Transthoracic versus transesophageal cardioversion of atrial fibrillation under light sedation: a prospective randomized trial

BACKGROUND: Electrical cardioversion (ECV) of atrial fibrillation (AF) is limited by a 5-10% failure rate and by the expense arising from a perceived need for general anesthesia. A transesophageal approach using light sedation has been proposed as a means of augmenting the success rate and avoiding the need for general anesthesia. We hypothesized that the high rate of success and the lower energy requirement associated with biphasic cardioversion might eliminate any advantage of the transesophageal approach. METHODS: We randomly assigned 60 patients attending for ECV of persistent AF to a transesophageal or a transthoracic approach. Sedation of moderate depth was achieved with intravenous midazolam. The dose of midazolam was titrated in the same manner in both groups. RESULTS: Sinus rhythm was restored in 29/30 patients (97%) in each group using a similar number of shocks for both groups (1.3 +/- 0.6 transesophageal vs 1.4 +/- 0.7 transthoracic, P = NS) with a similar procedure duration (14.1 +/- 8.2 minutes vs 13.8 +/- 7.5 minutes, P = NS). Both groups received similar doses of midazolam (4.2 +/- 2.7 mg vs 4.4 +/- 2.8 mg, P = NS) and both reported a similar discomfort score in (0.9 +/- 1.3 vs 1.1 +/- 1.8, P = NS). No complication occurred in either group. CONCLUSION: AF may be cardioverted safely and effectively by either a transthoracic or a transesophageal approach. The use of sedation of moderate depth renders cardioversion by either approach acceptable. As transesophageal ECV shows no clear advantage, transthoracic cardioversion should remain the approach of first choice.     

Significance of external cardioversion induced atrial tachyarrhythmias

External cardioversion is used to stop VT or VF in emergency. Supraventricular tachyarrhythmias are sometimes noted after cardioversion in patients known to be previously in sinus rhythm. The purpose of the study was to evaluate the significance of supraventricular tachyarrhythmias induced by external cardioversion. The study population consisted of 22 patients who developed supraventricular tachyarrhythmias after transthoracic cardioversion (300 J) delivered to stop a VT or VF induced by electrophysiological study. Defibrillation used monophasic waveform. Supraventricular tachyarrhythmias complicated 6% of cardioversions for VT; before cardioversion, all patients were in sinus rhythm. After cardioversion, three patients developed a paroxysmal reentrant supraventricular tachycardia (PSVT), which was stopped by atrial pacing. The remaining patients developed AF that lasted from 3 minutes to 24 hours (n = 4). One patient remained in AF. AF developed after a sinus pause or bradycardia, which was due to the interruption of VT or VF in nine patients or was noted just when VT or VF stopped (n = 10). The analysis of clinical data indicated that all three patients who presented a PSVT had a history of PSVT. Among patients who developed a sinus pause dependent AF, two had a history of AF. Among ten patients who developed AF at the time of cardioversion, three had a history of AF. During follow-up (1-9 years), no patient without a history of AF developed spontaneous AF, but patients with history of tachycardias had arrhythmia recurrences. The mechanism of cardioversion related tachycardias can be a pause related dispersion of atrial refractoriness or an adrenergic reaction induced by VT or VF, factors that precipitate arrhythmias in patients with history of atrial arrhythmias (one third of patients). In conclusion, supraventricular tachyarrhythmia is relatively frequent after external cardioversion for ventricular tachyarrhythmia, has no prognostic significance in patients without previous history of atrial arrhythmias, but in those with history of tachycardias is associated with a high risk of recurrence.     

Sedation with midazolam for electrical cardioversion

BACKGROUND: Electrical cardioversion (ECV) usually requires the assistance of the anesthesiology team. To avoid this dependence, previous studies have considered the use of sedation with benzodiazepines administered by cardiologists. We describe our experience with intravenous Midazolam during cardioversion. METHODS: We performed 280 ECV in 202 patients sedated with intravenous Midazolam, without anesthesiology supervision. In scheduled cardioversions, we tested two protocols of Midazolam administration: a bolus of 3 mg, followed by 2 mg each minute until necessary, and a loading dose of 0.09-0.1 mg/kg. In cardioversions performed during electrophysiology studies or defibrillator implant, Midazolam was administered by small repeated doses during the entire procedure. RESULTS: Midazolam was effective to obtain adequate sedation in 99% of cases. All patients had amnesia with regards of the cardioversion. A loading dose of Midazolam allowed a shortening of the procedural time without serious adverse events. Intubation or the assistance of an anesthetist was never necessary. CONCLUSION: Sedation with Midazolam for ECV is effective and well tolerated, with some cautions discussed. A loading dose of Midazolam is well tolerated and further reduces the procedural time.     

