What is your approach during DCCV if you have an obese patient with atrial fibrillation refractory to up to 3, 360 J shocks?

To some degree it depends on what happened with the first three shocks, (I would have applied pressure to shorten the AP diameter for the second and/or third).

If the patient converted but it didn't stick, I would consider AAD loading followed by a repeat procedure.

If the patient did not appear to convert, I would go with double vector DCCV with two shocks simultaneously. I probably have to do this a couple times a year.

The main question is are we sure there is a cardioversion and not just a quick recurrence. If it is a recurrence, would use AAD like amio. If not capturing myocardium, would use another vector or use 2 synced shocks (and 360 biphasic if you have that).

Agree with the above comments. I also would consider the addition of ibutilide with mag. The "dueling defibrillator" technique works, but the more important question is if sinus rhythm in such obese patients will be maintained long term. How about rate control, and weight loss (by whatever means -GLP1 agonists/bariatric surgery) with a shared decision on the perceived benefits of sinus rhythm for the individual patient?

Assuming the question is not about management of ERAF and the patient did NOT convert at all, we are dealing with defibrillation threshold, not maintaining of SR post CV.

Then, you have to apply science to improve the current density going through the chamber you are trying to defibrillate (for AFIB, it is mainly LA).

First step is positioning patches correctly, you have to "sandwich" LA between the anterior and posterior patch, very often the heart sits lower than you think in an obese patient. In difficult cases, use fluoroscopy to place patches correctly to make sure the LA is right in between the anterior and posterior patch.

Second (already mentioned), put pressure on the anterior patch to decrease the distance between the anterior an...

No point in doing repeated cardioversions. These patients simply do not hold NSR.

Choose a different strategy.

We’re fortunate to have a 360 biphasic device which generally works for obese patients. If not working the first time, I apply pressure on the second attempt. If there is conversion and reversion, I would stop at 3 and add AED for a couple of weeks then try DCCV again.

If no conversion at all, am just end up in perm AF as most of those folks won’t stay out regardless.

I had better luck with biphasic.

Try anterolateral pad position.

I open with AP placement of the pads, so if the patient doesn't cardiovert with 360J x 2:

• If the patient converts but it doesn't stick, consider AED and revisiting a cardioversion.
• If they don't convert then I will place a second set of pads in the sternoapical position to shock with 720 Joules (combined).
• If the patient doesn't convert (or does but it doesn't stick) with that (2-3 attempts), consider AED and revisiting a cardioversion.

Generally, I would first load with Amiodarone AND ranolazine, the combination is much more effective. If true failure and not ERAF, internal cardioversion is "old-timey" but highly effective, and virtually never fails to convert. From my experience, a successful internal CV appears to be more effective in maintaining sinus than a successful external, although certainly an anecdotal observation. Over the years, I have done this many times with never any complications. Since the incorporation of biphasic, the necessity of this approach has diminished, however.