyer for ECVs at the ER .

Also, for those who might need an ECV and are going to an ER, do NOT be shy about giving the ER doc a friendly reminder to please do a pinch test or touch your eyelids after the propofol takes effect and before they push the zapper button, just to confirm you are truly oblivious before they push that button. As Ive shared here too a number of times, my last ECV in a small Cottonwood AZ hospital the Doc gave me too low a dose of propofol and pushed it too slowly and thus when he had his nurse pushed the shock button I was still wide awake and got the most violent experience of my life that you truly want to avoid! And its easy to avoid if the ER doc will wait a minimum of 30 second once you are out on the propofol and are unresponsive to speech and then have them pinch you, or use a needle prick on toes or fingers, or lightly brush your eye lids, or give a little slap on your cheek etc to make darn sure you are no longer at home when the shock hits!

Shannon



Edited 1 time(s). Last edit at 11/21/2016 01:28PM by Shannon.

If its true that Mg infusion by IV works 60% of the time, and that's what the limited amount of small studies show, then why is not that tried as normal protocol before doing an ECV?

I've had 4 of my own Cardio Dr's plus numerous associates of those Dr's as well as 5-6 ER Docs do ECV's but have never mentioned Chemical or Mg to Convert. I have brought it up several times, one Dr. never heard of using Mg for CV, and the other one told me bring it up with his Associate who does his ECV's. The Associate Dr. argued with me about it, didn't want to do it, then had the Nurse bring in a 400mg Mg tablet right before they were going to blast me with an ECV. What a joke, like a pilI of 400mg Mg given 5 minutes prior to an EVC was worthwhile. I had even brought all of my research to the Hospital with the Studies that were done, and there was no time for that. The arrogance of Hospital Staff is a big issue in getting ECV's as they assume they know way more than the patient, but that it not necessarily the case.

I am wondering if this is a money issue. During an EVC procedure they need a DR., Anesthesiologist, Respiratory Specialist and 1 or 2 Nurses. If a Patient just converts with simple Mg, then all they need is a Nurse, and a Dr. to oversee things.

Finally I too have gotten blasted while not being under, felt like a small bomb was inserted inside my neck and head, then simultanous to the bomb being detonated, they stuck my head out in front of a fast moving freight train. Never even felt it in my chest. A fringe benefit from an ECV is getting a free Electroshock treatment of the Brain.

I was never fortunate enough to have the ER docs treat with IV magnesium sulfate. Probably, that was too many years ago and before the practice became common-place.

Early in my AF saga, and mostly driven out of fear and panic, I would head to the ER if I had prolonged events that didn't convert after 24 hours even though I tried various suggestions. What I learned is that the IV infusions back then didn't do anything, either but as is typical and with time, the arrhythmia becomes normalized. In attempts to assist with conversion without going to the ER, the PIP approach worked well for me. That's not always the case with everyone. I suspect in my case, the knowledge that I was in control with the PIP and added electrolytes including magnesium, potassium and taurine taken at the same time, helped settled my nerves so I could relax and ride out the event.

Then, along came A-flutter and all my 'magic' didn't work. Often, just waiting and relaxing would eventually allow for conversion to NSR, but required waiting well past the 48-hour rule.

I also learned that if I was in flutter and it lasted longer than a day, I'd probably need ECV... and also learned not to go to our local ER system because they weren't equipped to do that. It required checking in formally to a hospital setting for the time slot. As Shannon mentions, the prep drugs work well for calming and the ECV works efficiently. There was only one incidence where I felt a minor part of the 'jolt' but it wasn't horrific, thankfully. Often, prior to the ECV, they would also do a TEE just to be sure a clot had not formed during the extended time during sustained arrhythmia. I've probably had 6 - 8 ECVs.

Retired neurosurgeon, Dr. Russell Blaylock, years ago, reported that using the Magnesium sulfate IVs with his surgical patients prevented related cardiac arrhythmias that occur frequently. There are also studies noting that the use of the magnesium sulfate IVs during cardiac surgeries also help prevent arrhythmias so the practice definitely has been substantiated.

I've gone to four different centers for cardioversion treatment and learned by experience that some are much better than others. At least here in my area, the facility that is linked directly to EPs in cardiac centers offer the most effective treatment, compared to the local ERs.

Jackie

Given my experience, if I had to have an ECV, I'd probably take a bunch of mag in powder form, likely citrate, before I went in. For me, I'd try 2-4g of mag. Worst case is I'd have an underpants emergency, but again for me, likely not.

Shannon,
Good tip on the pinch test.....I certainly wouldn't want to experience that.....but I must admit, I did laugh out loud at your description....LOL....laughing with you, not at you!
I was shocked 3 times on one occasion....but was dead asleep. However, I couldn't sleep at all that night from the burning on my chest, no matter how much aloe & lotion I rubbed on it.
Be well, my friend!
Ken

Ive had a Mag sulfate infusion with 12 of my 16 ECV and only two of those where pre-ordered by the ER doc at Queens Medical Center in Honolulu where I was a regular during the 14 months from the time my LAA trigger that we all knew I would have to have my second ablation to finish isolating the LAA that Dr Natale was unable to finish during my index ablation, once this LAA tachycardia began acting up 3 years after almost total silence from the time of my index persistent AFIB ablation with Dr Natale. ItI started like clock work every 3 to 4 weeks for those 14 months and I knew from the good Doc that I had to get myself to the nearest ER pronto and get an ECV as there was zero chance of drug cardioversion working on an LAA flutter/tachycardia trigger.

The folks at Queens got to know me very well and after the first few ECV visits I would just call the ER when I flipped into flutter and say; This is Shannon Dickson and I'll be in shortly for an ECV so please get the zapper and 110mg of Propofol ready and I'll be out of your hair in two hours tops :-)! They would have the nurse anesthetist already waiting for me and one of four ER docs I knew there all ready to see how quick we could get me in and out.. I even had them film my ECV with my early generation IPHone on one such ECV and perhaps I'll dig it out and post it on the new website once we get the redesign finished and can more easily host videos.

Anyway, I asked for Mag sulfate 2 grams IV for every ECV and most of the time they just gave it after the ECV while recovering before going home, but a few times they hung the bag of Mag Sulfate to drip in my arm prior to the ECV as is ideal. We all knew that the Mag Sulfate going in first was not going to cardiovert me on its own in any event so before or after wasn't as much a key thing.

Shannon



Edited 1 time(s). Last edit at 11/21/2016 06:35PM by Shannon.

Here's a Research Paper done 2009 on the use of Mg for Cardioversion

[commons.pacificu.edu]