Is Transesophageal Echocardiography Always Necessary Before Cardioversion of AF Patients After Conventional Anticoagulation Therapy?
Cardioversion of patients from atrial fibrillation (AF) to normal sinus rhythm is frequently performed to relieve symptoms, improve cardiac performance, and decrease cardioembolic risk. However, the cardioversion procedure itself carries an inherent risk of stroke, presumably due to embolization of extant thrombus or postcardioversion thrombogenesis in the left atrium [1,2].
To decrease this risk, patients with AF of more than 48 h or of unknown duration who undergo cardioversion are conventionally treated with therapeutic anticoagulation [international normalized ratio (INR) 2.0-3.0] for at least 34 weeks before and 4 weeks following cardioversion . Screening for the presence of thrombus in the left atrial or left atrium appendage by transesophageal echocardiography (TEE) is an alternative to routine pre-anticoagulation in candidates for cardioversion of AF . ACC/AHA/ESC guidelines recommend anticoagulation treatment of patients in whom no thrombus is identified with an initial bolus injection of intravenous unfractionated heparin before cardioversion, followed by continuous infusion at a dosage adjusted to prolong the activated partial thromboplastin time to 1.5-2 times the reference control value . Next, the guidelines indicate provision of oral anticoagulation (INR 2.0-3.0) for a period of at least 3-4 weeks, as for patients undergoing elective cardioversion . If a thrombus is identified by TEE, patients should be treated with oral anticoagulation for at least 3-4 weeks before and after restoration of sinus rhythm .
KeywordsAtrial Fibrillation International Normalize Ratio Left Atrial Transesophageal Echocardiography Oral Anticoagulation
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