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European Heart Journal Advance Access originally published online on June 14, 2007
European Heart Journal 2007 28(14):1731-1738; doi:10.1093/eurheartj/ehm211
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© The European Society of Cardiology 2007. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

External cardioversion of atrial fibrillation in patients with implanted pacemaker or cardioverter-defibrillator systems: a randomized comparison of monophasic and biphasic shock energy application

Johannes C. Manegold{dagger}, Carsten W. Israel{dagger}, Joachim R. Ehrlich, Gabor Duray, Dmitri Pajitnev, Florian T. Wegener and Stefan H. Hohnloser*

Division of Cardiology, Department of Medicine, J. W. Goethe University Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany

Received 18 January 2007; revised 17 April 2007; accepted 3 May 2007; online publish-ahead-of-print 14 June 2007.

* Corresponding author. Tel: +49 69 6301 7404; fax: +49 69 6301 7017. E-mail address: hohnloser{at}em.uni-frankfurt.de

See page 1668 for the editorial comment on this article (doi:10.1093/eurheartj/ehm214)

Aims: External cardioversion (ECV) of atrial fibrillation (AF) may damage implanted pacemaker and cardioverter-defibrillator (ICD) systems. This prospective study evaluated the safety and efficacy of ECV comparing mono- to biphasic shock waveforms in patients with implanted rhythm devices.

Methods and results: Patients with pacemaker or ICD systems and an indication for ECV were randomized to receive mono- or biphasic shocks. Systems were tested immediately before and after ECV, 1 h and 1 week later with respect to device and lead integrity. Forty-four patients (71 ± 10 years, 31 male; 29 pacemakers, 12 ICDs, three cardiac resynchronization systems) underwent ECV with antero-posterior paddle orientation (monophasic in 21 and biphasic in 23 patients). Pacing impedances were reduced immediately after ECV (atrial 402–392 ohm, P < 0.001; ventricular 517–496 ohm, P = 0.001) and returned to baseline values within 1 week. Ventricular sensing was reduced immediately after ECV (12.4–11.6 mV, P = 0.004). There was no device or lead dysfunction in any patient. ECV was successful in 42/44 patients (95%), cumulative energy was significantly lower for biphasic compared with monophasic shocks (P = 0.001).

Conclusion: ECV for AF seems to be safe and effective in patients with implanted rhythm devices.

Key Words: Cardioversion • Monophasic shocks • Biphasic shocks • Pacemaker • Implantable cardioverter-defibrillator • Atrial fibrillation

{dagger} Both authors contributed equally to this study.


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