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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

View larger version (20K): [in a new window]   Figure 1 Shock waveforms used in the study, across a 77 ohm resistance. This represents the median transthoracic impedance observed in the study. A monophasic damped sine (MDS) waveform (solid line) was compared with a biphasic truncated exponential (BTE) waveform (dashed line). Dashed line = BTE (150 J); solid line = MDS (150 J).

View larger version (54K): [in a new window]   Figure 2 Cumulative success in conversion of atrial fibrillation, according to the number of shocks delivered per protocol. See text for details of protocol. Greater success was observed using the biphasic waveform (hatched bar) with a total of one, two or three shocks (100 J, 150 J and 200 J). After the fourth shock (repeat 200 J biphasic or 360 J monophasic [dashed bar]), there was no significant difference in conversion success. *p < 0.0001.

View larger version (22K): [in a new window]   Figure 3 Number of shocks and cumulative delivered energy for monophasic and biphasic shocks. As shown in panel A, a median of three shocks were required using monophasic shocks, compared with a median of one shock for biphasic. Panel B demonstrates that the total energy delivered, likewise, was less for biphasic shocks.

View larger version (32K): [in a new window]   Figure 4 Dermal injury for all patients enrolled, according to shock waveform delivered. Injury, defined as moderate (erythema with tenderness) or severe (blistering) was more frequent in those receiving monophasic (dashed bar) shocks (p < 0.0001). See text for further details. Hatched bar = biphasic.