Ali Vafa

Christian Sohns

CT Buschmann

Dirk Vollmann

Joachim Seegers

Lars Lüthje

Marc Dorenkamp

Markus Zabel

P Kirchhof

RE Kerber

W Ahmar

English

PubMed

Vollmann, Dirk

Luethje, Lars

Seegers, Joachim

Sohns, Christian

Dorenkamp, Marc

Vafa, Ali

Zabel, Markus

GRO.publications (Univ. Göttingen)

Sternal fracture after elective electrical cardioversion of atrial fibrillation

Springer - Publisher Connector

Crossref

Clinical Research in Cardiology

LETTER TO THE EDITORS
Sternal fracture after elective electrical cardioversion of atrial
fibrillation
Dirk Vollmann • Lars Lu¨thje • Joachim Seegers •
Christian Sohns • Marc Dorenkamp •
Ali Vafa • Markus Zabel
Received: 23 August 2010 / Accepted: 20 October 2010 / Published online: 9 November 2010
 The Author(s) 2010. This article is published with open access at Springerlink.com
Sirs:
A 69-year-old female was admitted to our institution for
ablative treatment of paroxysmal atrial fibrillation (AF)
after her amiodarone medication had to be discontinued
due to visual side effects. She suffered from intermittent
palpitations and had a history of hypertension, coronary
artery disease, and ICD implantation for ventricular
tachycardia. On echocardiography her left atrial diameter
was found to be normal and her left ventricular ejection
fraction mildly reduced. One day after catheter-based
ablation and circumferential pulmonary vein isolation the
patient experienced a symptomatic AF recurrence. After an
internal cardioversion attempt with a synchronized 30-J
ICD shock had failed, external cardioversion with an
anterior–posterior (AP) electrode position was attempted,
utilizing a hand-held paddle to apply firm pressure to the
sternal electrode during application of a 150-and a 200-J
biphasic shock. Sinus rhythm, however, was not main-
tained due to immediate recurrences of AF. As the patient
recovered from sedation, she complained of a new, sharp
pre-sternal chest pain that increased with deep breathing.
On physical examination of the chest there was pre-sternal
tenderness without crepitation on palpation. Findings were
interpreted as an irritation of the musculoskeletal tissue
from direct current application, and pain medication was
prescribed. Over the following days, however, symptoms
persisted. After conventional chest X-ray findings did not
explain the symptoms, a computed tomography (CT) of the
chest revealed a fracture of the sternal body, approximately
2.5 cm below the manubriosternal joint (Fig. 1). The
patient had no history of prior chest trauma, and there were
no overt medical conditions predisposing to fractures. Dual
energy X-ray absorptiometry revealed normal bone mineral
density, thereby ruling out osteoporosis. Conservative
treatment with a chest bandage was added and pain med-
ication was continued since the fracture was stable and not
significantly dislocated.
Since decades, electrical cardioversion is very fre-
quently and widely applied to terminate persistent AF.
Recent randomized controlled trials suggest that an AP
electrode position [1] and the use of hand-held paddles [2]
optimize cardioversion success rates without compromis-
ing on patient safety. The present case illustrates that
application of this electrode configuration may carry a risk
of sternal fracture, a complication usually caused by blunt
chest trauma (e.g., traffic or sports accidents), but hitherto
unrelated to electrical cardioversion of AF. Iatrogenic
sternal fracture is known to occur after cardio-pulmonary
resuscitation due to chest compression [3] or application of
a pre-cordial thumb [4]. In the present case, electrical
cardioversion caused sternal fracture because the elec-
trodes for direct current application were attached in an AP
position and because a hand-held paddle was pressed to the
sternum. Manual application of firm pressure to the anterior
sternal electrode enhances electrode–tissue contact and
reduces transthoracic resistance, thereby increasing current
D. Vollmann  L. Lu¨thje  J. Seegers  C. Sohns 
M. Dorenkamp  M. Zabel
Department of Cardiology and Pneumology, University Medical
Centre, Georg-August-Universita¨t, Go¨ttingen, Germany
A. Vafa
Department of Diagnostic Radiology, University Medical
Centre, Georg-August-Universita¨t, Go¨ttingen, Germany
D. Vollmann (&)
Abteilung Kardiologie, Schwerpunkt Klinische
Elektrophysiologie, Universita¨tsmedizin
der Georg-August-Universita¨t Go¨ttingen,
Robert-Koch-Strasse 40, 37075 Go¨ttingen, Germany
e-mail: d.vollmann@med.uni-goettingen.de
123
Clin Res Cardiol (2011) 100:261–262
DOI 10.1007/s00392-010-0251-6
flow to the heart and defibrillation success [5]. With an AP
electrode position and hand-held paddles, however, pro-
nounced pressure to the sternum may cause sternal fracture,
as illustrated by the present case. Of note, this complication
occurred in the absence of conditions that predispose to
fractures, e.g., osteoporosis, and despite the fact that the
procedure was carried out by a physician with substantial
experience in electrical cardioversion.
In conclusion, this case illustrates that sternal fracture
should be considered as a potential complication of elec-
trical cardioversion when an AP electrode position and
hand-held paddles are utilized. With this electrode con-
figuration, excessive pre-sternal pressure to the anterior
electrode should be avoided.
Conflict of interest The authors declare that they have no conflict
of interest.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
References
1. Kirchhof P, Eckardt L, Loh P, Weber K, Fischer RJ, Seidl KH et al
(2002) Anterior–posterior versus anterior–lateral electrode posi-
tions for external cardioversion of atrial fibrillation: a randomised
trial. Lancet 360(9342):1275–1279
2. Kirchhof P, Monnig G, Wasmer K, Heinecke A, Breithardt G,
Eckardt L et al (2005) A trial of self-adhesive patch electrodes and
hand-held paddle electrodes for external cardioversion of atrial
fibrillation (MOBIPAPA). Eur Heart J 26(13):1292–1297
3. Buschmann CT, Tsokos M (2009) Frequent and rare complications
of resuscitation attempts. Intensive Care Med 35(3):397–404
4. Ahmar W, Morley P, Marasco S, Chan W, Aggarwal A (2007)
Sternal fracture and osteomyelitis: an unusual complication of a
precordial thump. Resuscitation 75(3):540–542
5. Kerber RE, Grayzel J, Hoyt R, Marcus M, Kennedy J (1981)
Transthoracic resistance in human defibrillation. Influence of body
weight, chest size, serial shocks, paddle size and paddle contact
pressure. Circulation 63(3):676–682
Fig. 1 Chest CT with
intravenous administration
of contrast material showing
fracture in the upper portion
of the sternal body (arrow)
262 Clin Res Cardiol (2011) 100:261–262
123


A trial of self-adhesive patch electrodes and hand-held paddle electrodes for external cardioversion of atrial ﬁbrillation (MOBIPAPA).

Aggarwal A

Frequent and rare complications of resuscitation attempts.

Seidl KH et al (2002) Anterior–posterior versus anterior–lateral electrode positions for external cardioversion of atrial ﬁbrillation: a randomised trial.

Transthoracic resistance in human deﬁbrillation. Inﬂuence of body weight, chest size, serial shocks, paddle size and paddle contact pressure.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3040824

Sternal fracture after elective electrical cardioversion of atrial fibrillation

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