Cardiac arrhythmias are responsible for a significant portion of cardiovascular disease among pregnant people. As the incidence of arrhythmias in pregnancy continues to increase, anesthesiologists who care for obstetric patients should be experts managing arrhythmias in pregnancy. This article examines the most common arrhythmias encountered in pregnancy, including risk factors, diagnosis, and management strategies. Peripartum monitoring and labor analgesia recommendations are discussed. Additionally, management of cardioversion, management of pacemakers and implantable cardioverter-defibrillators, and advanced cardiac life support in the setting of pregnancy is reviewed.

BACKGROUND: Direct current cardioversion is frequently used to return patients with atrial fibrillation (AF) to sinus rhythm. Chest pressure during cardioversion may improve the efficacy of cardioversion through decreasing transthoracic impedance and increasing cardiac energy delivery.
OBJECTIVE: This study aimed to assess the efficacy and safety of upfront chest pressure during direct current cardioversion for AF with anterior-posterior pad positioning.
METHODS: This was a multicenter, investigator-initiated, double-blinded, randomized clinical trial. Recruitment occurred from 2021 to 2023. Follow-up was until hospital discharge. Recruitment occurred across 3 centers in New South Wales, Australia. Inclusion criteria were age ≥18 years, referred for cardioversion for AF, and anticoagulation for 3 weeks or transesophageal echocardiography excluding left atrial appendage thrombus. Exclusion criteria were other arrhythmias requiring cardioversion, such as atrial flutter and atrial tachycardia. The intervention arm received chest pressure during cardioversion from the first shock. The primary efficacy outcome was total joules required per patient encounter. Secondary efficacy outcomes included first shock success, transthoracic impedance, cardioversion success, and sinus rhythm at 30 minutes post cardioversion.
RESULTS: A total of 311 patients were randomized, 153 to control and 158 to intervention. There was no difference in total joules applied per encounter in the control arm vs intervention arm (355.0 ± 301 J vs 413.8 ± 347 J; P = 0.19). There was no difference in first shock success, total shocks provided, average impedance, and cardioversion success.
CONCLUSIONS: This study does not support the routine application of chest pressure for direct current cardioversion in atrial fibrillation (PRESSURE-AF [Investigating the Efficacy of Chest Pressure for Direct Current Cardioversion in Atrial Fibrillation: A Randomized Controlled Trial]; ACTRN12620001028998).

Atrial fibrillation (AF) is a rarely reported arrhythmia in otherwise healthy newborn foals, with a single case of cardioversion using procainamide administration described in the literature. Two neonatal Thoroughbred colts were presented to an equine hospital because of an irregularly irregular tachyarrhythmia and poor latching when trying to nurse. History, physical examination, and initial diagnostic testing including ECG and echocardiography confirmed AF without structural heart disease. The 1st foal converted into normal sinus rhythm after treatment with IV metoprolol and quinidine. The 2nd foal converted to normal sinus rhythm after a single IV dose of metoprolol, intended for rate control. Demeanor and nursing behavior improved markedly after conversion. The 2 foals had normal heart rates and sinus rhythm that persisted for 6 weeks until euthanasia in the 1st foal and for 2 years in the 2nd foal. Rate control and cardioversion should be considered as a treatment for persistent lone AF in neonatal foals.