The prognostic significance of atrial arrhythmias recorded early after cardioversion for atrial fibrillation

In a substantial number of patients, AF recurs after successful electrical cardioversion. The purpose of this study was to investigate if the atrial arrhythmias recorded immediately after cardioversion are associated with the risk of recurrence of the arrhythmia and to compare the prognostic significance of this parameter with that of other established risk factors. In a series of 71 patients, the risk factors for recurrence of AF during the first year after successful electrical cardioversion were analyzed. A new parameter that was investigated was the frequency of atrial premature beats and the presence of runs of supraventricular tachycardia in the Holter recording started immediately after the cardioversion. Age, left atrial size, left ventricular systolic function, duration of the arrhythmia before cardioversion, underlying cardiac disease, or medication taken were not found to be predictive of recurrence of the arrhythmia. However, the natural logarithm of the number of atrial premature complexes per hour of the Holter recording in the 37 patients in whom AF recurred was higher compared to that of the 34 patients who maintained sinus rhythm (P < 0.0005). The same was true if only the first 6 hours of the recording were analyzed (P < 0.0005). There was a trend for more frequent arrhythmia recurrence if runs of supraventricular tachycardia were present. The finding of > 10 atrial premature complexes per hour in the recording had a relative risk of 2.57 (1.51-4.37), a positive predictive accuracy of 76.5%, and a negative predictive accuracy of 70.3% for subsequent arrhythmia recurrence. We can conclude that frequent (> 10/hour) atrial premature complexes in the Holter recording after electrical cardioversion for AF is a significant risk factor for recurrence of the arrhythmia.     

体外电复律治疗房颤对植入左心耳封堵器患者的影响

目的：探讨植入左心耳封堵器的房颤患者接受体外电复律治疗的可行性和安全性。方法：选取2016年5月至2019年12月北京医院收治的经皮成功植入左心耳封堵器患者51例，其中接受体外电复律治疗7例（13.7%），观察电复律对装置的影响及相关不良事件。结果：51例患者中，接受电复律治疗的7例（13.7%）患者未发生封堵器移位或脱落，围手术期未发生严重不良事件。结论：植入左心耳封堵器的房颤患者接受体外电复律治疗是安全、可行的。     

Effect of coexisting cardiovascular disease on the long-term efficacy and safety of the implantable atrial defibrillator

The long-term efficacy and safety of implantable atrial defibrillator (IAD) therapy in patients with AF and cardiovascular disease is unclear. The aim of this study was to evaluate the efficacy and safety of IAD therapy in patients with and without coexisting cardiovascular disease. In 115 patients implanted with an IAD, 85 patients had cardiovascular disease: 41 (48%) patients had 1 cardiovascular abnormality, 29 (35%) patients had 2, 13 (15%) patients had 3, and 2 (2%) patients had 4 different cardiovascular abnormalities. The device was programmed into a rhythm monitoring mode for the first 3-month postimplant period. All defibrillation therapy was performed under physician supervision to monitor safety and efficacy. After this initial monitoring period, patients were allowed to activate their device away from the hospital or clinic. A total of 357 spontaneous AF episodes occurred in 83 (72%) patients during observed operation and the mean shock efficacy was 93.5+/-20.3% (lower 95% confidence interval [CI] 89.8%). As of the lastfollow-up, 58 (55%) patients had transition to receive nonphysician observed therapy. Forty-two (72%) patients had experienced 332 episodes of AF for which theyhad received device therapy away from the hospital/clinic (mean shock efficacy 90.5+/-39.7%). The presence of hypertension, valvular heart disease, and ischemic heart disease did not affect the shock efficacy of the IAD during physician observed and nonobserved therapy (P > 0.05). However, the presence of congestive heart failure was associated with a lower clinical efficacy during observed and nonobserved therapy (P < 0.05). Overall, 5,262 shocks have been delivered with the IAD without any episode of proarrhythmia. The observed proarrhythmic risk was 0%, with an estimated maximum proarrhythmic risk of 0.06% per shock (95% upper CI). A stand-alone IAD appears to be safe in the presence of cardiovascular disease. The lower clinical efficacy for AF associated with congestive heart failure might be related to a higher rate of early reinitiation of AF after defibrillation.     

