This Article Figures Only Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Klein, A. L. Articles by Grimm, R. A. Search for Related Content PubMed PubMed Citation Articles by Klein, A. L. Articles by Grimm, R. A.

REVIEW ARTICLE

Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation

^a Cardiovascular Imaging Section, Department of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA

Manuscript received April 19, 1999; revised manuscript received October 6, 2000, accepted November 10, 2000.

Reprint requests and correspondence: Dr. Allan L. Klein, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Department of Cardiology/Desk F-15, Cleveland, Ohio 44195
kleina{at}ccf.org

Electrical cardioversion of patients with atrial fibrillation (AF) is frequently performed to relieve symptoms and improve cardiac performance. Patients undergoing cardioversion are treated conventionally with therapeutic anticoagulation for three weeks before and four weeks after cardioversion to decrease the risk of thromboembolism. A transesophageal echocardiography (TEE)-guided strategy has been proposed as an alternative that may lower stroke and bleeding events. Patients without atrial cavity thrombus or atrial appendage thrombus by TEE are cardioverted on achievement of therapeutic anticoagulation, whereas cardioversion is delayed in higher risk patients with thrombus. The aim of this review is to discuss the issues and controversies associated with the management of patients with AF undergoing cardioversion. We provide an overview of the TEE-guided and conventional anticoagulation strategies in light of the recently completed Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) clinical trial. The two management strategies comparably lower the patient’s embolic risk when the guidelines are properly followed. The TEE-guided strategy with shorter term anticoagulation may lower the incidence of bleeding complications and safely expedite early cardioversion. The inherent advantages and disadvantages of both strategies are presented. The TEE-guided approach with short-term anticoagulation is considered to be a safe and clinically effective alternative to the conventional approach, and it is advocated in patients in whom earlier cardioversion would be clinically beneficial.

Abbreviations and Acronyms   ACC = American College of Cardiology   AHA = American Heart Association   ACCP = American College of Chest Physicians   ACUTE = Assessment of Cardioversion Using Transesophageal Echocardiography trial   AF = atrial fibrillation   DC = direct current   INR = international normalized ratio   TEE = transesophageal echocardiography   TTE = transthoracic echocardiography

This article has been cited by other articles:

				M. J. Garcia Detection of left atrial appendage thrombus by cardiac computed tomography: a word of caution. J. Am. Coll. Cardiol. Img., January 1, 2009; 2(1): 77 - 79. [Full Text] [PDF]

				L. F Tops, E. E van der Wall, M. J Schalij, and J. J Bax Multi-modality imaging to assess left atrial size, anatomy and function Heart, November 1, 2007; 93(11): 1461 - 1470. [Abstract] [Full Text] [PDF]

				D. Gupta, M. J Earley, G. A Haywood, L. Richmond, M. Fitzgerald, P. Kojodjojo, S. C Sporton, N. S Peters, P. Broadhurst, R. J Schilling, et al. Can atrial fibrillation with a coarse electrocardiographic appearance be treated with catheter ablation of the tricuspid valve-inferior vena cava isthmus? Results of a multicentre randomised controlled trial Heart, June 1, 2007; 93(6): 688 - 693. [Abstract] [Full Text] [PDF]

				K. Marchiondo Transesophageal Imaging and Interventions: Nursing Implications Crit. Care Nurse, April 1, 2007; 27(2): 25 - 35. [Full Text] [PDF]

				A. L. Klein, S. E. Jasper, W. E. Katz, J. F. Malouf, L. A. Pape, M. F. Stoddard, C. Apperson-Hansen, E. A. Lieber, and The ACUTE II Steering and Publications Committee F The use of enoxaparin compared with unfractionated heparin for short-term antithrombotic therapy in atrial fibrillation patients undergoing transoesophageal echocardiography-guided cardioversion: Assessment of Cardioversion Using Transoesophageal Echocardiography (ACUTE) II randomized multicentre study Eur. Heart J., December 1, 2006; 27(23): 2858 - 2865. [Abstract] [Full Text] [PDF]

				O. M. Wazni, H.-M. Tsao, S.-A. Chen, H.-H. Chuang, W. Saliba, A. Natale, and A. L. Klein Cardiovascular Imaging in the Management of Atrial Fibrillation J. Am. Coll. Cardiol., November 21, 2006; 48(10): 2077 - 2084. [Abstract] [Full Text] [PDF]

				M. Strandberg, M.J. P. Raatikainen, M. Niemela, M. Luotolahti, J. Hartiala, and K.E. J. Airaksinen Clinical practicality and predictive value of transoesophageal echocardiography in early cardioversion of atrial fibrillation Europace, June 1, 2006; 8(6): 408 - 412. [Abstract] [Full Text] [PDF]

				S Achenbach, D Sacher, D Ropers, K Pohle, U Nixdorff, U Hoffmann, G Muschiol, F A Flachskampf, and W G Daniel Electron beam computed tomography for the detection of left atrial thrombi in patients with atrial fibrillation Heart, December 1, 2004; 90(12): 1477 - 1478. [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]

				R. L. McNamara, L. J. Tamariz, J. B. Segal, and E. B. Bass Management of Atrial Fibrillation: Review of the Evidence for the Role of Pharmacologic Therapy, Electrical Cardioversion, and Echocardiography Ann Intern Med, December 16, 2003; 139(12): 1018 - 1033. [Abstract] [Full Text] [PDF]

				R. W Troughton, C. R Asher, and A. L Klein The role of echocardiography in atrial fibrillation and cardioversion Heart, December 1, 2003; 89(12): 1447 - 1454. [Full Text] [PDF]

				A. Palinkas, E. Antonielli, E. Picano, A. Pizzuti, A. Varga, B. Nyuzo, J.M. Alegret, A. Bonzano, M. Tanga, A. Coppolino, et al. Clinical value of left atrial appendage flow velocity for predicting of cardioversion success in patients with non-valvular atrial fibrillation Eur. Heart J., December 1, 2001; 22(23): 2201 - 2208. [Abstract] [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]

				K. P. Anderson, P.J. Devereaux, S. Yusuf, G. Barbaro, M. Soldini, G. Giancaspro, J. R. Stratton, A. L. Klein, R. D. Murray, and R. A. Grimm Transesophageal Echocardiography to Guide Cardioversion in Patients with Atrial Fibrillation N. Engl. J. Med., September 13, 2001; 345(11): 837 - 839. [Full Text] [PDF]

				P. B. Sparks and J. M. Kalman Is atrial flutter a risk factor for stroke? J. Am. Coll. Cardiol., September 1, 2001; 38(3): 785 - 788. [Full Text] [PDF]