Usefulness of transoesophageal echocardiography before cardioversion in patients with atrial fibrillation and different anticoagulant regimens

Abstract

Objectives: To evaluate the prevalence of atrial thrombi in patients with atrial fibrillation undergoing different anticoagulation regimens before cardioversion; to evaluate the usefulness of transoesophageal echocardiography (TOE) guided cardioversion to prevent thromboembolic complications; and to correlate the presence of atrial thrombi with clinical and echocardiographic data. Methods: 757 consecutive patients admitted as candidates for cardioversion of atrial fibrillation were enrolled in the study. They were divided into four groups: effective conventional oral anticoagulation, short term anticoagulation, ineffective oral anticoagulation or subtherapeutic anticoagulation, and effective oral anticoagulation with a duration of , 3 weeks for various clinical reasons. All patients underwent TOE before cardioversion; in the presence of atrial thrombi or extreme left atrial echo contrast, cardioversion was postponed. The incidence of thromboembolic events was evaluated after cardioversion. Results: Atrial thrombi were detected in 48 of the 757 (6.3%) patients. No significant differences in the percentage of atrial thrombosis were found in the four study groups. Patients with atrial thrombosis were older and had a higher percentage of mitral prosthetic valves, lower left ventricular ejection fraction, more severe atrial spontaneous echo contrast, and lower Doppler left atrial appendage velocities. 648 patients were scheduled for cardioversion. Cardioversion was successful in 89% of patients without any major thromboembolic event.Conclusions: The prevalence of atrial thrombosis before cardioversion despite different treatments with anticoagulants is about 7% and a TOE guided approach may prevent the risk of embolic events.

Is Early Cardioversion for Atrial Fibrillation Safe in Patients with Spontaneous Echocardiographic Contrast?

“…21,28 -33 Though these trials did not directly look at the relationship between the presence of SEC on TEE and postcardioversion thromboembolic risk, they did incorporate a large number of patients with SEC into the cardioversion group (Table I). These studies showed a low thromboembolic risk despite varying methods of anticoagulation, including studies with no or subtherapeutic anticoagulation 28,29,32 prior to cardioversion.…”

Executive summary on the use of ultrasound in the critically ill: consensus report from the 3rd Course on Acute Care Ultrasound (CACU)

“…TOE is useful in the bedside investigation of thromboembolic events through visualisation of thrombi involving the proximal pulmonary arteries, atheroma plaques (≥ 5 mm) in the thoracic aorta, patent foramen ovale and atrial septal aneurysm [19]. TOE may also visualize thrombi into the main or the right pulmonary artery, then allowing diagnosis of proximal pulmonary embolism at the bedside in a mechanically ventilated patient.…”

Practical Implementation of Anticoagulation Strategy for Patients Undergoing Cardioversion of Atrial Fibrillation

“…while some data exist to support its use, 22,23 it has been argued that current evidence is insufficient to justify its cost. In addition, TOE may fail to detect small thrombi, TOE examination is labour intensive, and small medical centres may lack the necessary expertise to detect thrombi.…”