Silent cerebral ischemia after anticoagulation- or TEE-guided cardioversion: The randomized AFTER-CV trial

Silent cerebral ischemia after elective cardioversion is incompletely characterized, and randomized MRI-based evidence comparing anticoagulation-guided and transesophageal echocardiography (TEE)-guided pathways is limited. AFTER-CV was a prospective, randomized, open-label, parallel-group trial of 112 patients undergoing elective cardioversion, assigned 1:1 by sealed-envelope randomization to at least 3 weeks of therapeutic oral anticoagulation or a TEE-guided strategy. Brain diffusion-weighted magnetic resonance imaging (DWI-MRI) was performed before and 1 week after cardioversion and was interpreted by an experienced radiologist blinded to treatment allocation. Clinical thromboembolic and bleeding outcomes were assessed during 2 years of follow-up. New silent cerebral ischemic lesions were detected in 2 of 56 patients (3.6%) in the anticoagulation-guided group and 4 of 56 (7.1%) in the TEE-guided group (absolute risk difference, -3.6 percentage points; 95% CI, -13.7 to 6.0; Fisher exact p = 0.68). No statistically significant between-group differences were detected for the reported long-term clinical efficacy, bleeding, or composite outcomes. New MRI-detected cerebral ischemic lesions were uncommon in both randomized groups. The small sample, few imaging events, single-center design, and predominantly warfarin-treated cohort preclude conclusions of equivalence or non-inferiority.