cumulative ECV / DCR electrocardioversions

Hello. Anyone have knowledge or experience with multiple jumpstarts ECV-electrocardioversions - I must have had at least 15- 20 over the last 10 years. Paroxysmal AF in a fit 50 year wmn. Had an ablation finally in September, I was in AF then for 7 weeks following ablation, before another ECV gave me 10 days reprieve in glorious NSR... my question is: my EP cardio insists that the ECV has no cumulative impact. However many ER doctors are hesitant to offer me ECV . And now I’ve heard from one cardio that it could impact my heart ability to stay in NSR longer term. Certainly my heart is scarred from the ablation and may behave differently. Thoughts?

A number of our members have had quite a few.

The Anti-Fib & susan.d are at least in the high 40's, & Carey may be in that range also. Shannon has had mid-teens ECVs.

The Anti-Fib has actually had longer term success staying in NSR for long periods (at least 18 months) recently after all those ECV's.

Per Carey [www.afibbers.org] "No. Cardioversions do no lasting harm. "



Edited 1 time(s). Last edit at 12/04/2021 06:19PM by GeorgeN.

I've only had two cardioversions. Both were 3 years ago. I've been A-fib free until recently. Then, when I presented at the E.D. twice since October 2021, with highly symptomatic A-fib, I was not given ECV. I noticed a different attitude both in the Emergency Department, and in the two cardiologists I have had appointments with since. One cardiologist did book an appointment for me to have ECV 30 days from when I saw her, but I did not keep that appointment as my heart went back into normal rhythm on its own.

The E.D. doctor and both cardiologists explained that a lot of doctors want to know that a patient has been on blood thinners for a month or so before they will confidently do ECV. These days, here, they defined "blood thinner" as something like xarelto, and NOT the low dose aspirin I had been taking during the last few years of my 3 year remission from A-fib. This didn't seem to be the case 3 years ago. Back then, my first ECV was performed 20 days after I had only been taking low dose aspirin. So the doctors at my local E.D. back then either didn't care about blood thinners or they accepted that low dose aspirin for 20 days was acceptable.

Those A-fib episodes 3 years ago were the first I had ever had, and I was a young whippersnapper (only 68 years old!) at the time, whereas now I am an old geezer (71). How old a patient is, and how long since their A-fib became apparent also seem to be factors in how physicians assess risk.

The doctors who performed ECV on me were very reassuring. They do these "all the time". Risk? Schmrisk. I noticed they made me sign something that I thought meant I wouldn't hold it against them if they seriously damaged or killed me. I'm somewhat cynical: I assume there is actually a risk when I have to sign something like that.

The Mayo Clinic has a webpage that has a section discussing risk. Johns Hopkins also has a webpage up.

Compared to Anti-Fib and Susan I'm a total cardioversion lightweight. My count is only in the 15-20 range.

As for risk, the risk of cardioversion is extremely low, but it's not zero (nothing is). The main risk in cardioversion is human error, and the easiest error to make is the doctor (or paramedic) forgetting to push the SYNC button on the defibrillator. If you don't push that button, the shock is delivered instantaneously when you push the SHOCK button. That's intended only for defibrillating someone in ventricular fibrillation (v-fib, aka cardiac arrest). But when you push the SYNC button, the defibrillator will synchronize the shock to coincide with the R wave. That avoids delivering the shock during the apex of the T wave when there is a risk of the shock putting the patient into v-fib. Knowing this you can be your own guardian by cheerfully asking the doc if the machine is in sync mode before they put you under. The doc will either be impressed with your knowledge or very embarrassed by you pointing out their mistake.

The other risk is cardioverting you with a big old clot lurking in your left atrium. When your atria begin pumping normally again, that clot can be pumped out and cause a stroke, heart attack, or systemic embolism. That's why they ask if you've been on anticoagulants for at least 3 weeks. If you haven't, they should do a TEE first to make sure there isn't a clot present.

Beyond those two risks, there really isn't anything more that's serious. Yes, you can be left with minor burns from the pads if they're not applied properly, and some people have skin reactions to the adhesive used in the pads, but that's about it,

Technically in total it’s 49 including three times I had to be ecv twice due to pad placement/human error. I was informed by the ER last week not to count the 12 times I was ecv during two of my three ablations (#1=4, #3=8). I think they should count. So that is 34 “visits “ to the ER when I was ecv plus 12 during ablations and three redo’s ecv’s due to human error of too low joules or placement.