Effects of pretreatment with intravenous flecainide on efficacy of external cardioversion of persistent atrial fibrillation

Electrical cardioversion is the most effective and safe method to restore sinus rhythm in patients with persistent AF. However, at least 25% of electrical cardioversions are unsuccessful. The aim of the present study was to evaluate, in a prospective, randomized and double-blind study, the efficacy of a pretreatment with intravenous flecainide in patients who underwent electrical cardioversion. Fifty-four consecutive patients with persistent AF, mean arrhythmia duration 8 (mean 3-18) weeks, were randomized in two groups. In the first group (n = 26), patients received flecainide (2 mg/kg as a 30-minute IV infusion) before electrical cardioversion. In the second group (n = 28), 100 mL IV infusion of 5% glucose was administered 30 minutes before electrical cardioversion. The study evaluated the (1). acute efficacy of electrical cardioversion, (2). mean and maximal energy required, (3). mean number of shocks needed, and (4). incidence of complications. The two groups were similar in terms of age, sex, mean AF duration, left ventricular systolic function, atrial dimension, and cardiovascular risk factors. Seventy-seven percent of patients recovered sinus rhythm with electrical cardioversion. No statistical difference was noted between the two groups: flecainide 19/26 (73%) versus placebo 23/28 (82%). No significant differences were found concerning mean or maximal energy and number of shocks required. No major complications were observed. After a 30-day follow-up, 54% of patients maintained sinus rhythm with no difference between the two groups. Pretreatment with intravenous flecainide before electrical cardioversion is not useful in reducing technical failure of cardioversion, however, flecainide does not diminish the effectiveness of electrical cardioversion.     

A pilot study of a low-tilt biphasic waveform for transvenous cardioversion of atrial fibrillation: improved efficacy compared with conventional capacitor-based waveforms in patients

Background: The optimal waveform tilt for defibrillation is not known. Most modern defibrillators used for the cardioversion of atrial fibrillation (AF) employ high-tilt, capacitor-based biphasic waveforms.
Methods: We have developed a low-tilt biphasic waveform for defibrillation. This low-tilt waveform was compared with a conventional waveform of equivalent duration and voltage in patients with AF. Patients with persistent AF or AF induced during a routine electrophysiology study (EPS) were randomized to receive either the low-tilt waveform or a conventional waveform. Defibrillation electrodes were positioned in the right atrial appendage and distal coronary sinus. Phase 1 peak voltage was increased in a stepwise progression from 50 V to 300V. Shock success was defined as return of sinus rhythm for ≥30 seconds.
Results: The low-tilt waveform produced successful termination of persistent AF at a mean voltage of 223 V (8.2 J) versus 270 V (6.7 J) with the conventional waveform (P = 0.002 for voltage, P = ns for energy). In patients with induced AF the mean voltage for the low-tilt waveform was 91V (1.6 J) and for the conventional waveform was 158 V (2.0 J) (P = 0.005 for voltage, P = ns for energy). The waveform was much more successful at very low voltages (less than or equal to 100 V) compared with the conventional waveform (Novel: 82% vs Conventional 22%, P = 0.008).
Conclusion: The low-tilt biphasic waveform was more successful for the internal cardioversion of both persistent and induced AF in patients (in terms of leading edge voltage).     

Sex,age, and time to cardioversion. Risk factors for cardioversion of acute atrial fibrillation from the FinCV study

Background: Female sex, old age, and time to cardioversion increase the risk of thromboembolic complications (TEC) after cardioversion of atrial fibrillation (AF)?Methods and results: The primary outcome was a TEC within 30 days following ECV. Patients were divided into three age groups and time to cardioversion into <12?h and ≥12?h in 4715 ECVs. TEC occurred in 40 (0.8%) patients. In multivariate analysis, female sex, time to ECV, and vascular disease were independent predictors of TEC. For patients ≤75 cardioverted within 12?h, the incidence of TEC was low. In patients >75 TEC increased in both sexes and particularly in women (1.4% vs. 0.9%, p?=?0.03). When ECVs exceeded 12?h, the risk of TEC was two- to four-fold higher in women in all age groups.

