Elective cardioversion of atrial fibrillation is safe without transesophageal echocardiography in patients treated with non-vitamin K antagonist oral anticoagulants: Multicenter experience

Abstract

Background: Current guidelines recommend electrical cardioversion (ECV) in patients with atrial fibrillation (AF) after at least 3 weeks of adequate non-vitamin K antagonist oral anticoagulant (NOAC) treatment without prior transesophageal echocardiography (TEE). However, in clinical practice in some centres, TEE is performed before ECV in patients with AF. The aim of the study was to evaluate prevalence of thromboembolic and hemorrhagic complications in patients with AF treated with NOACs and undergoing ECV without prior TEE. 2 Methods: This observational, multicentre study included consecutive patients with AF treated with NOACs who were admitted for ECV without prior TEE. Thromboembolic events and major bleeding complications were investigated during a 30-day follow-up. Results: In the study group there were 611 patients, mean age was 66.3 ± 9.2 years, 40% were women. 52 (8.5%) patients had a low thromboembolic risk, 148 (24.2%) patients had an intermediate thromboembolic risk and 411 (67.2%) patients had a high thromboembolic risk. In the study group 253 (41.4%) patients were treated with rivaroxaban, 252 (41.2%) patients were treated with dabigatran and 106 (17.3%) patients were treated with apixaban. Reduced doses of NOACs were administered to 113 (18.9%) patients. In the entire study group, there were no thromboembolic events or major bleeding complications during the in-hospital stay and the 30-day follow-up. Conclusions: In this "real-world" study of AF patients treated with NOACs, it was proved that ECV is safe without a preceding TEE, regardless of the risk of thromboembolic complications and of the type of NOAC used.

Risk factors for thrombosis and spontaneous echocardiographic contrast with sludge in atrial fibrillation patients treated with oral anticoagulants before electrical cardioversion

“…Multivariable logistic analysis of clinical data among our 300 patients showed that persistent AF is an independent risk factor for T and SEC4+ with sludge. Several publications indicate the formation of thrombotic material in the heart in both paroxysmal AF and non-paroxysmal AF [22,23,[25][26][27]. Non-paroxysmal AF patients are a heterogeneous group (persistent and permanent AF), and different durations of arrhythmia may have different effects on thrombogenic material formation.…”

“…Multivariable logistic analysis revealed that female gender is an independent predictor of thrombogenic milieu formation in LA/LAA. The high CHA2DS2-VASc score, comorbidities including CKD, as well as higher platelet and white blood cell counts found among the female study group are considered to be favorable factors for the formation of thrombogenic material [25,26,[34][35][36].…”

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

“…Conversely, while TEE has demonstrated utility in detecting LAA thrombi, a well-known risk factor for stroke, a 2021 observational multicenter study observed no evidence of thromboembolic events in patients adequately treated with anticoagulation (apixaban, dabigatran, and rivaroxaban) without pre-procedural TEE [ 29 ]. AFib patients on oral anticoagulation demonstrated a risk of thromboembolism below 1% overall in another study [ 26 ], and anticoagulated patients with thrombi discovered on TEE experienced no embolic events after cardioversion in other studies [ 30 , 31 ].…”

“…AFib patients on oral anticoagulation demonstrated a risk of thromboembolism below 1% overall in another study [ 26 ], and anticoagulated patients with thrombi discovered on TEE experienced no embolic events after cardioversion in other studies [ 30 , 31 ]. Despite these findings, there is evidence of the additional utility of TEE before cardioversion in patients with certain risk factors [ 29 ].…”