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Consider TEE Before Cardioversion of AF

Anticoagulation with warfarin is recommended for 3 weeks before and for 4 weeks after cardioversion of atrial fibrillation (AF) because of increased stroke risk. An alternative strategy is pre-cardioversion transesophageal echocardiography (TEE) to screen for left atrial thrombi, and then 4 weeks of post-cardioversion anticoagulation. In this prospective, multicenter trial, investigators randomized 1222 patients with AF of at least 2 days' duration to either a conventional or a TEE-guided anticoagulation strategy.

Thrombi were detected in 13.8 percent of TEE-guided patients. Rates of the composite endpoint of cerebrovascular accident, transient ischemic attack, or peripheral embolism within 8 weeks of cardioversion were similar in the 2 groups: TEE-guided, 0.8 percent; conventional, 0.5 percent. The 8-week incidence of hemorrhagic events was significantly lower in the TEE-guided group (2.9 percent vs. 5.5 percent). In addition, initial restoration of sinus rhythm was significantly more common among TEE-guided patients (71.1 percent vs. 65.2 percent). However, at 8 weeks, the 2 groups did not differ significantly in mortality incidence (TEE-guided, 2.4 percent; conventional, 1.0 percent) or in maintenance of sinus rhythm (52.7 percent vs. 50.4 percent, respectively).

Comment: These data show that the incidence of thromboembolic complications after cardioversion of AF is similar with a conventional versus a TEE-guided anticoagulation strategy. The potential advantages of the TEE-guided approach -- including shorter time to cardioversion, higher acute cardioversion rate, and lower risk for hemorrhagic complications -- must be weighed against the discomfort, cost, and inconvenience associated with it and against its lack of improvement over the conventional approach in long-term maintenance of sinus rhythm. The low efficacy rate of cardioversion in both groups likely reflects that defibrillators with biphasic waveforms were unavailable at the time of this study.

— Hugh Calkins, MD

Published in Journal Watch Cardiology January 1, 2002

Citation(s):

Klein AL et al. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med 2001 May 10 344 1411-1420.

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