Role of transesophageal echocardiography guided cardioversion in patients with atrial fibrillation, previous left atrial thrombus and effective anticoagulation
Introduction
Transesophageal echocardiography (TEE) is a valuable diagnostic tool for detecting formed left atrial (LA) thrombi in patients with atrial fibrillation (AF) [1], [2]. Patients with no evidence of thrombus by TEE can be early and safely cardioverted to sinus rhythm (SR) on achievement of therapeutic systemic anticoagulation [3], [4], [5]. The advantages of this strategy, whose application is increasing nationally [6], as compared with the conventional approach, are: (1) shorter course of prophylactic oral anticoagulation before cardioversion, thus reducing the risk of hemorrhagic complications; and (2) more expedited restoration of SR, thereby allowing for rapid recovery of atrial mechanical function [3], [4], [5].
If LA thrombi are identified by TEE, the management of these patients at high risk for subsequent clinical thromboembolism is controversial and not substantiated by any long-term large cohort study [7], [8]. Some physicians advocate “blind” cardioversion after 4–8 weeks of anticoagulant therapy, whereas others are reluctant to refer their patients for cardioversion without follow-up TEE. However, no consistent data are available on the embolic risk associated with these two strategies after several weeks of effective anticoagulation.
Therefore, our primary goal was to compare the embolic risk associated with a strategy of follow-up TEE-guided direct-current cardioversion (DCCV) with that of blind DCCV in patients with AF, LA thrombus and effective anticoagulation.
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Study design and patient selection
The TEE database at the University of Texas Medical Branch, Galveston was searched to identify patients in whom the indication for TEE was to screen for the presence of LA thrombus before elective DCCV for AF. Once a TEE study with thrombus was identified, clinical, demographic and procedural data were obtained from a review of the patient's chart. We identified 67 subjects with LA appendage (LAA) thrombi from a total of 520 consecutive patients with AF who were referred for TEE between January
Patients' characteristics
Of the 67 AF patients identified with LAA thrombi, 47 underwent blind DCCV and 20 received follow-up TEE-guided DCCV. Table 1 shows the clinical features and echocardiographic findings for patients grouped according to the DCCV strategy used. There were no significant differences in the arrhythmia duration, clinical and echocardiographic features between the two groups as well as in the characteristics of thrombi and presence of severe SEC.
Outcomes
After a median time of 4 weeks on warfarin, 22 of 25
Discussion
This study compared a strategy of follow-up TEE-guided DCCV with that of blind DCCV for the assessment of the postcardioversion risk of clinical thromboembolism in patients with non-rheumatic AF, evidence of LAA thrombi by TEE and effective anticoagulation.
Our major findings are: (1) there was no significant difference in the risk of embolic events between the two strategies; and (2) after a median of 4 weeks of effective anticoagulation, thrombus resolution and prevention of new thrombus
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Prevalence and Resolution of Left Atrial Thrombus in Patients With Nonvalvular Atrial Fibrillation and Flutter With Oral Anticoagulation
2019, American Journal of CardiologyCitation Excerpt :The XTRA trial demonstrated comparable resolution of LAA thrombus with rivaroxaban and warfarin.28 Our data suggest that left atrial thrombi resolve at similar rates with NOACs as with warfarin and although some prospective, controlled studies have reported higher rates of thrombus resolution,23–25,27 our results may better represent the real-world effectiveness of these medications when nonadherence to anticoagulant therapy, which has been reported to be as high as 50%5,29,30 plays a more important role. Thus, compliance should not be assumed, but the opposite considered when planning electrical cardioversion.
New oral anticoagulants and dual antiplatelet therapy: Focus on apixaban
2016, International Journal of CardiologyCitation Excerpt :The observation that 2.5 mg BID reduced the primary efficacy endpoint in ATLAS ACS 2-TIMI 51 supports the hypothesis that modest factor Xa inhibition can reduce recurrent ischemic events after an acute coronary syndrome without being associated with an excess in bleeding complications. Cardioversion (both electric and pharmacological) is associated with an increased risk of thromboembolism, particularly if the patients have not been adequately anticoagulated [34–36]. Current guidelines recommend anticoagulation for at least 3 weeks prior to and 4 weeks after cardioversion for patients with AF of unknown duration or duration > 48 h [37].
Neurologic complications of arrhythmia treatment
2014, Handbook of Clinical NeurologyCitation Excerpt :The routine use of warfarin therapy in arrhythmias other than atrial fibrillation is still controversial (Tracy et al., 2000). The benefits of warfarin are thought to be related to thrombus resolution and prevention of new thrombus formation (Saeed et al., 2006). This appears to be confirmed by the findings of Nabavi et al. (2001), who investigated whether cardioversion of atrial fibrillation was associated with occurrence of circulating microemboli.
TEE screening in Atrial flutter: A single-centre experience with retrospective validation of a new risk score for the presence of atrial thrombi
2008, International Journal of Cardiology