Factors determining elective cardioversion preceded with transesophageal echocardiography: two cardiology centres’ experiences

Abstract

INTROduCTION Although guidelines endorse cardioversion after adequate non-vitamin K antagonist oral anticoagulant (NOAC) treatment without prior transesophageal echocardiography (TEE), the majority of patients still undergo this examination. ObjECTIvEs The aim of this study was to assess factors determining the decision to perform TEE in patients with atrial fibrillation (AF) who are eligible for elective cardioversion. PATIENTs ANd mEThOds In this study, we evaluated the medical records of consecutive patients with AF who were admitted for elective cardioversion after prior NOAC treatment. REsuLTs Of a total of 668 patients included in the study, 362 individuals (54%) underwent TEE before cardioversion. In the univariable analysis, paroxysmal AF, hypertension, coronary artery disease (CAD), thromboembolic events, a history of percutaneous coronary intervention, a history of bleeding, left ventricular ejection fraction, left ventricular end-diastolic diameter, a reduced dose of NOACs, hemoglobin levels, impaired renal filtration, and a high CHA 2 DS 2-VASc score were significant predictors of the decision to perform TEE. In the multivariable logistic regression analysis, a history of CAD, bleeding, and stroke / transient ischemic attack / thromboembolism remained independent predictors of referring a patient for TEE (odds ratio [OR], 3.92, P <0.001; OR, 7.92, P <0.001; and OR, 2.36, P = 0.02, respectively). In contrast, paroxysmal AF (OR, 0.31; P = 0.02) and hypertension (OR, 0.28; P <0.001) were indicators of refraining from TEE. CONCLusIONs Transesophageal echocardiography before cardioversion was more frequently performed in patients with a history of CAD, bleeding, or thromboembolic events. Patients with paroxysmal AF and hypertension more often received cardioversion without prior TEE.

Effectiveness of Transesophageal Echocardiography in Preventing Thromboembolic Complications Before Cardioversion: A Narrative Review

“…While it offers the ability to directly visualize thrombi in the LAA, the actual utility of routine use before cardioversion to prevent thromboembolism in AFib patients who have undergone adequate anticoagulation is still evolving [ 23 ]. Despite recommendations against TEE in adequately anticoagulated patients, in practice many clinicians choose to evaluate patients with TEE regardless of anticoagulation status when they have an increased risk of thromboembolism [ 24 ].…”

Is transesophageal echocardiography necessary before electrical cardioversion in patients treated with non-vitamin K antagonist oral anticoagulants? Current evidence and practical approach

“…The results of the study by Frederiksen et al [ 11 ] involving a group of 2150 patients undergoing ECV were consistent with the results of the previous study. Thromboembolic complications were not observed in any of the patients during the 30-day follow-up period of this study, which included 668 patients treated with NOACs before ECV [ 12 ]. Also, Barysiene et al [ 13 ] did not acknowledge thromboembolic events in the 30-day follow-up period for a group of 432 patients receiving pertinent anticoagulant therapy prior to ECV.…”

“…An additional 4.6% of the centers recommended TEE routinely for all patients [ 41 ]. In the study including 668 AF patients treated with NOACs before ECV, TEE was performed in 54% of patients [ 12 ]. Data from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II showed that 25% of patients had pre-cardioversion TEE [ 10 ].…”

Differences in the predictors of left atrial appendage thrombus between men and women treated with dabigatran or rivaroxaban

“…The gold standard for the exclusion of LAAT is transesophageal echocardiography (TOE) [9,10]. However, there are no unequivocal data on whether patients awaiting ablation or electric cardioversion should routinely undergo TOE, which is an invasive procedure that should be performed by trained and experienced personnel [11][12][13][14]. Risk stratification according to sex is common in clinical practice.…”