Factors determining elective cardioversion preceded with transesophageal echocardiography: two cardiology centres’ experiences

INTRODUCTION: Although guidelines endorse cardioversion after adequate non-vitamin K antagonist oral anticoagulant (NOAC) treatment without prior transesophageal echocardiography (TEE), the majority of patients still undergo this examination. OBJECTIVES: The aim of this study was to assess factors determining the decision to perform TEE in patients with atrial fibrillation (AF) who are eligible for elective cardioversion. PATIENTS AND METHODS: In this study, we evaluated the medical records of consecutive patients with AF who were admitted for elective cardioversion after prior NOAC treatment. RESULTS: Of a total of 668 patients included in the study, 362 individuals (54%) underwent TEE before cardioversion. In the univariable analysis, paroxysmal AF, hypertension, coronary artery disease (CAD), thromboembolic events, a history of percutaneous coronary intervention, a history of bleeding, left ventricular ejection fraction, left ventricular end‑ diastolic diameter, a reduced dose of NOACs, hemoglobin levels, impaired renal filtration, and a high CHA2DS2‑VASc score were significant predictors of the decision to perform TEE. In the multivariable logistic regression analysis, a history of CAD, bleeding, and stroke / transient ischemic attack / thromboembolism remained independent predictors of referring a patient for TEE (odds ratio [OR], 3.92, P <0.001; OR, 7.92, P <0.001; and OR, 2.36, P = 0.02, respectively). In contrast, paroxysmal AF (OR, 0.31; P = 0.02) and hypertension (OR, 0.28; P <0.001) were indicators of refraining from TEE. CONCLUSIONS: Transesophageal echocardiography before cardioversion was more frequently performed in patients with a history of CAD, bleeding, or thromboembolic events. Patients with paroxysmal AF and hypertension more often received cardioversion without prior TEE.