1. { Cardioversion turns 50 Seth Bilazarian MD Private practice theheart.org

2. 50 years ago today, Lown et al described cardioversion as a "new electronic method" http://www.nejm.org/doi/full/10.1056/NEJM196308152690701 "A new electronic method"

3. Atrial fibrillation: Is the most prevalent of the chronic rhythm disorders of the heart Increased tendency to systemic and pulmonary emboli Impairs cardiac performance New method was designated "cardioversion" http://www.nejm.org/doi/full/10.1056/NEJM196308152690701 A lot hasn't changed

4. The method of terminating AF has not changed since Frey introduced quinidine in 1918 Quinidine commonly produces untoward reactions that range from gastrointestinal upset to sudden death. The American literature alone has documented 26 deaths up to 1956 http://www.nejm.org/doi/full/10.1056/NEJM196308152690701 Some things have changed

5. Single limitation is the need for anesthesia. Patient is usually unconscious for 2-5 minutes, procedure completed in 15-30 minutes. Single limitation is the need for anesthesia. Patient is usually unconscious for 2-5 minutes, procedure completed in 15-30 minutes. Cardioversion is safe: Cardioversion is safe: When DC pulse is synchronized to discharge outside the ventricular vulnerable period, the possibility of fibrillation is entirely prevented When DC pulse is synchronized to discharge outside the ventricular vulnerable period, the possibility of fibrillation is entirely prevented EKG before and after reversion showed no change in the ventricular complex. EKG before and after reversion showed no change in the ventricular complex. In a few patients persistent sinus bradycardia, episodic nodal rhythm and atrioventricular dissociation occurred. These either were the result of overdigitalization or perhaps represented depression or pre-existing injury of the sinus node. In a few patients persistent sinus bradycardia, episodic nodal rhythm and atrioventricular dissociation occurred. These either were the result of overdigitalization or perhaps represented depression or pre-existing injury of the sinus node. Definite but small risk of embolism with any reversion of AF to normal rhythm. Therapy is carried out for a period of 3 weeks before and 1 week after cardioversion. Definite but small risk of embolism with any reversion of AF to normal rhythm. Therapy is carried out for a period of 3 weeks before and 1 week after cardioversion. What else hasn't changed? http://www.nejm.org/doi/full/10.1056/NEJM196308152690701

6. "This procedure has been designated as cardioversion, and the instrument is referred to as a cardioverter." One name caught on, one didn't http://www.nejm.org/doi/full/10.1056/NEJM196308152690701

7. Source: 2008 to 2012 Medicare Physician Fee Schedule, national average (unadjusted) rates. 2008 to 2012 Medicare Physician Claims Database (100% sample). Created by Dr Seth Bilazarian Medicare claims data analyses

8. Source: 2008 to 2012 Medicare Physician Fee Schedule, national average (unadjusted) rates. 2008 to 2012 Medicare Physician Claims Database (100% sample). Created by Dr Seth Bilazarian Medicare claims data analyses

9. Source: 2008 to 2012 Medicare Physician Fee Schedule, national average (unadjusted) rates. 2008 to 2012 Medicare Physician Claims Database (100% sample). Created by Dr Seth Bilazarian Medicare claims data analyses

10. Decline in our use of cardioversion Source: Dr Seth Bilazarian

11. Contributing to the numbers Growing because: AF increasing with aging population and increase in obesity Ease of TEE and cardioversion "Part" of the AF ablation treatment algorithm Not growing as fast: Comfort with rate control alone in asymptomatic patients Use of ibutilide (Corvert) as an alternative

12. Management of AF with the rhythm-control strategy offers: No survival advantage over the rate-control strategy Potential advantages, such as a lower risk of adverse drug effects Anticoagulation should be continued in this group of high-risk patients AFFIRM Trial 12/15/2002 http://www.nejm.org/doi/full/10.1056/NEJMoa021328

13. Rate control: Safe, negative chronotropic drugs, anticoagulation Symptoms? AV nodal ablation and pacing Rhythm control: Drugs Cardioversion Drugs then cardioversion AF ablation Options for the AF Patient

14. Procedure lasts 90 minutes to four hours 30% to 40% chance it will need to be repeated Works about 80% of the time for three to five years but higher likelihood of recurrence beyond five years Procedure-related risks Will not change the need for anticoagulation This is not curative, it's palliative AF ablation: Pre–EP-consult consent

15. Effective nontoxic drug therapy for maintenance of sinus rhythm. We have: Effective and toxic Ineffective and safe Ineffective and toxic Better definition of who will best benefit by AF ablation (predicted to be $2.4 billion in 2021) and improvement in acute success and durability Still unmet need