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Background: Electrophysiological studies demonstrate that a short atrial fibrillation cycle length (AFCL) is related with poor outcome of electrical cardioversion (ECV) of atrial fibrillation (AF). We found previously that the mechanical AFCL (AFCL-tvi) and atrial fibrillatory velocity (AFV-tvi) may be determined noninvasively using color tissue velocity imaging (TVI) and closely relates to the electrophysiological AFCL., Objective: To evaluate the relation between AFCL-tvi, AFV-tvi, and success of ECV in patients with AF., Methods: We prospectively studied 133 patients with persistent AF by performing echocardiography before ECV and measured the AFCL-tvi and AFV-tvi in the right atrium and left atrium. Recurrent AF was monitored., Results: Nineteen (14%) patients had failure of ECV, 42 (32%) remained in sinus rhythm after 1-year follow-up, and 72 (54%) had a recurrence of persistent AF. Patients with immediate ECV failure had a lower median AFV-tvi measured in the right atrium than did patients with a successful ECV: 0.7 cm/s (0.2-1.0 cm/s) vs. 1.7 cm/s (0.9-2.8 cm/s) (P = .008). Patients with maintenance of sinus rhythm after 1 year had a longer AFCL-tvi measured in the left atrium than did patients with recurrence of AF (150 ms vs 137 ms; P = .017) and had a higher AFV-tvi in both atria (1.4 vs. 0.9 cm/s in the left atrium; P = .013 and 2.2 vs 1.4 cm/s in the right atrium; P = .011). Multivariate analyses showed that all atrial TVI parameters were independently associated with the maintenance of sinus rhythm after 1 year., Conclusion: Higher atrial fibrillatory wall velocities and longer AFCLs determined by echocardiography are associated with acute and long-term success of ECV., (Copyright © 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Acute atrial fibrillation (AF) is often treated with the administration of intravenous flecainide; however, this treatment may not always be successful and is potentially hazardous. Previous studies suggest that electro-echocardiographic tissue velocity imaging (TVI) of the atrial wall may reflect atrial remodeling., Objective: To study whether atrial TVI can be used to identify nonresponders of flecainide administered intravenously in patients with acute AF., Methods: We used atrial TVI to measure atrial fibrillatory cycle length determined by using tissue velocity imaging (AFCL-TVI) and atrial fibrillatory wall motion velocity determined by using tissue velocity imaging (AFV-TVI) in the left atrium in 52 (55%) patients presenting with acute AF in the emergency department. These 2 parameters reflect electrical and structural remodeling, respectively. Standard baseline characteristics were recorded., Results: Patients were predominantly men (76%) and 64 ± 11 years old. Thirty-six (69%) patients had successful cardioversion after flecainide infusion. There were no significant differences in baseline characteristics between responders and nonresponders. Patients with a successful cardioversion had a longer mean AFCL-TVI and higher median (interquartile range) AFV-TVI compared with patients with failed cardioversion: 172 ± 29 ms vs 137 ± 35 ms (P < .001) and 4.2 (3.3-6.2) cm/s vs 2.3 (1.9-3.5) cm/s (P = .001)., Conclusions: Electro-echocardiographic atrial TVI measurement is a promising noninvasive tool for predicting outcome of pharmacological cardioversion. A short AFCL-TVI and a low AFV-TVI are related to failure of cardioversion of AF using flecainide., (Copyright © 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to evaluate the hypothesis that presumed reversion of electrical remodeling after cardioversion of atrial fibrillation (AF) restores the efficacy of flecainide., Background: Flecainide loses its efficacy to cardiovert when AF has been present for more than 24 hours. Most probably, the loss is caused by atrial electrical remodeling. Studies suggest electrical remodeling is completely reversible within 4 days after restoration of sinus rhythm (SR)., Methods: One hundred eighty-one patients with persistent AF (median duration 3 months) were included in this prospective study. After failure of pharmacologic cardioversion by flecainide 2 mg/kg IV (maximum 150 mg in 10 minutes) and subsequent successful electrical cardioversion, we performed intense transtelephonic rhythm monitoring three times daily for 1 month. In case of AF recurrence, a second cardioversion by flecainide was attempted as soon as possible., Results: AF recurred in 123 patients (68%). Successful cardioversion by flecainide occurred only when SR had been maintained for more than 4 days (7/51 patients [14%]). Failure to cardiovert was associated with a prolonged duration of the recurrent AF episode and concurrent digoxin use. Multivariate logistic regression confirmed that successful cardioversion was determined by digoxin use (odds ratio [OR] 0.093, P = .047) and by the interaction between the duration of SR and the (inverse) duration of recurrent AF (OR 6.499, P < .001). When flecainide was administered within 10 hours after AF onset and the duration of SR was greater than 4 days, the success rate was 58%., Conclusions: Flecainide recovers its antiarrhythmic action after cardioversion of AF. However, successful pharmacologic cardioversion occurs only after SR has lasted at least 4 days and is expected only for recurrences having duration of a few hours. Immediate pharmacologic cardioversion of AF recurrence may be a worthwhile strategy for management of persistent AF.