Atrial Fibrillation Caused by Intractable Hiccups: A Unique Cause and Cure

We present the case of a 61-year-old male who developed persistent hiccups concurrently with the onset of atrial fibrillation (AF). The hiccups were refractory to traditional treatment but resolved immediately upon electrical cardioversion (ECV) to normal sinus rhythm (NSR). The patient has remained in NSR and free of hiccups. The potential etiologies for hiccups are numerous and varied, and the management of persistent hiccups can be difficult. Cardiac associations including myocardial infarction and pericarditis have been described, while few cases of first-time onset of atrial fibrillation leading to hiccups have been documented. This case discusses a unique instance demonstrating a connection between hiccups and cardiac pathology and an overview of its management.

Characteristics of left atrial strain in patients with atrial fibrillatio after cardioversion

The aim of the study – to evaluate the parameters of left atrial myocardial strain in patients with atrial fibrillation who underwent electrical and drug cardioversion.Materials and methods. The study included 118 patients of the University Clinical Hospital No 1 of the First Sechenov Moscow State Medical University. The analysis was carried out in three groups of patients: group 1 (n=54) – patients with atrial fibrillation who underwent electrical cardioversion; group 2 (n=31) – patients with atrial fibrillation who underwent drug cardioversion; group 3 (n=43) – patients without a history of atrial fibrillation. The clinical and anamnestic data of the medical history of each patient, as well as ultrasound indicators were evaluated: global strain of the left atrial, the values of negative peaks as a reflection of the left atrial systole and the values of positive peaks as a reflection of the filling of the left atrium, LASI – the left atrial stiffness index.Results. The analysis showed that left atrial strain in patients with atrial fibrillation were reduced in all analyzed parameters: negative strain peaks (-9.00 vs. -12.6 in the control group, p<0.001), positive strain peaks (12.6 vs. 14.6 in the control group, p<0.001), global left atrial strain (21.5 in the atrial fibrillation group vs. 27.3 in the control group, p<0.001). Left Atrial Stiffness Index (LASI) was significantly higher in patients with a stopped episode of atrial fibrillation (0.50 vs. 0.40, p=0.006).Conclusions. The indicators of left atrial strain were significantly reduced, and the left atrial stiffness index was significantly increased both in the group with electrical cardioversion and in the group with drug-induced cardioversion, compared with patients with similar cardiovascular pathologies, but without a history of atrial fibrillation episodes.

Biomarker Levels in Patients with Atrial Fibrillation Before and After Electrical Cardioversion

Background Biomarkers may help to improve our knowledge about the complex pathophysiology of atrial fibrillation (AF), the most common sustained cardiac arrhythmia. We aimed to identify significant changes in biomarkers and clinical measures in patients with and without AF recurrence after electrical cardioversion. Methods Patients with persistent AF undergoing elective electrical cardioversion were enrolled. We measured 21 conventional and new biomarkers before and 30 days after electrical cardioversion and assessed the associations of changes in biomarker levels with rhythm status at follow-up using multivariable logistic regression models. Results Of the 100 patients included (mean [SD] age 66 (10) years, 25% women), 28 (28%) had an AF recurrence. Of the 21 biomarkers assessed, 4 reached the predefined between group significance of p<0.01. The most significant ones were bone morphogenetic protein 10 (BMP10), N-terminal pro-B-type natriuretic peptide (NT-proBNP) and total bilirubin. Their respective changes were -10.4%, -62.0% and -25.6% in patients with sinus rhythm, and 3.1%, 1.1% and -9.4% in patients with recurrent AF, for a between group difference of -13.5% (95% confidence interval [CI], -19.3% to -7.6%; P<0.001), -63.1% (95% CI, -76.6% to -49.6%; P<0.001) and -16.3 (95% CI, -27.9% to -4.7%; P=0.007). In age and sex adjusted models, reductions of BMP10 and NT-proBNP were significantly associated with rhythm status at follow-up (β coefficient per 1-SD decrease, -2.03; 95% CI, -3.06 to -1.00; P<0.001 and -3.98; 95% CI, -5.75 to -2.22; P<0.001, respectively). After additional adjustment for demographic characteristics, risk factors for AF, and changes in clinical measures, the β coefficients per 1-SD were -3.85 (95% CI, -6.34 to -1.35; P=0.003) for BMP10 and -5.84 (95% CI, -10.22 to -1.47; P=0.009) for NT-proBNP. Conclusions Changes in BMP10 und NT-proBNP levels were strongly associated with rhythm status after electrical cardioversion, suggesting that these markers may be dependent on the actual heart rhythm.

Clinical experience of new antiarrhythmic drug refralon for pharmacological cardioversion in patients with atrial fibrillation after pulmonary vein cryoablation

We present two cases of successful pharmacological cardioversion using antiarrhythmic drug refralon in patients with persistent atrial fibrillation after pulmonary vein cryoablation and ineffective electrical cardioversion. These clinical cases represent the first experience of successful use of refralon in patients who underwent cryoablation.

