Successful external cardioversion of atrial fibrillation in patients referred to an electrophysiologist for internal cardioversion

Background: Internal cardioversion of atrial fibrillation with direct current energy has become an increasingly employed technique for patients who fail external cardioversion. Hypothesis: The purpose of this study was to determine whether internal cardioversion could be avoided by careful attention to cardioversion technique in a group of patients referred specifically for internal cardioversion after failed external cardioversion by community cardiologists. Methods: We performed external cardioversion utilizing two operators applying significant pressure to the thorax with up to 360 J prior to the planned internal cardioversion in 20 patients referred for internal cardioversion after failed attempts at external cardioversion. Results: Sixteen patients (80%) were successfully cardioverted and avoided the risk, inconvenience, and cost of internal cardioversion. Conclusion: External cardioversion with significant anterior paddle pressure by two operators can decrease the need for internal cardioversion in a significant portion of patients referred to electrophysiologists for internal cardioversion and should be considered prior to an invasive procedure.