Conclusions: The risk of TEC increases substantially in patients >75 and ECVs ≥12?h, particularly in women. Time to cardioversion should be added to risk-stratification of ECVs of acute AF.

• Key messages

• The ideal timing of cardioversion is still unknown and not based on solid evidence. Delay to cardioversion ≥12?h should be added to the risk stratification of atrial fibrillation cardioversion.

• Female sex increases the risk of complications and failure of cardioversion after electrical cardioversion of atrial fibrillation?<48?h, especially with age?>75 years and time to cardioversion exceeding 12?h.

     

Clinical predictors and time course of arrhythmia recurrence in patients with early reinitiation of atrial fibrillation after successful internal cardioversion

Early reinitiation of atrial fibrillation (ERAF) was commonly observed after successful electrical cardioversion, however, the effect of ERAF on the subsequent time course of arrhythmia recurrence remains unclear. The aim of this study was to evaluate the clinical predictors and time course of AF recurrence with respect to the occurrence of ERAF after successful cardioversion. The clinical predictors and time course of AF recurrence were prospectively evaluated in 124 patients (94 men, 30 women; mean age 65 +/- 9 years) with persistent AF (mean AF duration 36 +/- 40 months), who underwent internal cardioversion. After cardioversion, all patients received treatment with sotalol and were monitored for AF recurrence. Successful restoration of sinus rhythm was achieved in 104 (84%) of 124 patients. ERAF was observed in 28 (27%) of 104 patients in whom 26 of them were successfully treated acutely with intravenous sotalol and repeated cardioversion. After a mean follow-up of 26 months, 29 (28%) of 104 patients remained in sinus rhythm. Kaplan-Meier analysis revealed a significantly poorer outcome with regard to the recurrence of AF in patients with ERAF (hazard ratio 1.7,P = 0.03) and in those with AF for more than 3 years (hazard ratio 1.6,P = 0.03). Despite treatment with sotalol, patients with ERAF had a significantly higher AF recurrence rate within the first day (13/26 [50%] vs 12/76 [16%],P < 0.01), but not during long-term follow-up (21/26 [81%] vs 52/76 [68%],P = 0.3). In contrast, patients with AF for more than 3 years had a similar AF recurrence rate within the first day (7/29 [24%] vs 18/73 [25%],P = 1.0), but a significantly higher recurrence rate during long-term follow-up (27/29 [93%] vs 46/73 [37%],P < 0.01). In conclusion, the occurrence of ERAF and long AF duration were independent predictors for AF recurrence after successful internal cardioversion. The difference in the time course of AF recurrence in patients with ERAF from those with long AF duration suggests distinct arrhythmogenic mechanisms.     

Incidence and rate characteristics of atrial tachyarrhythmias in patients with a dual chamber defibrillator

Atrial tachyarrhythmias play an important role in the treatment of patients with malignant ventricular tachyarrhythmias not only with respect to inappropriate discharges but also to left ventricular function and stroke risk. A combined dual chamber defibrillator provides separate therapies for atrial and ventricular tachyarrhythmias. To assess the incidence of atrial tachyarrhythmias in patients with this dual chamber implantable defibrillator, 40 patients with ventricular tachyarrhythmias and concomitant atrial tachyarrhythmias and/or AV conduction disturbances were included in a prospective study. During a mean follow-up of 25 +/- 11 months, 26 of 40 patients had a total of 1,430 recurrences of atrial tachyarrhythmias. The vast majority of the atrial tachyarrhythmias with regular atrial cycles had a mean median atrial cycle length of 235 +/- 37 ms and a mean duration of 34 +/- 144 minutes. Atrial tachyarrhythmias with irregular atrial cycles exhibited a median atrial cycle length of 198 +/- 31 ms and had a mean duration of 246 +/- 1,264 minutes. In addition, 67% of 375 tachyarrhythmias, in which the median ventricular cycle length during the ongoing episode could be documented, had a ventricular rate <100 beats/min. Continuous atrial arrhythmia detection with a dual chamber ICD reveals a high incidence of atrial tachyarrhythmias with a predominantly short duration of paroxysmal recurrences <1 hour in the vast majority of episodes.     

