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CLINICAL STUDY: ATRIAL FIBRILLATION

Embolic events in patients with atrial fibrillation and effective anticoagulation: value of transesophageal echocardiography to guide direct-current cardioversion

Final results of the Ludwigshafen Observational Cardioversion Study

^* Department of Cardiology, Herzzentrum Ludwigshafen, Ludwigshafen, Germany

Manuscript received October 10, 2001; revised manuscript received January 24, 2002, accepted February 6, 2002.

^* Reprint requests and correspondence: Dr. Karlheinz Seidl, Herzzentrum Ludwigshafen, Bremserstrasse 79, 67063 Ludwigshafen, Germany.
Seidlk{at}klilu.de

OBJECTIVES: The primary objective was to evaluate the usefulness of transesophageal echocardiography (TEE)-guided cardioversion to prevent thromboembolic complications in patients with atrial fibrillation (AF) and effective anticoagulation (International Normalized Ratio of 2 or 3) at least three weeks before cardioversion.

BACKGROUND: Transesophageal echocardiography has been proposed as a method of screening patients for left atrial thrombi before direct-current cardioversion of AF. The usefulness of TEE as a screening tool has always been evaluated in patients without long-term anticoagulation before cardioversion.

METHODS: This prospective, single-center, observational study, performed on an intention-to-cardiovert basis, comprised 1,076 consecutive, unselected patients with AF. The initial two years were designed to be the control phase, during which the conventional approach was used. After that, cardioversion guided by TEE was performed in consecutive patients.

RESULTS: The prevalence of left atrial thrombi was 7.7% in patients with persistent AF and effective anticoagulation. During the first four weeks after electrical cardioversion, six thromboembolic complications were observed in patients in whom the TEE-guided approach was employed (6 [0.8%] of 719 patients), compared with three thromboembolic complications in patients in whom the conventional approach was used (3 [0.8%] of 357 patients). None of the patients in whom electrical cardioversion was not performed experienced an embolic event.

CONCLUSIONS: There were no differences in the rate of embolic events between the two treatment groups. In patients with AF and effective anticoagulation, TEE-guided electrical cardioversion does not reduce the embolic risk. However, TEE revealed left atrial thrombi in 7.7% of patients with AF and effective anticoagulation, before direct-current cardioversion.

Abbreviations and Acronyms   ACUTE   Assessment of Cardioversion Using Transesophageal Echocardiography study   AF   atrial fibrillation   INR   International Normalized Ratio   LV   left ventricular   TEE   transesophageal echocardiography   TTE   transthoracic echocardiography

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