I never told any ER doctor in advance how many I’ve had in fear they wouldn’t ecv me if they knew my ecv total. Last Friday early morning the ER insisted to consul me about the effects of an ecv and I must had rolled my eyes and I did say how many (48 then) I already had with no problems. She resisted #49 until I whipped out my EP letter saying to ecv me…thus releasing her of any legal problems. I felt afterwards it wasn’t done properly (my heart didn’t feel calm afterwards) because I lost the argument that due to my ecv experience, one of the leads wasn’t at the right spot and it’s location mimics the three other failed ecv. They sent me home and my flutter returned. I was right about the pads and two days later-last Sunday, I returned after 12 hours in flutter twice once discharged Friday and I wasn’t allowed an ecv because the ER wrote my count on my medical records. I was stuck 3 days admitted with failed chemical conversions.

So for me I prefer a quick ecv so I can lower my flutter burden and go home vs staying admitted during thanksgiving weekend when I was ignored in telemetry with high tachycardia. It’s just faster to get ecv and go home now knowing with flutter my body won’t naturally convert as easily.

The only difference I have noticed with multiple ecv is the first two dozen I never got skin burns. Now each ecv results in a nasty burn underneath the pads. Another difference is the first 18-20 I only needed 50 joules to convert me. Then after 2-3 dozen 75 joules was successful. Now it’s at 100 joules. I speculate flutter (new since my ablations) I need more joules to convert and afib less joules.

The ER is trying out pacemaker conversions now. The problem is finding a Metronics tech to come by to tweak the settings while on a video chat with an EP.



Edited 1 time(s). Last edit at 12/04/2021 10:09PM by susan.d.

Very informative posts, particularly Carey's.
I knew about the risks of dislodging a possible clot and the need to perform a TEE when the patient isn't on a blood thinner, but nothing about the device sync mode.
I've had a couple ECVs before my first ablation, back then my episodes were 15-24hrs long. The first one worked, and I think it did for I was in afib for more than 12hrs. The next CV did not work, despite at least three shocks (the last one at 300J, if I remember correctly).
I then suffered from some burns on my chest and very painful bottom left ribs... And I spontaneously went back to NSR 12hrs later or so.

Okay, here is the question - When should someone in afib go for a CV? During my initial 11 years of afib (first 5 yrs. undiagnosed), I had well over 200 episodes of afib and only one CV. When on meds for the last 6 years of that 11 year period before ablation, I always converted on my own, with the longest period of afib being 72 hrs. So, if rate control and blood thinner drugs are working - how long does one wait before deciding on a CV?



Edited 1 time(s). Last edit at 12/05/2021 11:28AM by Ken.

Quote
Carey
Compared to Anti-Fib and Susan I'm a total cardioversion lightweight. My count is only in the 15-20 range.

As for risk, the risk of cardioversion is extremely low, but it's not zero (nothing is). The main risk in cardioversion is human error, and the easiest error to make is the doctor (or paramedic) forgetting to push the SYNC button on ,

The last time I called 911 they sent me to this community hospital where in fact the settings were set to defibrillator and not sync. But with my high ECV history, I do my own safety check before I allow the propofol to be Injected—including confirmation of propofol dose, joules settings AND if it’s set to sync.

It was mistakenly set to defibrillator. I told the dr when he walked in and he yelled at all the staff.

I believe one should always double check themselves. Another time the machine was set to 300 joules instead of 75. Another time the syringe was filled double by mistake.

Quote
Ken
Okay, here is the question - When should someone in afib go for a CV?

There's no simple answer to that, but in general the things an ER would consider are:

Rate - Is it very fast, say over 180? That's a rate most ER docs would cardiovert. But that 180 number needs to be adjusted for age and coexisting health issues. For someone in their 80s or with other cardiac issues, 150 is probably too fast.

Stability - Are you experiencing dizziness, lightheadedness, chest pain, or shortness of breath? If so, it's time to cardiovert.

Duration - Have you been in afib for 4 hours or 4 days? If it's 4 hours, an ER will likely put you on a diltiazem drip and wait it out. If it's 4 days they might go ahead and cardiovert you, or they might just try rate control and refer you to your EP. The bottom line is how much you can tolerate. For those who are highly symptomatic, everyone reaches a point where they feel they just can't tolerate it any longer.

It's always better to do a planned cardioversion with your EP, so if you can wait until office hours and talk to them, that's preferable. But if it's a holiday weekend, you've been in afib for two days with a rate of 140 and you just can't tolerate it any longer, an ER would be the place to go.

(I assume all the Brits here know that ER = A&E.)