6. Interrogate any CIED before CV. 7. Review case with supervising physician. Procedure 1. Apply cardioversion skin pads using anterior-posterior or base-apex placement. 2. Connect the pads to a synchronized biphasic defibrillator. 3. Complete a Time-Out procedure pursuant to hospital policy. 4. Anesthesia team provides deep sedation. 5. Select initial shock energy: AF begin at 200 to 360 joules. Atrial flutter begin at 50 to 100 joules. Atrial tachycardia begin at 50 joules. 6. If sinus rhythm was restored but there is an IRAF: Resynchronize defibrillator and repeat CV at same energy. If IRAF continues, contact supervising physician. Consider ibutilide 1 mg IV over 10 minutes with repeat CV after 10 additional minutes. https://www.uptodate.com/contents/cardioversion-for-specific-arrhythmias/print 23/36 7/6/23, 2:50 PM Cardioversion for specific arrhythmias - UpToDate Post procedure 1. Perform ECG. 2. Interrogation of any CIED post procedure. 3. Document post procedure note including appropriate discharge medications. 4. Continue anticoagulation for a minimum of 4 weeks. 5. Update family or friends accompanying patient. 6. Ensure follow-up is arranged. NPO: nothing by mouth; INR: internal normalized ratio; NOAC: non-vitamin K oral anticoagulants; TEE: transesophageal echocardiography; OAC: oral anticoagulant; ECG: electrocardiogram; CIED: cardiac implantable electronic device; IRAF: immediate reoccurrence of atrial fibrillation; IV: intravenous. Original gure modi ed for this publication. From: Strzelczyk TA, Kaplan RM, Medler M, Knight BP. Outcomes Associated With Electrical Cardioversion for Atrial Fibrillation When Performed Autonomously by an Advanced Practice Provider. J Am Coll Cardiol 2017; 3:1447. Table used with the permission of Elsevier Inc. All rights reserved. Graphic 121196 Version 1.0 https://www.uptodate.com/contents/cardioversion-for-specific-arrhythmias/print 24/36 7/6/23, 2:50 PM Cardioversion for specific arrhythmias - UpToDate Options for hands-free pacemaker/defibrillator pad positioning Positioning options for hands-free pacemaker/defibrillator pads showing anterior/lateral positioning (left) and anterior/posterior positioning (right). Graphic 103268 Version 2.0 https://www.uptodate.com/contents/cardioversion-for-specific-arrhythmias/print 25/36 7/6/23, 2:50 PM Cardioversion for specific arrhythmias - UpToDate Defibrillation waveforms in implantable cardioverter- defibrillators Figure A shows the monophasic, exponentially decaying pulse was the waveform used in the first generation of ICDs. Figure B shows the biphasic waveform, which is generated with a single capacitor by switching the output polarity during discharge. Each division is 2 milliseconds. ICD: implantable cardioverter-defibrillator. Graphic 51842 Version 3.0 https://www.uptodate.com/contents/cardioversion-for-specific-arrhythmias/print 26/36 7/6/23, 2:50 PM Cardioversion for specific arrhythmias - UpToDate Adult tachycardia with a pulse algorithm 2020 update Reprinted with permission. ACLS Provider Manual. Copyright 2020 American Heart Association, Inc. Graphic 130747 Version 10.0 https://www.uptodate.com/contents/cardioversion-for-specific-arrhythmias/print 27/36 7/6/23, 2:50 PM Cardioversion for specific arrhythmias - UpToDate Adult cardiac arrest algorithm https://www.uptodate.com/contents/cardioversion-for-specific-arrhythmias/print 28/36 7/6/23, 2:50 PM Cardioversion for specific arrhythmias - UpToDate https://www.uptodate.com/contents/cardioversion-for-specific-arrhythmias/print 29/36 7/6/23, 2:50 PM Cardioversion for specific arrhythmias - UpToDate Reprinted with permission. Highlights of the 2020 American Heart Association Guidelines for CPR and ECC. Copyright 2020 American Association, Inc. Graphic 129983 Version 9.0 https://www.uptodate.com/contents/cardioversion-for-specific-arrhythmias/print 30/36 7/6/23, 2:50 PM Cardioversion for specific arrhythmias - UpToDate The effect of antiarrhythmic agents on cardioversion energy requirements Antiarrhythmic agent Energy requirement Lidocane Increased or no change Quinidine Increased Phenytoin Increased Amiodarone Increased Flecainide Increased Ibutilide Decreased Graphic 81781 Version 3.0 https://www.uptodate.com/contents/cardioversion-for-specific-arrhythmias/print 31/36 7/6/23, 2:50 PM Cardioversion