Use of Transesophageal Echocardiography to Guide Cardioversion in Patients with Atrial Fibrillation

University of Louisville, Louisville, Kentucky, United States
New England Journal of Medicine (Impact Factor: 55.87). 05/2001; 344(19):1411-20. DOI: 10.1056/NEJM200105103441901
Source: PubMed


The conventional treatment strategy for patients with atrial fibrillation who are to undergo electrical cardioversion is to prescribe warfarin for anticoagulation for three weeks before cardioversion. It has been proposed that if transesophageal echocardiography reveals no atrial thrombus, cardioversion may be performed safely after only a short period of anticoagulant therapy.
In a multicenter, randomized, prospective clinical trial, we enrolled 1222 patients with atrial fibrillation of more than two days' duration and assigned them to either treatment guided by the findings on transesophageal echocardiography or conventional treatment. The composite primary end point was cerebrovascular accident, transient ischemic attack, and peripheral embolism within eight weeks. Secondary end points were functional status, successful restoration and maintenance of sinus rhythm, hemorrhage, and death.
There was no significant difference between the two treatment groups in the rate of embolic events (five embolic events among 619 patients in the transesophageal-echocardiography group [0.8 percent]) vs. three among 603 patients in the conventional-treatment group [0.5 percent], P=0.50). However, the rate of hemorrhagic events was significantly lower in the transesophageal-echocardiography group (18 events [2.9 percent] vs. 33 events [5.5 percent], P=0.03). Patients in the transesophageal-echocardiography group also had a shorter time to cardioversion (mean [+/-SD], 3.0+/-5.6 vs. 30.6+/-10.6 days, P<0.001) and a greater rate of successful restoration of sinus rhythm (440 patients [71.1 percent] vs. 393 patients [65.2 percent], P=0.03). At eight weeks, there were no significant differences between the two groups in the rates of death or maintenance of sinus rhythm or in functional status.
The use of transesophageal echocardiography to guide the management of atrial fibrillation may be considered a clinically effective alternative strategy to conventional therapy for patients in whom elective cardioversion is planned.

