Should all patients undergo transesophageal echocardiography before electrical cardioversion of atrial fibrillation?

Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195-5064.

The management of anticoagulant therapy in patients with atrial fibrillation undergoing electrical cardioversion remains controversial, largely because of inadequate studies demonstrating risk or benefit, a relatively inconvenient anticoagulation management strategy and the increasing use of transesophageal echocardiography. Recent investigations into the potential mechanisms involved in the development of thrombus and systemic embolism in patients undergoing electrical cardioversion of atrial fibrillation may provide insight into underlying predisposing factors, with subsequent modification of management strategies. Conventional wisdom suggests that preexisting thrombus is responsible for thromboembolic events after cardioversion. However, development of a thrombogenic milieu after cardioversion, particularly in the left atrial appendage, may also be an important predisposing factor. To protect against both potential mechanisms of embolization, these data support therapeutic anticoagulation for all patients with atrial fibrillation of > 2 days in duration from the time of, as well as after cardioversion for a total of 4 weeks, undergoing cardioversion, even in the absence of thrombus on echocardiography. Therefore, the role of transesophageal echocardiography in this setting should be to enable early cardioversion if atrial thrombus is excluded and to identify high risk patients with atrial thrombi so as to postpone cardioversion and avoid the risk of embolization. Ultimately, however, a controlled, randomized and prospective clinical trial will be required to compare conventional management with a transesophageal echocardiography-guided strategy.

This article has been cited by other articles:

				D. N. Salem, P. T. O'Gara, C. Madias, and S. G. Pauker Valvular and Structural Heart Disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, June 1, 2008; 133(6_suppl): 593S - 629S. [Abstract] [Full Text] [PDF]

				I. A. Paraskevaidis, T. Dodouras, D. Tsiapras, and D. T. Kremastinos Prediction of Successful Cardioversion and Maintenance of Sinus Rhythm in Patients With Lone Atrial Fibrillation Chest, February 1, 2005; 127(2): 488 - 494. [Abstract] [Full Text] [PDF]

				D. N. Salem, P. D. Stein, A. Al-Ahmad, H. I. Bussey, D. Horstkotte, N. Miller, and S. G. Pauker Antithrombotic Therapy in Valvular Heart Disease--Native and Prosthetic: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest, September 1, 2004; 126(3_suppl): 457S - 482S. [Abstract] [Full Text] [PDF]

				A. L. Klein, R. D. Murray, E. R. Becker, S. D. Culler, W. S. Weintraub, S. E. Jasper, E. A. Lieber, C. Apperson-Hansen, A. M. Heerey, R. A. Grimm, et al. Economic analysis of a transesophageal echocardiography-guided approach to cardioversion of patients with atrial fibrillation: The ACUTE economic data at eight weeks J. Am. Coll. Cardiol., April 7, 2004; 43(7): 1217 - 1224. [Abstract] [Full Text] [PDF]

				T Bartel and R Erbel Transoesophageal echocardiography for immediate and safe cardioversion in patients with atrial fibrillation Eur. Heart J., November 2, 2001; 22(22): 2041 - 2044. [PDF]

				A. L. Klein, R. D. Murray, and R. A. Grimm Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation J. Am. Coll. Cardiol., March 1, 2001; 37(3): 691 - 704. [Abstract] [Full Text] [PDF]

				D. N. Salem, D. Hartnett Daudelin, H. J. Levine, S. G. Pauker, M. H. Eckman, and J. Riff Antithrombotic Therapy in Valvular Heart Disease Chest, January 1, 2001; 119(2009): 207S - 219S. [Full Text] [PDF]

				J. R. Schlicht, R. C. Davis, K. Naqi, W. Cooper, and B. V. Rao Physician Practices Regarding Anticoagulation and Cardioversion of Atrial Fibrillation Arch Intern Med, February 12, 1996; 156(3): 290 - 294. [Abstract] [PDF]