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ؒ August 22, 1996The New England Journal o f Medicine
Correspondence
Management of Acute Mesenteric IschemiaTo the Editor: The Clinical Problem-Solving article entitled "The Invisible Patient" (April 4 issue) 1 describes a patient who died of bowel ischemia that manifested clinically several hours after coronary angiography. The discussant attributed the ischemic event to the dislodgment of an atheromatous plaque by arterial catheterization. Two days earlier, however, the patient had undergone cardioversion for atrial fibrillation of unknown duration. The discussant rejected the possibility of a left atrial thrombus as a potential embolic source because two days had elapsed since cardioversion.Thromboembolism occurring hours to days after the restoration of sinus rhythm is a well-known complication of cardioversion for long-standing atrial fibrillation.2 This complication may occur even in the absence of a preexisting left atrial thrombus at the time of cardioversion, because of a delay between the restoration of sinus rhythm and the resumption of atrial mechanical activity. 3 In fact, the function of the left atrial appendage may worsen transiently after cardioversion, as demonstrated by Fatkin et al. 3 For this reason, anticoagulation therapy is commonly administered for several weeks before and after cardioversion for atrial fibrillation lasting longer than 48 to 72 hours.In this case, an intracerebral arteriovenous malformation was considered a contraindication to anticoagulation therapy. Although the results of echocardiography were interpreted as normal, this imaging study does not provide ample visualization of thrombi in the left atrial appendage. It is therefore possible that cardioversion promoted mesenteric embolism, either by dislodging a preexisting thrombus or by facilitating its formation in a stunned atrium in the absence of anticoagulation therapy. Cardioversion without previous anticoagulation therapy has recently been demonstrated to be safe when transesophageal echocardiography is used to rule out a preexisting left atrial thrombus. 4 We believe that because of the contraindication to anticoagulation therapy, transesophageal echocardiography was required. This course of action might have prevented the patient's death. Had a left atrial thrombus been demonstrated, the decision to perform cardioversion could have been deferred. Had transesophageal echocardiography ruled out a left atrial thro...
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