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UNASSIGNED: Although the restoration and maintenance of sinus rhythm (SR) in patients with atrial fibrillation (AF) have long-term benefits, few studies have investigated the acute hemodynamic benefits immediately after SR restoration. Therefore, we investigated whether hemodynamic changes occurred in the first few minutes after cardioversion from AF to SR.
UNASSIGNED: We retrospectively enrolled 145 patients with AF and divided them into a pre-AF group comprising patients in whom SR was restored by electrical cardioversion during pulmonary vein isolation (PVI; n = 74) and a control group comprising patients who were in SR throughout the procedure (n = 71). The pre-AF group was subdivided into subgroups according to AF classification (paroxysmal AF (PAF), persistent AF (PerAF), and long-standing persistent AF (LSPAF)) and into quartiles based on the AF-heart rate (HR). The mean arterial pressure (MAP) and left atrial pressure (LAP) were measured immediately after transseptal puncture (pre-measurement) and before withdrawal from the left atrium after PVI (post-measurement). The changes in MAP and LAP between the pre- and post-measurement (ΔMAP and ΔLAP) were calculated by subtracting the pre-measurements (MAPpre and LAPpre) from the post-measurements (MAPpost and LAPpost).
UNASSIGNED: In the pre-AF group, the time from cardioversion to post-measurement was 19 ± 16 min. When ΔMAP and ΔLAP were compared with the control group, ΔMAP was significantly smaller (4.9 ± 17.8 vs. 11.0 ± 14.2 mm Hg, respectively; P = 0.025), and ΔLAP was not significantly different between the groups. In the subgroup analyses, although ΔLAP was not significantly different among AF types, ΔMAP was significantly increased in the PAF group compared to the PerAF and LSPAF groups (24.0 ± 18.5 vs. 3.1 ± 16.8 and 4.5 ± 18.1 mm Hg, respectively; P = 0.042). The HRpre in the quartiles with the lowest, second, third, and highest AF-HR were approximately 58, 74, 86, and 109 beats per minute (bpm), respectively. The ΔLAP and ΔMAP were not significantly different among the AF-HR quartile groups.
UNASSIGNED: In patients with PAF, atrial contractions may resume quickly, which leads to hemodynamic improvement immediately after SR restoration. As for AF-HR, there was no significant impairment of ventricular diastolic filling at approximately < 109 bpm.

OBJECTIVE: Management in recent-onset atrial fibrillation (AF) is to achieve sinus rhythm (SR) by cardioversion (CV). However, frequently SR is spontaneously restored, making scheduled admission unnecessary and causing misutilization of healthcare resources. Emerging medical technology allows accurate heart rhythm monitoring. This study evaluated this technology in these patients, preventing unnecessary admission and providing an earlier management.
METHODS: A multicenter study was designed including patients with AF scheduled for elective electrical CV. Patients submitted ECG recordings to a central CoreLab daily, twice a day and whenever they present symptoms, until CV (spontaneous or scheduled) and a week afterwards. Whenever a spontaneous conversion to SR was detected, investigators were contacted to confirm SR and abort admission. Patients\' satisfaction was evaluated using a test for perceived utility, convenience, and accessibility.
RESULTS: 74 patients were enrolled (age 62±10 years). Twenty-two patients (30%) showed spontaneous conversion to SR. A total of 22 admissions and 16 transesophageal echocardiograms were prevented. Among 52 patients admitted for CV, 45 (88%) were discharged in SR. During follow-up after conversion to SR (spontaneous or electrical), recurrences of AF occurred in 24 patients (34%). At the end of the follow-up 51 patients (69%) remained in SR. The CoreLab received 93% of the expected ECG transmissions. Patient\'s overall satisfaction score was 9.1 over 10.
CONCLUSIONS: Digital devices for heart rhythm monitoring can optimize the management of AF patients scheduled for elective CV, preventing unnecessary admissions and providing a more rational use of healthcare resources.

UNASSIGNED: Atrial fibrillation (AF) represents the most common arrhythmia in the postoperative setting. We aimed to investigate the incidence of postoperative AF (POAF) and determine its predictors, with a specific focus on inflammation markers.
UNASSIGNED: We performed a retrospective single tertiary center cohort study including consecutive adult patients who underwent a major surgical procedure between January 2016 and January 2020. Patients were divided into four subgroups according to the type of surgery.
UNASSIGNED: Among 53,387 included patients (79.4% male, age 64.5 ± 9.5 years), POAF occurred in 570 (1.1%) with a mean latency after surgery of 3.4 ± 2.6 days. Ninety patients died (0.17%) after a mean of 13.7 ± 8.4 days. The 28-day arrhythmia-free survival was lower in patients undergoing lung and cardiovascular surgery (p < .001). Patients who developed POAF had higher levels of C-reactive protein (CRP) (0.70 ± 0.03 vs. 0.40 ± 0.01 log10 mg/dl; p < .001). In the multivariable Cox regression analysis, adjusting for confounding factors, CRP was an independent predictor of POAF [HR per 1 mg/dL increase in log-scale = 1.81 (95% CI 1.18-2.79); p = .007]. Moreover, independent predictors of POAF were also age (HR/1 year increase = 1.06 (95% CI 1.04-1.08); I < .001), lung and cardiovascular surgery (HR 23.62; (95% CI 5.65-98.73); p < .001), and abdominal and esophageal surgery (HR 6.26; 95% CI 1.48-26.49; p = .013).
UNASSIGNED: Lung and cardiovascular surgery had the highest risk of POAF in the presented cohort. CRP was an independent predictor of POAF and postsurgery inflammation may represent a major driver in the pathophysiology of the arrhythmia.

