Limitations of transesophageal echocardiography in the risk assessment of patients before nonanticoagulated cardioversion from atrial fibrillation and flutter: An analysis of pooled trials

Moreyra, Eduardo; Finkelhor, Robert S.; Cebul, Randall D.

doi:10.1016/0002-8703(95)90045-4

Cited by 93 publications

(38 citation statements)

References 43 publications

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“…The absence of left atrial thrombus on TEE does not preclude the need for intracardioversion and postcardioversion anticoagulation. 23 In the present analysis, the use of TEE was higher in patients assigned to dabigatran compared with those assigned to warfarin. This difference might be attributable to study guidance or investigator preference for cardioverting with prior TEE on an experimental therapy, in this case, dabigatran.…”

Section: Discussionmentioning

confidence: 48%

Dabigatran Versus Warfarin in Patients With Atrial Fibrillation

et al. 2011

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Background-The Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial compared dabigatran 110 mg BID (D110) and 150 mg BID (D150) with warfarin for stroke prevention in 18 113 patients with nonvalvular atrial fibrillation. Methods and Results-Cardioversion on randomized treatment was permitted. Precardioversion transesophageal echocardiography was encouraged, particularly in dabigatran-assigned patients. Data from before, during, and 30 days after cardioversion were analyzed. A total of 1983 cardioversions were performed in 1270 patients: 647, 672, and 664 in the D110, D150, and warfarin groups, respectively. For D110, D150, and warfarin, transesophageal echocardiography was performed before 25.5%, 24.1%, and 13.3% of cardioversions, of which 1.8%, 1.

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Section: Discussionmentioning

confidence: 48%

Dabigatran Versus Warfarin in Patients With Atrial Fibrillation

et al. 2011

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“…Manning et al 304 suggested that TEE might be used to identify patients without LAA thrombus who do not require anticoagulation, but a subsequent investigation 324 and meta-analysis found this approach to be unreliable. 720 If most AF-associated strokes result from embolism of stasis-induced thrombus from the LAA, then restoration and maintenance of atrial contraction should logically reduce thromboembolic risk. LV function can also improve after cardioversion, 721 potentially lowering embolic risk and improving cerebral hemodynamics.…”

Section: Type III Antiarrhythmic Agentsmentioning

confidence: 99%

2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation

Fuster¹,

Rydén²,

Cannom³

et al. 2011

Circulation

809

463

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“…Transoesophageal echocardiography is a sensitive tool for identification of thrombus formation in the left atrium and left atrial appendage [7,8] . The safety of transoesophageal echocardiography-guided cardioversion without previous anticoagulation in patients without a thrombus has been reported in several studies [9][10][11][12][13][14][15] , but also questioned in some reports since patients have suffered cardioversion-related embolic events even when no thrombi were found before cardioversion [16,17] . Immediately following conversion to sinus rhythm, however, atrial mechanical function is not fully restored [18] .…”

Section: Introductionmentioning

confidence: 99%

Transoesophageal echocardiography-guided cardioversion of atrial fibrillation or flutter. Selection of a low-risk group for immediate cardioversion

Roijer

Eskilsson

Olsson

2000

European Heart Journal

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Aims Despite exclusion of left atrial thrombi by transoesophageal echocardiography, cardioversion-related thromboembolism has been reported in atrial fibrillation or flutter. To define a low-risk group for cardioversion without previous anticoagulation, patients were selected for immediate cardioversion if there were no thrombi, no echo spontaneous contrast and the outflow velocity of the left atrial appendage was greater than 0·25 m . s 1 on transoesophageal echocardiography. Methods and ResultsTwo hundred and forty-two consecutive patients referred for cardioversion of atrial fibrillation or flutter with a duration of more than 2 days and no anticoagulation therapy were examined with transoesophageal echocardiography. After the transoesophageal echocardiography examination, patients who were eligible for immediate cardioversion were anticoagulated with low molecular weight heparin (dalteparin) subcutaneously, together with warfarin prior to cardioversion. Dalteparin treatment was continued until the patient had reached therapeutic prothrombin values.Based on the transoesophageal echocardiographic findings the patients were divided into two groups: immediate cardioversion, group A, with a mean age of 62 13 years (n=162); or conventional warfarin treatment before cardioversion, group B, with a mean age of 67 10 years (P<0·05) (n=80). In group A, lone atrial fibrillation or flutter was more common (53%; 95% CI: 45-61) compared to group B (34%; 95% CI: 23-44, P<0·05), while heart disease was more common in group B (45%; 95% CI: 34-56) compared to group A (31%; 95% CI: 24-39, P<0·05). Echocardiography revealed thrombi in 5% (95% CI: 2·6-8) of the patients, left atrial size was larger, fractional shortening lower, and a higher proportion had impaired left ventricular function in group B. No thromboembolic event occurred at or after cardioversion in any of the patients; however, before planned cardioversion one transitory ischaemic attack, one lethal stroke and one cardiac death occurred in three of the patients with thrombi despite warfarin therapy. One-month follow-up maintenance of sinus rhythm was 75% in group A compared to 45% in group B (P<0·01).Conclusion After using our transoesophageal echocardiographic exclusion criteria (no thrombi, no spontaneous echo contrast and left atrial appendage outflow velocity d0·25 m . s 1 ) cardioversion can safely be performed in 2/3 of patients with atrial fibrillation or flutter without previous anticoagulation therapy. These patients maintained sinus rhythm significantly better after 1 month compared to patients with prolonged warfarin therapy before cardioversion.

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Limitations of transesophageal echocardiography in the risk assessment of patients before nonanticoagulated cardioversion from atrial fibrillation and flutter: An analysis of pooled trials

Cited by 93 publications

References 43 publications

Dabigatran Versus Warfarin in Patients With Atrial Fibrillation

Dabigatran Versus Warfarin in Patients With Atrial Fibrillation

2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation

Transoesophageal echocardiography-guided cardioversion of atrial fibrillation or flutter. Selection of a low-risk group for immediate cardioversion

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