Key result
Double consecutive electrical countershock yields ~2.2-fold higher survival to hospital discharge in refractory VF.
Why the study?
Strategies using two consecutive biphasic shocks for refractory VF and AF have shown varying evidence of success, prompting a synthesis of outcome data on double consecutive electrical countershock across both arrhythmias.
Does double consecutive electrical countershock (DCEC) improve survival, neurological outcomes, and arrhythmia termination compared to standard single-shock countershock in patients with refractory ventricular fibrillation or atrial fibrillation?
Does double consecutive electrical countershock (DCEC) improve survival, neurological outcomes, and arrhythmia termination compared to standard single-shock countershock in patients with refractory ventricular fibrillation or atrial fibrillation?
Answers are grounded in this paper and cite their sources.
Unifying double sequential external defibrillation for VF and dual direct-current cardioversion for AF under double consecutive electrical countershock (DCEC) highlights consistent randomized evidence of benefit in refractory VF and high-BMI AF, while explaining neutral observational findings as confounding by salvage use.
BACKGROUND: Recent strategies for refractory ventricular fibrillation (VF) and atrial fibrillation (AF) employ two consecutive, biphasic shocks with varying evidence of success. Due to their electrophysiological similarities, the strategies used for VF and AF can be collectively referred to as double consecutive electrical countershock (DCEC). This review aims to identify and synthesize outcome data on the effectiveness of DCEC across both VF and AF. METHODS: This narrative critical review with systematic search methods was conducted in accordance with the PRISMA checklist where applicable. From 672 identified articles, 262 duplicates were removed and 410 screened; 316 articles irrelevant to the study were excluded. Of 94 sought for retrieval, 8 were unavailable and 67 failed full-text screening, leaving 19 included articles (16 VF, 3 AF). All 19 underwent risk-of-bias assessment (RoB2, ROBINS-I, or AMSTAR-2) and data extraction. RESULTS: Full-scale randomized controlled trials (RCTs) showed low risk of bias, pilot RCTs had "some concerns," observational studies carried serious risk of bias, and meta-analyses showed "low confidence." High-quality randomized evidence showed improved primary outcomes for DCEC in both refractory VF (survival to discharge, return of spontaneous circulation, good neurological outcome) and high-BMI AF (arrhythmia termination). Non-randomized observational studies predominantly showed non-statistically significant differences. CONCLUSIONS: DCEC shows potential to improve arrhythmia termination in refractory VF and high-BMI AF. Randomized evidence supports its efficacy, while observational findings remain neutral due to confounding. Success in high-BMI AF supports elevated BMI as a hypothetical indication for DCEC in VF.
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Ray et al. (2026) conducted a review in Refractory ventricular fibrillation (VF) and atrial fibrillation (AF). Double consecutive electrical countershock (DCEC), encompassing double sequential external defibrillation (DSED) for VF and dual direct-current cardioversion (dual-DCCV) for AF vs. Standard single-shock defibrillation or standard single-shock cardioversion was evaluated on Survival to hospital discharge (SHD), return of spontaneous circulation (ROSC), and good neurological outcome (GNO; mRS <= 2) for VF; arrhythmia termination (AT) for AF. Double consecutive electrical countershock improved survival to hospital discharge in refractory VF (RR 2.21) and arrhythmia termination in high-BMI AF (OR 6.7) in randomized trials.
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