Asymmetric dimethylarginine concentration and early recurrence of atrial fibrillation after electrical cardioversion

Background: The purpose of this study was to determine whether high asymmetric dimethylarginine (ADMA) levels could predict early recurrence of atrial fibrillation (AF) after successful electrical cardioversion (CV).
Methods : Seventy patients with persistent AF, but without known heart disease, who underwent elective electrical CV were enrolled. Blood samples for ADMA determination were drawn from all patients just before the CV.
Results : The study population comprised 64 patients (men 73%, age 62.56 ± 7.72 years, duration of AF 6.00 ± 1.90 months) in whom sinus rhythm was restored. After 1-month follow-up, 30 (47%) patients had recurrence of AF. The median ADMA concentration was significantly higher in patients with AF recurrence (1.93 μmol/L vs 1.43 μmol/L; P = 0.001). AF recurrence was associated with higher pre-CV ADMA levels (odds ratio [OR]= 4.20; 95% confidence interval [CI], 1.44–12.22; P = 0.001). On multivariate analysis, ADMA was the only independent predictor of arrhythmia recurrence (OR = 4.19; 95%CI, 1.12–15.77; P = 0.034).
Conclusion : Our data suggest that high levels of ADMA are associated with an increased risk of AF recurrence within 1 month after electrical CV, supporting the hypothesis that ADMA might participate in the process of atrial remodeling.     

Heart rate variability and recurrence of atrial fibrillation after electrical cardioversion

BACKGROUND: Heart rate (HR) variability has been shown to predict spontaneous onset of atrial fibrillation (AF). This study was designed to test the hypothesis that HR variability after electrical cardioversion (CV) of persistent AF predicts the recurrence of AF. METHODS: Various time and frequency domain measures of HR variability, along with the non‐linear measures of HR dynamics, were analyzed from the 24‐hour ECG recordings in 78 patients with persistent AF after restoration of sinus rhythm with electrical CV. RESULTS: During the follow‐up of one month, 27 patients (35%) had recurrence of AF. The patients with AF recurrence had significantly higher standard deviation of all R‐R intervals (SDNN 117?±?34versus100?±?29P ?<?0.05), increased high‐frequency (lnHF 5.7?±?0.6versus5.3?±?0.7P ?<?0.05 ), low‐frequency (lnLF 6.2?±?0.8versus5.6?±?0.9P ?<?0.01) and very‐low‐frequency (InVLF 7.1?±?0.8versus6.5?±?0.8P ?<?0.01) power spectral components of HR variability than those who remained in sinus rhythm. Approximate entropy, a measure of complexity of HR dynamics, and the short‐term fractal scaling exponent did not differ between the groups, but the long‐term power‐law slope β was steeper among the patients who remained in sinus rhythm ( P ?<?0.05). During the first week after the CV, increased HF power (highest tertile) was the most powerful predictor of AF recurrence with odds ratio of 2.8 (95% confidence interval 1.0 to 8.0,P ?<?0.05). Increased VLF power spectral component at baseline predicted best the late recurrence of AF with odds ratio of 3.3 (95% confidence interval 1.6 to 7.2,P ?<?0.01). No clinical or echocardiographic variable predicted the recurrence of AF. CONCLUSIONS: Increased HR variability in all major power spectral bands is associated with late recurrence of AF after electrical CV. Enhanced cardiac vagal outflow, reflected as an increased HF power spectral component, seems to predict specifically the early recurrence of AF after the CV.     

Discordant regulation of CRP and NT-proBNP plasma levels after electrical cardioversion of persistent atrial fibrillation

BACKGROUND: B-type natriuretic peptide (BNP) and C-reactive protein (CRP) have been suggested to be prognostically relevant markers in patients with cardiovascular disease. Additionally, BNP and CRP plasma levels seem to be independently elevated in patients with atrial fibrillation (AF). However, there are only sparse data about the significance and temporal course of these plasma markers after restoration of sinus rhythm (SR). METHODS: We performed a prospective study in consecutive patients with symptomatic atrial fibrillation. NT-proBNP and CRP plasma levels were measured before and one month after electrical cardioversion (CV). Patients with infections, an acute coronary syndrome, or surgery 4 weeks prior to CV, were excluded. RESULT: Twenty-five patients (men 84%, age 66 +/- 8 years, duration of AF 90 +/- 75 days, left ventricular ejection fraction 0.57 +/- 0.11) were analyzed. At follow-up (33 +/- 6 days after CV) 14 patients (56%) were in SR and 11 patients (44%) in AF. In patients with SR there was a significant reduction of NT-proBNP levels (baseline 1647 +/- 1272 pg/mL, follow-up 772 +/- 866 pg/mL, P < 0.05), even in a subgroup of patients (n = 10) with normal left ventricular ejection fraction (1262 +/- 538 vs 413 +/- 344 pg/mL, P < 0.001). CRP levels in patients with SR were similar at baseline and at follow-up (3.5 +/- 3.6 vs 3.2 +/- 2.5 mg/L, P = 0.8). CONCLUSION: We conclude that even in patients with normal left ventricular ejection fraction restoration of sinus rhythm leads to a significant reduction of NT-proBNP plasma levels. In contrast, CRP plasma levels seem not to be influenced during the first 4 weeks after electrical cardioversion.     

