Key result
TEE-guided cardioversion provides a safe alternative to conventional anticoagulation, expediting early cardioversion in AF.
Why the study?
A transesophageal echocardiography-guided strategy has been proposed as an alternative to conventional anticoagulation for cardioversion in AF patients to potentially lower stroke and bleeding events.
Does a transesophageal echocardiography (TEE)-guided strategy with short-term anticoagulation lower stroke and bleeding events compared to conventional anticoagulation in patients with atrial fibrillation undergoing cardioversion?
Does a transesophageal echocardiography (TEE)-guided strategy with short-term anticoagulation lower stroke and bleeding events compared to conventional anticoagulation in patients with atrial fibrillation undergoing cardioversion?
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“It is common practice to perform cardioversion of AF/AFI without a TEE if the patient has been on adequate oral anticoagulation for more than three weeks. This study suggests this practice runs the risk of cardioverting four out of 100 patients with a thrombus.”
“TEE is a very nice technique and a logistic option, but it is not necessary. TEE is the quicker approach—there's absolutely no question about it. But if you have the time, I prefer the conventional approach.”
“Prystowsky pointed out some major pitfalls with the routine use of TEE in patients with AF. I believe he made some very cogent points about the fact that TEE should never be considered routine and that it's actually most important to provide adequate anticoagulation for all patients undergoing cardioversion.”
A TEE-guided approach with short-term anticoagulation is a safe, clinically effective alternative to conventional prolonged anticoagulation, particularly when early cardioversion is beneficial.
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.
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Klein et al. (2001) conducted a review in Atrial fibrillation. Transesophageal echocardiography (TEE)-guided cardioversion vs. Conventional anticoagulation was evaluated. TEE-guided cardioversion with short-term anticoagulation is a safe and effective alternative to conventional approaches for lowering embolic risk and expediting early cardioversion in AF patients.
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