CLINICAL STUDY
Biphasic versus monophasic shock waveform for conversion of atrial fibrillation
The results of an international randomized, double-blind multicenter trial
Richard L. Page, MD, FACC*,*,
Richard E. Kerber, MD, FACC ,
James K. Russell, PhD ,
Tom Trouton, MD ,
Johan Waktare, MD||,
Donna Gallik, MD, FACC¶,
Jeff E. Olgin, MD, FACC#,
Philippe Ricard, MD**,
Gavin W. Dalzell, MD,
Ramakota Reddy, MD, FACC,
Ralph Lazzara, MD, FACC,
Kerry Lee, PhD||||,
Mark Carlson, MD, FACC¶¶,
Blair Halperin, MD, FACC##,
Gust H. Bardy, MD, FACC*** BiCard Investigators
* Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
Department of Internal Medicine, University of Iowa Hospital, Iowa City, Iowa, USA
Research Department, Philips Medical Systems, Heartstream, Seattle, Washington, USA
Cardiology Department, Antrim Area Hospital, Antrim, Northern Ireland
|| Cardiological Sciences, St. George’s Hospital, London, United Kingdom
¶ Cedars Sinai Medical Center, Los Angeles, California, USA
# Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
** Service de Cardiologie, Hospital Nord, Marseille, France
Department of Cardiology, Royal Victoria Hospital, Belfast, Northern Ireland
Cardiology Department, Wright-Patterson Air Force Base, Dayton, Ohio, USA
Health Sciences, University of Oklahoma, Oklahoma City, OklahomaUSA
|||| Duke Clinical Research Institute, Durham, North Carolina, USA
¶¶ Division of Cardiology, University Hospitals of Cleveland, Cleveland, Ohio, USA
## Oregon Health & Sciences University, Portland, Oregon, USA
*** Department of Medicine, University of Washington, Seattle, Washington, USA
Manuscript received November 13, 2001;
revised manuscript received March 12, 2002,
accepted April 1, 2002.
* Reprint requests and correspondence: Dr. Richard L. Page, Department of Internal Medicine (Cardiology, Clinical Cardiac Electrophysiology), University of Texas Southwestern Medical Center, Room CS7.102, 5323 Harry Hines Boulevard, Dallas, Texas 75390-9047, USA.
rpage{at}parknet.pmh.org
OBJECTIVES: This study compared a biphasic waveform with a conventional monophasic waveform for cardioversion of atrial fibrillation (AF).
BACKGROUND: Biphasic shock waveforms have been demonstrated to be superior to monophasic shocks for termination of ventricular fibrillation, but data regarding biphasic shocks for conversion of AF are still emerging.
METHODS: In an international, multicenter, randomized, double-blind clinical trial, we compared the effectiveness of damped sine wave monophasic versus impedance-compensated truncated exponential biphasic shocks for the cardioversion of AF. Patients received up to five shocks, as necessary for conversion: 100 J, 150 J, 200 J, a fourth shock at maximum output for the initial waveform (200 J biphasic, 360 J monophasic) and a final cross-over shock at maximum output of the alternate waveform.
RESULTS: Analysis included 107 monophasic and 96 biphasic patients. The success rate was higher for biphasic than for monophasic shocks at each of the three shared energy levels (100 J: 60% vs. 22%, p < 0.0001; 150 J: 77% vs. 44%, p < 0.0001; 200 J: 90% vs. 53%, p < 0.0001). Through four shocks, at a maximum of 200 J, biphasic performance was similar to monophasic performance at 360 J (91% vs. 85%, p = 0.29). Biphasic patients required fewer shocks (1.7 ± 1.0 vs. 2.8 ± 1.2, p < 0.0001) and lower total energy delivered (217 ± 176 J vs. 548 ± 331 J, p < 0.0001). The biphasic shock waveform was also associated with a lower frequency of dermal injury (17% vs. 41%, p < 0.0001).
CONCLUSIONS: For the cardioversion of AF, a biphasic shock waveform has greater efficacy, requires fewer shocks and lower delivered energy, and results in less dermal injury than a monophasic shock waveform.
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Abbreviations and Acronyms
| | AF | | atrial fibrillation | | ANOVA | | analysis of variance | | ECG | | electrocardiogram/electrocardiographic | | LA | | left atrial | | NYHA | | New York Heart Association |
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