- Email: [email protected]
The effect of transesophageal echocardiography on the incidence of thromboembolism after electrical cardioversion in atrial fibrillation: A multicenter analysis
International Journal of Cardiology 202 (2016) 880–882
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
The effect of transesophageal echocardiography on the incidence of thromboembolism after electrical cardioversion in atrial fibrillation: A multicenter analysis☆,☆☆,★ Dong Geum Shin a, Hee-Sun Mun b, Hye-Young Lee c, Eui Seock Hwang d, Jae-Sun Uhm a, Hui-Nam Pak a, Moon-Hyoung Lee a, Boyoung Joung a,⁎ a
Division of Cardiology, Yonsei University College of Medicine, Seoul, Republic of Korea Division of Cardiology, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Seoul, Republic of Korea c Division of Cardiology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea d Division of Cardiology, Myongji Hospital, Gyeonggi-do, Republic of Korea b
a r t i c l e
i n f o
Article history: Received 20 September 2015 Accepted 4 October 2015 Available online 9 October 2015 Keywords: Atrial fibrillation Transesophageal echocardiography Cardioversion Thromboembolism
Current guidelines advocate for patients with AF ≥ 48 h to achieve a therapeutic International Normalized Ratio (INR) 3 weeks prior to cardioversion and maintain anticoagulation for at least 4 weeks following cardioversion. If a patient did not receive anticoagulation for preceding 3 weeks, it is reasonable to perform a transesophageal echocardiography (TEE) prior to cardioversion [1,2]. However, whether TEE reduces thromboembolism during cardioversion in AF patients receiving guideline-oriented anticoagulation is still controversial. Recently, it was revealed that in AF patients with a low stroke risk, a routine TEE even before ablation might be unnecessary to decrease periprocedural stroke [3,4]. The aim of this study was to determine clinical impact of an additional pre-cardioversion TEE on the incidence of thromboembolism in patients with AF ≥ 48 h under adequate anticoagulation in realworld clinical practice. ☆ No conflicts of interest or relationship with industry. ☆☆ Sources of Funding: This study was supported in part by research grants from the Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education, Science and Technology (NRF-2012R1A2A2A02045367), and a grant of the Korean Healthcare technology R&D project funded by the Ministry of Health & Welfare (HI12C1552). ★ Disclosures: None. ⁎ Corresponding author at: Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 250 Seungsanno, Seodaemun-gu, Seoul 120-752, Republic of Korea. E-mail address: [email protected] (B. Joung).
http://dx.doi.org/10.1016/j.ijcard.2015.10.037 0167-5273/© 2015 Published by Elsevier Ireland Ltd.
From 2005 through 2013, 1077 non-valvular AF patients at four tertiary hospitals in Korea were retrospectively analyzed. Patients with AF ≥ 48 h who underwent electric cardioversion were enrolled. Anticoagulation was performed following current guidelines. Cardiologists decided whether to perform TEE and performed within 24 h before cardioversion with a detailed evaluation of thrombi or spontaneous echo contrast (SEC). Cardioversion was canceled when TEE showed an evidence of thrombi. Physician decided whether to perform cardioversion in case of SEC. Study population was divided into two groups: group 1, patients with TEE and group 2, patients without TEE before cardioversion. The clinical outcomes during 30 days post-cardioversion were assessed for thromboembolism (stroke, transient ischemic attack, or systemic embolism) and bleeding (overt bleeding requiring admission including blood transfusion, decreased hemoglobin level ≥2.0 g/dL, or symptomatic bleeding in a critical organ). The mean duration of anticoagulation before cardioversion was 95 ± 52 days. Table 1 shows the comparisons in characteristics of study populations with TEE (n = 167) and no-TEE (n = 910). TEE group more frequently had heart failure (p = 0.04) and vascular disease (p = 0.002), and higher CHA2DS2-VASc (p b 0.001) and HAS-BLED (p = 0.04) scores. The left atrium (LA) size also was larger in TEE group. After propensity score matching, baseline characteristics were well matched and not differed between two groups (n = 306 vs n = 156). Two (1.2%) and 3 (0.3%) patients had thromboembolism in TEE and no-TEE group, respectively. The proportion of thromboembolisms did not differ between two groups (p = 0.17). Ironically, 2 patients in TEE group did not exhibit even SEC on TEE before cardioversion. The CHA2DS2-VASc score was above 2 in all 5 patients. The INR at the time of cardioversion was above 2 in all cases. However, three patients experienced thromboembolism within a week after cardioversion, and had an INR below 1.7. One (0.6%) and 4 (0.4%) patients were hospitalized for bleeding in TEE and no-TEE groups, respectively. There were no significant differences in the incidence of bleeding between two groups (p = 0.57). All patients with bleeding had a HAS-BLED score higher than 3. Only one patient, who was hospitalized for bleeding, had an INR higher than 3. After propensity score matching, there were 2 patients with thromboembolism in TEE group, and 1 patient with bleeding in both TEE and no-TEE groups without difference between two groups.
