A stepwise external cardioversion protocol for atrial fibrillation to maximize acute success rate

Yousef Darrat, Steve Leung, Liliane Elayi, Kevin Parrott, Gbolahan Ogunbayo, John Kotter, Vincent Sorrell, Vedant Gupta, Paul Anaya, Gustavo Morales, John Catanzarro, Brian Delisle, Claude S. Elayi

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Aims Cardioversion is a very commonly performed procedure for persistent atrial fibrillation (AF). However, there is no well-defined protocol to address failed external electrical direct current cardioversion. The aim of the study is to test the efficacy of a pre-defined stepwise cardioversion protocol for patients with persistent AF of ≤12 months. Success was the achievement of sinus rhythm.

Methods and results The study population included patients with persistent AF of ≤12 months duration requiring rhythm management. Patients were offered cardioversion using a pre-defined stepwise protocol using different electrode placement locations, applying compression at end of expiration, and higher energy delivered simultaneously through two defibrillators.: A total of 414 patients were included in the study, of which 362 (87.4%) required a single successful cardioversion. The remaining 52 (12.5%) patients required additional cardioversion attempts using the stepwise cardioversion protocol with an overall success rate of 99.3%. Two simultaneous defibrillators were required in 14 patients (3.4%). Patients with multiple cardioversions (13.5%) experienced more local skin irritation and pain compared with patients with single cardioversion (13.5% vs. 3.5%, P = 0.004). The predictor for the need for multiple cardioversion attempts is high body mass index, while high transthoracic impedance is associated with failed cardioversion. No major complications were observed during the study.

Conclusion The stepwise cardioversion protocol has a high success rate of >99% and can be safely performed in outpatient or inpatient settings.

Original languageEnglish
Pages (from-to)828-834
Number of pages7
Issue number3
StatePublished - Mar 1 2023

Bibliographical note

Publisher Copyright:
© 2023 Oxford University Press. All rights reserved.


  • Atrial fibrillation
  • External direct current cardioversion
  • Transthoracic impedance

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)


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