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy or \"broken heart syndrome,\" is a rare and reversible condition characterized by transient left ventricular dysfunction. It is typically triggered by acute emotional or physical stressors. Here, we present a unique case of TCM occurring in a 77-year-old woman following cardioversion for persistent and symptomatic atrial fibrillation. The patient underwent uncomplicated cardioversion with recent imaging showing intact global systolic function. She presented four days post-procedure for chest pain, shortness of breath, and peripheral edema. A repeat echocardiogram showed a marked decrease in cardiac function evidenced by an ejection fraction of 20-25%. The patient was readmitted and managed with IV diuretics. Symptoms resolved within three days and the patient showed improved cardiac function on imaging prior to discharge.

UNASSIGNED: Direct current cardioversion (DCCV) is used as elective and emergency rhythm control for atrial fibrillation (AF). We aimed to explore the role of P-wave parameters measured during sinus rhythm using body surface mapping (BSM) in predicting successful DCCV for persistent atrial fibrillation (persAF) at 12 months.
UNASSIGNED: This case-control study included 56 males >18 years old who underwent DCCV for persAF. P-wave parameter collection after DCCV for AF was done using 128 unipolar leads. A band-pass filter of 1-50 Hz was utilised. Corrected P-wave duration (PWDc), P-wave amplitude, and P-wave dispersion were measured to predict 12-month outcomes and time of recurrence.
UNASSIGNED: The mean age was 64 ± 4 years, and 23 patients (44%) were on amiodarone. The 12-month success rate was 44% (n = 23), while the rest reverted to AF after 2.6 ± 0.4 months. The parameters were comparable between successful and failed DCCV in the entire cohort and patients not on amiodarone. In patients on amiodarone, patients with failed arms had higher PWDc than those with successful arms (188 vs. 150 ms, P = 0.04). Receiver operator characteristic curve analysis for PWDc in the amiodarone cohort showed an area under the curve (AUC) of 0.75 and P = 0.049. A recurrence cut-off >161 ms had a sensitivity of 69% and a specificity of 100%, with a hazard ratio of 10.7, P = 0.004. The parameters were not predictive of the time of recurrence.
UNASSIGNED: In patients on amiodarone, increased PWDc measured using BSM was associated with higher AF recurrence at 12 months following DCCV for persAF.

UNASSIGNED: Atrial fibrillation (AF) is a prevalent cardiac condition characterized by irregular heart rhythm. Conventional non-invasive diagnostic techniques, while useful, have limitations in providing comprehensive information for treatment planning. To address this gap, electromechanical cycle length mapping (ECLM), a non-invasive echocardiography-based technique, has emerged as a promising approach. Electromechanical cycle length mapping offers quantitative and spatially specific insights into atrial electromechanical activation rate mapping, thereby enhancing our understanding of arrhythmia disease progression in AF patients.
UNASSIGNED: In this case series, we present two patient cases demonstrating the potential utility of ECLM in monitoring and evaluating treatment responses in atrial arrhythmia. The 1st case involved a 61-year-old male with persistent AF who underwent multiple procedures, including direct current cardioversion (DCCV) and radiofrequency ablation. Over three different DCCV encounters, pre- and post-procedure ECLM scans were performed, and the results showed the localization and incomplete elimination of arrhythmic triggers post-DCCV, which were used as early indicators of AF recurrence. The 2nd case involved a 71-year-old male with paroxysmal AF who also underwent cardioversion and ablation procedures. Electromechanical cycle length mapping imaging demonstrated a progressive reduction and elimination of arrhythmia triggers after each encounter, resulting in long-term maintenance of sinus rhythm.
UNASSIGNED: The findings from this case series highlight the potential of ECLM as a non-invasive imaging tool for long-term monitoring and evaluating immediate and long-term treatment responses in AF patients. The integration of ECLM with standard echocardiograms holds promise in guiding clinical decisions and improving patient outcomes in managing atrial fibrillation.