title: Transesophageal echocardiographic guidance of cardioversion in patients with atrial fibrillation.
abstract: The role of TEE in the guidance of cardioversion of atrial fibrillation was studied. Thirty-seven (18%) of 206 patients had left atrial thrombus. Cardioversion was attempted in 153 patients receiving no (n = 107) or < 7 days (n = 46) of anticoagulation prophylaxis, in 27 patients after > or = 3 weeks of anticoagulation, and was cancelled in 26 patients, primarily on the basis of TEE findings. Left atrial thrombus was observed in 37 (18%) of 206 patients. No embolic complications occurred over a 4-week follow-up period. In 7 (41%) of 17 patients new left atrial appendage spontaneous echocardiographic contrast developed immediately after electric cardioversion. In this group, significant decreases occurred in the left atrial appendage maximal emptying shear rate (11.1 +/- 11.1 sec-1 vs 5.0 +/- 5.1 sec-1; p < 0.05), maximal filling shear rate (6.7 +/- 5.9 sec-1 vs 3.7 +/- 3.5 sec-1; p < 0.05), and peak emptying velocity (0.38 +/- 0.29 cm/sec vs 0.19 +/- 0.14 cm/sec; p < 0.05). In one patient a left atrial appendage thrombus formed after electric cardioversion. Left atrial thrombus resolved in 1 (5%) of 21 patients and became immobile in 0 (0%) of 16 patients after 3 to 5 weeks of anticoagulation but resolved (n = 9) or became immobile (n = 6) in 15 (71%) of 21 patients after > 5 weeks of anticoagulation. TEE-guided cardioversion was safely done without or with < 7 days of anticoagulation prophylaxis in selected patients, but the potential for left atrial thrombus to form after electric cardioversion makes anticoagulation advisable in all patients. The conventional recommendation of 3 to 4 weeks of anticoagulation prophylaxis before cardioversion is usually inadequate for left atrial thrombus to resolve or to become immobile.
authors.affiliation: Department of Medicine, University of Louisville KY 40202, USA.
authors.forename: M F
authors.initials: MF
authors.lastname: Stoddard
authors.forename: P R
authors.initials: PR
authors.lastname: Dawkins
authors.forename: C R
authors.initials: CR
authors.lastname: Prince
authors.forename: R A
authors.initials: RA
authors.lastname: Longaker
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000000981:diagnostic imaging / Q000628:therapy*; D016279:Atrial Function, Left; D001783:Blood Flow Velocity; D002302:Cardiac Output; D017548:Echocardiography, Transesophageal; D004554:Electric Countershock; D005260:Female; D005500:Follow-Up Studies; D006325:Heart Atria / Q000000981:diagnostic imaging; D006331:Heart Diseases / Q000000981:diagnostic imaging / Q000188:drug therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000188:drug therapy; D013997:Time Factors; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional
chemical_list: D000925:Anticoagulants