Noninvasive assessment of acute changes in atrial electrophysiology after cardioversion by signal-averaged P-wave electrocardiography

BACKGROUND: Atrial remodeling secondary to atrial fibrillation (AF) may be important in the arrhythmogenic process. Unfortunately, the study of electrophysiologic remodeling in humans has been limited by the invasive nature of most tests of electrophysiologic characteristics. We sought to determine whether changes in atrial electrophysiology occur acutely (within the first hour) after cardioversion and whether these changes could be detected noninvasively by measuring the signal-averaged P-wave. METHODS: The filtered P-wave duration (FPD) was measured by signal-averaged electrocardiography (ECG) at 20 and 60 minutes after cardioversion in 46 patients with AF, and the difference between the two values was calculated. The root-mean-square voltage of the terminal 40 ms of the signal-averaged P-wave at 20 and 60 minutes and the difference between them were also determined. RESULTS: The FPD at 20 minutes was significantly different from that at 60 minutes (153.0 +/- 19.1 vs 159.7 +/- 24.8 ms; P = 0.02). In a univariate linear regression model, none of the clinical variables studied was significantly associated with the change in FPD. The root-mean-square voltage at 20 minutes was not significantly different from that at 60 minutes (5.8 +/- 3.0 vs 5.5 +/- 2.7; P = 0.14). CONCLUSIONS: We conclude that significant changes in atrial electrophysiology occur within the first hour after cardioversion of AF. These changes can be detected by measuring the FPD.     

Termination of persistent atrial fibrillation resistant to cardioversion by a single radiofrequency application

This report describes the termination of persistent AF refractory to multiple cardioversions and antiarrhythmic therapy in a patient without structural heart disease, with a single radiofrequency application delivered in the left upper pulmonary vein. The observations and failure of repeated internal and external cardioversion suggest a rapidly firing arrhythmia focus sustaining atrial fibrillation amenable to curative pulmonary vein ablation.     

Reversion and maintenance of sinus rhythm in patients with permanent atrial fibrillation by internal cardioversion followed by biatrial pacing

Patients in atrialfibrillation (AF) who fail external cardioversion are usually regarded as in permanent AF. Internal cardioversion may revert many such patients into sinus rhythm (SR) but the majority relapse rapidly into AF. We investigated whether internal cardioversion followed by biatrial pacing is an effective to restore and subsequently maintain SR in patients with permanent AF. Patients in permanent AF underwent internal cardioversion that was followed by biatrial temporary pacing for 48 hours. Those who remained in SR received a permanent biatrial pacemaker programmed to a rate responsive mode with a lower rate 90 beats/min. Primary end point of the study included maintenance in SR 3 months after internal cardioversion. Sixteen patients (14 men, 57 +/- 11 years) were cardioverted. The median duration of AF was 24 months (quartiles, Q1 = 8.5 and Q3 = 102) and mean left atrium diameter was 48 +/- 04 mm. A permanent biatrial pacemaker was implanted in 11 patients. At a mean fallow-up of 15 months (range 4 to 24), 8 patients remained in SR for more than 3 months. AF was eliminated in 5 patients, while in two a second internal cardioversion on amiodarone was required. Antiarrhythmic therapy was used in half of our population and did not predict the long-term maintenance of SR. Following internal cardioversion with continuous biatrial pacing, 50% of patients with permanent AF were maintained for prolonged periods in SR. This is a new modality of treatment of permanent AF directed to the maintenance of SR that provides a further therapeutic option in end-stage AF.