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A STRATEGY TO GUIDE CARDIOVERSION IN ATRIAL FIBRILLATION.

Before undergoing cardioversion, patients with atrial fibrillation generally receive several weeks of anticoagulation to prevent embolization of atrial thrombi. If patients without atrial thrombi could be reliably identified, they could presumably be spared this delay. This study used transesophageal echocardiography (TEE) to determine the presence of atrial thrombi in 94 patients with atrial fibrillation of more than 2 days' duration.

Eighty-two patients had no atrial thrombi on TEE; 78 of these had successful pharmacologic or direct-current cardioversion without a prolonged prior course of warfarin. (Most received short-term heparin just before cardioversion, and many received warfarin for 1 month afterwards.) None had an embolic event.

The 12 patients with atrial thrombi had cardioversion deferred and began long-term warfarin. Two of these patients died suddenly before cardioversion; one apparently had a stroke and the other had sudden cardiac arrest. Four of the remaining 10 patients had successful cardioversion after prolonged anticoagulation (the other 6 did not undergo cardioversion for various reasons).

These findings suggest that early cardioversion is safe in patients without atrial thrombi on TEE. An editorialist supports using TEE in patients for whom anticoagulation is risky and withholding cardioversion if a thrombus is found. However, he calls for larger clinical trials before this strategy is adopted for all patients with atrial fibrillation.

— ASB

Published in Journal Watch General Medicine March 26, 1993

Citation(s):

Daniel WG. Should transesophageal echocardiography be used to guide cardioversion. N Engl J Med 1993 Mar 18 328 803-804.

• Original article (Subscription may be required)
• Medline abstract (Free)

Manning WJ et al. Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi. N Engl J Med 1993 Mar 18 328 750-755.

• Original article (Subscription may be required)
• Medline abstract (Free)