Transesophageal echocardiography before atrial fibrillation ablation: To do or not to do?

Transcatheter ablation (TCA) of atrial fibrillation (AF) has reached significant goals in the recent years, allowing stable sinus rhythm in the majority of treated patients independently by the available energy sources (thermal or not) that are implemented for rhythm control 1.Such results would have probably not been achieved without advanced echocardiographic imaging that evolved from transthoracic to transesophageal echocardiography (TEE), together with computed tomography, magnetic resonance, until left atrium (LA) and pulmonary veins tridimensional digital reconstruction through electroanatomic mapping.LA mechanical function, sinus rhythm and embolic stroke are the main considerations when a certain patient is scheduled for TCA of the arrhythmic substrate.Recent guidelines support the concept that in patients with AF, detection of intracardiac thrombus, mostly located in LA appendage (LAA), should prompt cancellation of planned cardioversion or TCA and institution of therapeutic anticoagulation in anticoagulant-naive patients 2.In the current issue of the Polish Heart Journal, Kaufmann and coworkers 3 consider critically to rule out the use of TEE in patients undergoing TCA of AF or atrial flutter; based on multiple echocardiographic parameters, including left ventricular ejection fraction >65%, LA diameter <40 mm, LA area <20 cm 2 , LA volume <113 ml, and LA volume index <51 ml/m 2 , they demonstrated 100% sensitivity and 100% negative