for specific arrhythmias - UpToDate 12 lead ECG of atrial flutter The 12 lead electrocardiogram (ECG) of atrial flutter shows a regular rhythm with a narrow QRS complex. Flutter waves are present, best seen in leads II, III, and aVF (*). In this ECG, the flutter waves are negative in leads II, III, and aVF, and positive in lead V1. One flutter wave is obvious between the QRS complexes, while the second one is superimposed on the terminal portion of the QRS complex; hence there is 2:1 atrioventricular nodal block, which is the most common presentation for atrial flutter. Reproduced with permission by Samuel Levy, MD. Graphic 75931 Version 3.0 https://www.uptodate.com/contents/cardioversion-for-specific-arrhythmias/print 32/36 7/6/23, 2:50 PM Cardioversion for specific arrhythmias - UpToDate Reentrant circuit of typical atrial flutter within the right atrium Schematic representation of reentrant circuit (red arrow) of typical (type 1) atrial flutter. The reentrant impulse rotates in a counterclockwise direction around the tricuspid annulus. The crista terminalis (CT) and eustacian ridge (ER) serve as lines of block, preventing the impulse from short-circuiting the annulus. Ablation is performed in the isthmus between the IVC and TA, which is an obligatory part of the circuit. SVC: superior vena cava; CS: coronary sinus; IVC: inferior vena cava; FO: foramen ovale Graphic 52904 Version 5.0 https://www.uptodate.com/contents/cardioversion-for-specific-arrhythmias/print 33/36 7/6/23, 2:50 PM Cardioversion for specific arrhythmias - UpToDate Cognitive skills necessary to perform internal DC cardioversion Physicians should have knowledge of the following: Cognitive and technical skills for performing intracardiac electrophysiologic study Principles of intracavitary cardioversion with catheter technology, catheters, chest electrodes, or whatever variant the operator plans to use Indications and complications associated with transvenous catheterization and with the intracavitary delivery of DC shock The safe delivery of DC shock and the limit of energy that can be delivered via electrode catheters The use of conscious sedation or, when appropriate, anesthesia The use of intravenous antiarrhythmic medications Cognitive skills necessary for external DC cardioversion Data from Tracy CM, Akhtar M, DiMarco JP, et al. Circulation 2000; 102:2309. Graphic 57223 Version 2.0 https://www.uptodate.com/contents/cardioversion-for-specific-arrhythmias/print 34/36 7/6/23, 2:50 PM Cardioversion for specific arrhythmias - UpToDate Technical skills necessary to perform internal DC cardioversion Competency in performing diagnostic cardiac electrophysiology studies Ability to place electrode catheters in appropriate locations for intracardiac synchronization and DC cardioversion Familiarity with the catheter characteristics, synchronization, and DC cardioversion equipment Ability to confirm the timing and energy of the shock for safe shock delivery Adequate electrocardiographic and rhythm monitoring equipment Ability to handle complications, including the use of temporary pacing and defibrillation Proficiency in the appropriate use of sedation during procedures, including airway management Data from Tracy CM, Akhtar M, DiMarco JP, et al. Circulation 2000; 102:2309. Graphic 65048 Version 2.0 https://www.uptodate.com/contents/cardioversion-for-specific-arrhythmias/print 35/36 7/6/23, 2:50 PM Cardioversion for specific arrhythmias - UpToDate Contributor Disclosures Bradley P Knight, MD, FACC Grant/Research/Clinical Trial Support: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; MDT [Electrophysiology]; Philips [Electrophysiology]. Consultant/Advisory Boards: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; CVRx [Heart failure]; MDT [Electrophysiology]; Philips [Electrophysiology]; Sanofi [Arrhythmias]. Speaker's Bureau: Abbott [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Transeptal catheterization]; BSCI [Electrophysiology]; MDT [Electrophysiology]. All of the relevant financial relationships listed have been mitigated. Richard L Page, MD No relevant financial relationship(s) with ineligible companies to disclose. Susan B Yeon, MD, JD, FACC No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/cardioversion-for-specific-arrhythmias/print 36/36