Atrial fibrillation is a common clinical disease especially in the elderly and in patients with organic heart disease. Electrical cardioversion is the first choice therapeutic approach for patients in which sinus rhythm could improve the quality of life and where the maintenance of sinus rhythm is considered likely. There are different techniques to perform an electrical cardioversion, each with specific indications, advantages, and limitations. The method most frequently used to restore sinus rhythm is external direct current cardioversion; however, this technique has some disadvantages, since it requires a high energy and usually general anesthesia. Esophageal cardioversion is an alternative method to obtain restoration of sinus rhythm, warranting acute and long-term results absolutely comparable with those obtained by the conventional transthoracic technique, especially in obese and COPD patients with high thoracic impedance for whom the standard technique may be less effective. 1. Introduction Atrial fibrillation is a common clinical disease especially in the elderly (3–5% of the population over 60 years), and in patients with organic heart disease (70–80%) [1]. Electrical cardioversion (ECV) is the first-choice therapeutic approach for patients in which sinus rhythm could improve the quality of life and where the maintenance of sinus rhythm is considered likely. This technique compared with pharmacological cardioversion shows some important advantages: immediate effect, high success rate, and safety in hemodynamically unstable patients. There are three main groups of patients in whom sinus rhythm is a benefit:(i)patients with severe symptoms during the arrhythmia,(ii)patients with recent-onset atrial fibrillation in order to prevent electrical remodeling,(iii)patients with structural heart disease, such as hypertension and ventricular hypertrophy, which can achieve a significant hemodynamic improvement by restoring sinus rhythm. There are several techniques to perform an electrical cardioversion, each with specific indications, advantages, and limitations. The method most often used to restore sinus rhythm is the external direct current cardioversion; however, this technique has some disadvantages, since it requires a high energy and usually general anesthesia. 2. Esophageal Electrical Cardioversion This type of cardioversion may overcome some limitations of the standard external cardioversion. In some patients, the high thoracic impedance, due to emphysema or to a high body surface, changes the transmission of direct current shock through the
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