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Available from: Carolyn Apperson-Hansen, Oct 05, 2015
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    • "Predicting LAAT is certainly important in some clinical scenarios, such as prior to electrical cardioversion [25,26]. Since LAAT is the source of the majority of systemic thromboembolic events in patients with AF, [2,3] it is plausible that diastolic function parameters (E:e’ and e’ velocity) can also help predict embolic stroke. "
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    ABSTRACT: Left ventricular diastolic impairment and consequently elevated filling pressure may contribute to stasis leading to left atrial appendage thrombus (LAAT) in nonvalvular atrial fibrillation (AF). We investigated whether transthoracic echocardiographic parameters can predict LAAT independent of traditional clinical predictors. We conducted a retrospective cohort study of 297 consecutive nonvalvular AF patients who underwent transthoracic echocardiogram followed by a transesophageal echocardiogram within one year. Multivariate logistic regression analysis models were used to determine factors independently associated with LAAT. Nineteen subjects (6.4%) were demonstrated to have LAAT by transesophageal echocardiography. These patients had higher mean CHADS2 scores [2.6 +/- 1.2 vs. 1.9 +/- 1.3, P = 0.009], higher E:e' ratios [16.6 +/- 6.1 vs. 12.0 +/- 5.4, P = 0.001], and lower mean e' velocities [6.5 +/- 2.1 cm/sec vs. 9.1 +/- 3.2 cm/sec, P = 0.001]. Both E:e' and e' velocity were associated with LAAT formation independent of the CHADS2 score, warfarin therapy, left ventricular ejection fraction (LVEF), and left atrial volume index (LAVI) [E:e' odds-ratio = 1.14 (95% confidence interval = 1.03 - 1.3), P = 0.009; e' velocity odds-ratio = 0.68 (95% confidence interval = 0.5 - 0.9), P = 0.007]. Similarly, diastolic function parameters were independently associated with spontaneous echo contrast. The diastolic function indices E:e' and e' velocity are independently associated with LAAT in nonvalvular AF patients and may help identify patients at risk for LAAT.
    Full-text · Article · Feb 2014 · Cardiovascular Ultrasound
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    • "Recently, SF and D-dimer levels have been considered useful for diagnosis of thrombosis [8-14]. The TEE-guided approach with short-term anticoagulation is considered to be as safe and clinically effective as the conventional approach, and is advocated in patients in whom earlier cardioversion would be clinically beneficial [8,15,16]. Addition of the TEE-guided approach to monitoring of fibrin-related markers such as SF and D-dimer may be safer than the simple TEE-guided approach for rhythm control strategy in AF patients. "
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    ABSTRACT: Left atrial appendage (LAA) thrombosis is an important cause of cardiogenic cerebral thromboembolism. Apixaban is a member of the class of novel oral anticoagulants (NOAC) and is superior to warfarin in preventing stroke or systemic embolism, causes less bleeding, and results in lower mortality in patients with atrial fibrillation. There are few reports of resolution of LAA thrombus with other NOAC. We present a 72-year-old male patient with persistent atrial fibrillation associated with left atrial thrombus. Sixteen days of apixaban treatment showed complete thrombus resolution. In this study, soluble fibrin and D-dimer levels decreased without prolongation of international normalized ratio (INR) and activated partial thromboplastin time (APTT).
    Full-text · Article · Dec 2013 · Thrombosis Journal
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    • "The event rate in our study was 3.9% in the control group, where native TEE was performed, and 0% in group 1 using contrast enhancement. Previous studies showed embolic complications of CV in as much as 1% of patients despite exclusion of thrombi with conventional TEE [9]. This corresponds well to the finding of another study comparing results of TEE with intraoperative findings, where 2 of 213 patients had a thrombus despite a normal TEE [19]. "
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    ABSTRACT: Aims Transesophageal echocardiography (TEE) is the gold standard for the detection of thrombi in patients with atrial fibrillation (AF) before undergoing early electrical cardioversion (CV). However, TEE generates inconclusive results in a considerable number of patients. This study investigated the influence of contrast enhancement on interpretability of TEE for the detection of left atrial (LA) thrombi compared to conventional TEE and assessed, whether there are differences in the rate of thromboembolic events after electrical cardioversion. Methods Of 180 patients with AF (51 females, 65.2±13 years) who were referred to CV, 90 were examined with native imaging and contrast enhancement within the same examination (group 1), and 90 were examined with native TEE alone and served as control (group 2). Cineloops of the multiplane examination of the LA and LA appendage (LAA) were stored digitally before and, in group 1, after intravenous bolus application of a transpulmonary contrast agent. Images of group 1 were assessed offline and the diagnosis of LA thrombi was made semi-quantitatively: 1= thrombus present; 2=inconclusive result; 3=no thrombus. The presence of spontaneous echocontrast (SEC) was registered and flow velocity in the LA appendage (LAA-flow) was measured. All patients in whom CV was performed were followed up for 1 year or until relapse of AF. CV related adverse events were defined as any thromboembolic event within 1 week after CV. Results No serious adverse events occurred during TEE and contrast enhanced imaging. In group 1 atrial thrombi were diagnosed in 14 (15.6%) during native and in 10 (11.1%) patients during contrast enhanced imaging (p<0.001). Of the 10 patients with thrombi in the contrast TEE group, 7 revealed a decreased LAA-flow (≤0,3m/s) and 8 showed moderate or marked SEC. Uncertain results were significantly more common during native imaging than with contrast enhanced TEE (16 vs. 5 patients, p<0.01). Thrombi could definitely be excluded in 60 (66.7%) during conventional and in 75 patients (83.3%) during contrast enhanced TEE (p<0.01). CV was performed subsequently after exclusion of thrombi and at the discretion of the investigator. In group 1, 74 patients (82.2%) were cardioverted and no patient suffered a CV related complication (p=0.084). In group 2, 76 patients (84.4%) underwent CV, of whom 3 suffered a thromboembolic complication after CV (2 strokes, 1 peripheral embolism). Conclusion In patients with AF planned for CV contrast enhancement renders TEE images more interpretable, facilitates the exclusion of atrial thrombi and may reduce the rate of embolic adverse events.
    Full-text · Article · Jan 2013 · Cardiovascular Ultrasound
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