Efficacy of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation at 6 months: a randomized controlled trial.
BACKGROUND
Electrical cardioversion in patients with atrial fibrillation (AF) is associated with an increased risk of stroke. We compared a transesophageal echocardiography (TEE)-guided strategy with a conventional strategy in patients with AF > 2 days' duration undergoing electrical cardioversion over a 6-month follow-up.


METHODS
The ACUTE study was a multicenter, randomized, clinical trial, with 1222 patients. Six-month follow-up was available in 1034 patients (85%), 525 in the TEE group and 509 in the conventional group. The primary composite end points were cerebrovascular accident, transient ischemic attack, and peripheral embolism at 6 months, which was a prespecified time point. Secondary end points were hemorrhage, mortality, and sinus rhythm.


RESULTS
At 6 months, there was no difference in composite embolic events between the TEE group and the conventional group (10 [2%] vs 4 [0.8%]; risk ratio (RR) 2.47, 95% CI 0.78-7.88; P = .11). However, the hemorrhagic rate was significantly lower in the TEE group (23 [4.4%] vs 38 [7.5%]; RR 0.58, 96% CI 0.35-0.97; P = .04). There was no difference between the 2 treatment groups in all-cause mortality (21 [4%] vs 14 [2.8%]; RR 1.48, 95% CI 0.76-2.92; P = .25) and in the occurrence of normal sinus rhythm between the 2 groups (305 [62.2%] vs 280 [58.1%]; P = .51). Sinus rhythm at 6 months was more common in the TEE-guided group, in those patients who had direct current cardioversion (238 [62.5%] vs 151 [53.9%]; P = .03).


CONCLUSIONS
The TEE-guided strategy may be considered a clinically effective alternative to a conventional anticoagulation strategy for patients with AF of > 2 days' duration undergoing electrical cardioversion over a 6-month period.
Klein
Allan L
AL
Cleveland Clinic Foundation, Cleveland, OH 44195, USA. kleina@ccf.org
Grimm
Richard A
RA
Jasper
Susan E
SE
Murray
R Daniel
RD
Apperson-Hansen
Carolyn
C
Lieber
Elizabeth A
EA
Black
Ian W
IW
Davidoff
Ravin
R
Erbel
Raimund
R
Halperin
Jonathan L
JL
Orsinelli
David A
DA
Porter
Thomas R
TR
Stoddard
Marcus F
MF
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000401:mortality / Q000628:therapy*; D017548:Echocardiography, Transesophageal; D004554:Electric Countershock / Q000379:methods*; D004617:Embolism / Q000209:etiology* / Q000401:mortality; D005260:Female; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D020521:Stroke / Q000209:etiology; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional / Q000379:methods
D000925:Anticoagulants