Indications for TEE before cardioversion for atrial fibrillation: implications for appropriateness criteria.
The purpose of this study was to evaluate appropriateness of transesophageal echocardiography (TEE) before direct current cardioversion (DCC), investigate indications for TEE, and analyze if indications are predictive of outcome. According to American College of Cardiology Foundation/American Society of Echocardiography 2011 Appropriateness Criteria, TEE is appropriate in the evaluation of patients with atrial fibrillation (AF) to facilitate clinical decision making with regards to anticoagulation and/or DCC. However, it is unclear in which instances physicians utilize TEE. We reviewed 671 TEE studies in 604 AF patients (age 66 ± 13 years, 67% male) in which TEE was performed before DCC for left atrial thrombus (LAT)/sludge. Studies were divided by the main indication for TEE into the following 8 categories: 1) congestive heart failure (CHF)/hemodynamic compromise; 2) symptomatic; 3) new onset AF; 4) hospitalized and symptomatic; 5) high stroke risk; 6) subtherapeutic anticoagulation; 7) miscellaneous; and 8) inappropriate for TEE. The main indications for TEE before DCC were symptomatic (26.4%) and CHF/hemodynamic compromise (26.1%). We deemed 2.7% of the studies as inappropriate. LAT/sludge was found in 8.2% of studies. Incidence of LAT/sludge differed significantly between indications (p = 0.0021) and the highest incidences occurred in the high stroke risk (17.6%) and hospitalized and symptomatic (14.1%) categories. No LAT/sludge was found in the miscellaneous or inappropriate groups. Stroke occurred in 2.5% (n = 15) of all patients and in all groups except for miscellaneous and inappropriate (p = 0.3). TEE is appropriately used prior to DCC for patients with the main indications of symptomatic and CHF/hemodynamic compromise. In a minority of studies, TEE utilization was inappropriate. Incidence of LAT/sludge differed between indications.
Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA.
Gaganpreet K
GK
Grewal
Tristan B
TB
Klosterman
Kevin
K
Shrestha
Hirad
H
Yarmohammadi
Andrew O
AO
Zurick
Brandon C
BC
Varr
W H Wilson
WH
Tang
Bruce D
BD
Lindsay
Allan L
AL
Klein
D000368:Aged; D001281:Atrial Fibrillation / Q000150:complications / Q000000981:diagnostic imaging* / Q000628:therapy*; D017548:Echocardiography, Transesophageal / Q000592:standards*; D004554:Electric Countershock / Q000009:adverse effects; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D013923:Thromboembolism / Q000209:etiology / Q000517:prevention & control; D013927:Thrombosis / Q000209:etiology / Q000517:prevention & control; D013997:Time Factors; D016896:Treatment Outcome; D019564:Unnecessary Procedures