The safety of electrical cardioversion under the control of transesophageal echocardiography in patients with atrial fibrillation and inadequate anticoagulation.

Research paper by Joanna J Zaprutko, Artur A Baszko, Michał M Michalak, Karol K Kochman, Radosław R Szymański, Jan J Kłopocki, Anna A Nowicka, Rafał R Dankowski, Marek M Michalski, Piotr P Kałmucki, Andrzej A Szyszka

Indexed on: 27 May '17Published on: 27 May '17Published in: Polskie Archiwum Medycyny Wewnetrznej


INTRODUCTION    Restoring sinus rhythm in patients with atrial fibrillation (AF)/atrial flutter (AF) requires adequate oral anticoagulation (OAC) prior to direct current cardioversion (DCC). Some patients eligible for DCC are not properly anticoagulated. OBJECTIVES    Assessment of risk factors for thrombus and spontaneous echo contrast (SEC) in the left atrium (LA) as well as the safety profile of DCC under transesophageal echocardiography control (TEE) in patients with inadequate anticoagulation. PATIENTS AND METHODS    From the cohort of 316 patients admitted for DCC, 139 (age 63.4 ± 11.5 years) had inadequate anticoagulation. 91 patients were admitted urgently for acute coronary syndrome, heart failure (HF), or poor tolerance of arrhythmia. The average CHA2DS2-VASc score was 3.0 ± 1.7.  RESULTS    TEE demonstrated LAA thrombus in 16 patients (11.5%), and LA SEC in 63 patients (45.3%). In univariate analysis, LAA thrombus was more common after myocardial infarction (OR 3.92, 95% CI 1.34-11.48, P=0.009), while LA SEC in patients with HF (OR 2.23, 95% CI 1.1-4.53, P=0.02) and left ventricular ejection fraction <40% (OR 3.65, 95% CI 1.66-8.06, P=0.001). In the multivariate model, the most powerful SEC predicting factor was LA size>45mm (OR 3.08, 95% CI 1.3-7.29). DCC was performed in 105 patients. No complications of TEE or DCC were observed. CONCLUSIONS    AF/AFL inadequately treated with OAC predispose to thrombus formation and SEC in the LA. Once thrombus is excluded, DCC is a safe procedure. There were no predictors of LAA thrombus and, thus, TEE before DCC should be performed in all patients with AF/AFL in accordance with the guidelines.

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