Echocardiographic E/e for the prediction of recurrent atrial fibrillation after ablation or electrical cardioversion: a systematic review and meta-analysis

Background Atrial Fibrillation (AF) is the most common arrhythmia, with important sequelae if left untreated. Markers help to predict the recurrence of AF after an intervention like ablation or electrical cardioversion (ECV). E/e' ratio is an echocardiographic marker which is potentially useful in predicting AF recurrence, however, present data is conflicting. Adding a simple tool like E/e' ratio to evaluation of patients for AF intervention may help in advising patients better about their risk for recurrent AF after intervention without adding much cost to the diagnostic work-up. Purpose To determine if there is a significant difference in pooled mean E/e' ratio among AF patients with recurrence after ablation or ECV compared to those who maintained sinus rhythm, and to determine the odds ratio of recurrent AF given an abnormal E/e' ratio. Methods The investigators systematically searched Pubmed, Medline, Cochrane Database, and Google Scholar for articles on patients undergoing catheter ablation or ECV for AF and who were adjudicated on recurrence of the arrhythmia. We calculated the weighted mean difference of E/e' ratio between those with recurring AF and those who maintained sinus rhythm, and the odds ratio of AF recurrence given an abnormal E/e' ratio. Statistical analysis was done using RevMan 5.4.1 software. Results A total of 38 studies involving 7048 patients were included in the initial analysis (26 studies on ablation with continuous data and 2 with dichotomous data based on a set cutoff, and 10 studies on ECV). One study was excluded due to absence of a blanking period and and another due to outlaying data in funnel plot analysis. The remaining 36 studies with 6910 patients were analyzed. There was a significant difference in the weighted mean E/e' ratio between the two groups in AF patients undergoing ablation (Mean Difference (MD)=0.60 (95% CI [0.20,1.00] p=0.003, I2=63%]), and ECV (MD=2.07 (95% CI [1.66, 2.49] p&lt;0.ehab724.0361, I2=12%), with an odds ratio of 1.88 (95% CI [1.04, 3.37] p=0.04, I2=52%) among those with dichotomous data. Subgroup analyses were done to reduce heterogeneity. E/e' ratio was not significantly different in the population of paroxysmal AF undergoing ablation (MD=0.64, 95% CI [−0.55, 1.83], p=0.29, I2=76%) but significantly different in patients with non-paroxysmal AF undergoing ECV (MD=2.19, 95% CI [1.82, 2.56], I2=0%). Conclusion This analysis suggests that a higher E/e' ratio may be used to predict recurrence of AF after ablation or ECV, especially in patients undergoing ECV. The heterogeneity of the data for E/e' ratio in AF ablation and the variety of co-morbid conditions to atrial fibrillation limits its clinical applicability. Further studies are recommended to determine the optimal cutoff of this ratio that would predict AF recurrence. FUNDunding Acknowledgement Type of funding sources: None. Forest plot for studies on Ablation Forest plot for studies on ECV

Novel rhythm conversion approach in unsuccessful electric cardioversion of persistent atrial fibrillation

The average effectiveness of electrical cardioversion in persistent atrial fibrillation (AF) is considered about 90%. The success is limited by arrhythmia longevity, essential heart pathology, excessive body mass, concomitant deceases. A novel developed in Russia class III intravenous medication “Refralon” (4-nitro-N-(1RS)-1(4-fluorophenyl)-2-(1-ethylpiperidin-4-ethyl) benzamide hydrochloride) seems to be promising in sinus rhythm restoration in such patients. The aim of the study was to assess the effectiveness of a novel class III intravenous medication “Refralon” in conversion to sinus rhythm in patients with permanent AF in whom electrical cardioversion was unsuccessful. Materials and methods 19 patients were included: 16 male and 3 female aged from 45 to 68 years old (59,9±5,84 (M±SD)). Left atrial size was 47±3,2 × 59±2,8 mm, BMI 38,5±7,0 kg/m2, arrhythmia duration from 2 to 21 months (6,7±4,99). Refralon was injected according to the approved manual in ICU; heart rhythm and rate, blood pressure, SpO2 were monitored. Dynamic assessment of QT and QRS duration was performed. Results In 17 of 19 patients (89,4%) sinus rhythm was restored. In 7 patients (41%) sinus rhythm was restored before 10 min, in 4 patients (24%) before one hour, in 4 patients (24%) before two hours, in 2 patients (11%) before six hours. In two patients sinus rhythm was not restored. In both target dose was not infused due to non-sustained ventricular tachycardia in one case, and QT prolongation in another. Conclusion In a small pilot study Refralon was highly effective in patients with persistent atrial fibrillation when electrical cardioversion was ineffective. All the patients had significantly increased BMI. The results may suggest the indication for Refralon usage in obese patients. FUNDunding Acknowledgement Type of funding sources: None.