TEE Before Cardioversion of AF
Abstract & Commentary
By Michael H. Crawford, MD, Editor
Source: Grewal GK, et al. Indications for TEE before cardioversion for atrial fibrillation: Implications for appropriateness criteria. J Am Coll Cardiol Img 2012;5:641-648.
In an effort to reduce unnecessary testing, these investigators performed a retrospective observational study of 671 TEE-guided direct current cardioversions (DCC) for atrial fibrillation (AF) to evaluate the indications used for TEE and the outcomes with regard to thromboembolism post DCC. Using the ACCF/ASE appropriateness criteria, the indications for TEE were classified as appropriate or inappropriate. Those studies unable to be classified were excluded (< 2%). If the TEE had more than one indication, the most serious was considered the main indication. In the 659 remaining patients, the most common indications for TEE prior to DCC of AF were marked symptoms (174) and heart failure or hemodynamic compromise (174): so that DCC could be expedited. Inappropriate indications (n = 18) comprised 2.7% of studies: stable INR for > 3 weeks (11), AF for < 48 hours (3), permanent AF (2), and hospitalized but asymptomatic (2). Left atrial thrombus or sludge was observed in 54 (8%). The TEE indications most likely to exhibit thrombus/sludge were high stroke risk (18%), hospitalized and symptomatic (14%), heart failure/hemodynamic compromise (10%), and subtherapeutic anticoagulation (7%). The lowest incidences of thrombus/sludge occurred in those with new onset AF for > 48 hours (5%) and inappropriate (0%). During a mean follow-up of 18 months, thromboembolism occurred in 15 patients (2.5%) and occurred in all indications except inappropriate. One thromboembolism occurred 3 days after DCC, the remainder occurred 2-18 months later. The authors concluded that TEE usage for DCC is largely used appropriately to expedite DCC in patients with significant symptoms or signs of decompensation due to AF.
Commentary
This study was designed to evaluate the appropriateness of TEE usage in DCC using the new ACCF/ASE appropriate use criteria. Not surprisingly, more than 97% of TEEs were judged appropriate. In some ways, TEE use is a straw man, since no one seriously believes it is being overutilized. After all, patients don’t like it, it takes more physician time and resources than can ever be profitable, and it has risks. I thought the study was interesting to see the outcomes of the modern approach to DCC for AF with selective use of TEE per guidelines.
TEE was mainly used to expedite DCC for patients who were very symptomatic with AF or had hemodynamic compromise; avoiding the 3-4 week wait for oral anticoagulants to work on eliminating atrial thrombi. This approach largely worked as there was only one stroke in the peri-DCC period at 3 days post-DCC. The total thromboembolic event rate was low (2.5%) and all but one occurred from 2 to 18 months after DCC. It is hard to blame these events on DCC in these patients with high risk of recurrent AF and other comorbidities. Thus, I believe the modern approach to DCC is highly safe.
The highest incidences of left atrial thrombus or sludge (18%) were observed in the group deemed at high risk for stroke because of a prior history of stroke/TIA, prior left atrial thrombus, and hypertrophic obstructive cardiomyopathy. Also, this group had the highest incidence of subsequent thromboembolism (6%). Thus, this group should have TEE-guided DCC, rather than relying on a month of anticoagulants alone to ensure safety.
One indication for TEE deemed appropriate is new onset AF for the first time, which has lasted > 48 hours. The theory here is that rapid cardioversion will prevent remodeling (enlargement) that will make it less likely to hold sinus rhythm when cardioverted after a month of anticoagulation. Left atrial thrombus/sludge was seen in 5%, and 2.5% of these patients had an embolic event over 18 months. This indication accepts the clinical adage that you can safely cardiovert first-time AF if it has lasted < 48 hours. Some of the TEE-guided cardioversions were in this latter category, and none had left atrial thrombus, sludge, or an embolic event over 18 months. Thus, the old clinical saw was upheld by this study.
In an effort to reduce unnecessary testing, these investigators performed a retrospective observational study of 671 TEE-guided direct current cardioversions (DCC) for atrial fibrillation (AF) to evaluate the indications used for TEE and the outcomes with regard to thromboembolism post DCC.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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