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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

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