Correspondence
881
Table 1 Characteristics of the study population. Total population
Age, years Sex, male Heart failure Hypertension Diabetes mellitus History of stroke/TIA Vascular disease CHA2DS2-VASc score HAS-BLED score Echocardiographic value LV ejection fraction, % LA diameter (AP), mm LAVI, mL/m2 INR at cardioversion Cardioversion success Outcome Thromboembolism Bleeding
Propensity score-matched population
Overall (n = 1077)
No-TEE (n = 910)
TEE (n = 167)
p-Value
No-TEE (n = 306)
TEE (n = 156)
p-Value
60 ± 11 804 (75) 161 (15) 681 (64) 261 (24) 150 (14) 48 (5) 2.0 ± 1.5 2.0 ± 1.2
60 ± 11 683 (75) 125 (14) 564 (62) 215 (24) 125 (14) 33 (4) 1.9 ± 1.4 1.9 ± 1.2
62 ± 12 122 (73) 36 (22) 117 (71) 46 (28) 25 (15) 15 (9) 2.4 ± 1.7 2.1 ± 1.1
0.09 0.58 0.009 0.06 0.28 0.67 0.002 b0.001 0.04
61 ± 10 226 (74) 51 (17) 206 (67) 97 (32) 55 (18) 9 (3) 2.2 ± 1.5 2.1 ± 1.2
61 ± 12 117 (75) 28 (18) 107 (69) 39 (25) 21 (14) 8 (5) 2.2 ± 1.5 2.1 ± 1.2
0.85 0.79 0.73 0.78 0.13 0.21 0.24 0.94 0.92
61 ± 10 47 ± 7 46 ± 17 2.5 ± 0.9 928 (87)
61 ± 9 46 ± 7 45 ± 16 2.5 ± 0.9 799 (88)
60 ± 12 48 ± 7 50 ± 22 2.5 ± 0.9 129 (83)
0.17 0.005 0.008 0.46 0.11
62 ± 9 47 ± 7 46 ± 17 2.5 ± 0.9 269 (88)
60 ± 12 48 ± 7 49 ± 23 2.5 ± 0.9 120 (83)
0.23 0.08 0.15 0.93 0.14
5 (0.5) 5 (0.5)
3 (0.3) 4 (0.4)
2 (1.2) 1 (0.6)
0.17 0.57
0 (0) 1 (0.3)
2 (1.3) 1 (0.6)
0.11 1.0
The numbers in parentheses represent percentages. CHA2DS2-VASc: congestive heart failure, hypertension, age ≥75 (doubled), diabetes mellitus, and prior ischemic stroke, transient ischemic attack or thromboembolism (doubled), vascular disease, age 65 to 74, sex category (female); HAS-BLED: hypertension, abnormal renal/liver function, stroke, bleeding tendency or predisposition, labile INR, elderly (eg. N65), drugs (eg. aspirin, clopidogrel or non-steroidal anti-inflammatory drug) or alcohol abuse; LA: left atrium; LAVI: left atrium volume index; LV: left ventricle; INR: International Normalized Ratio; TEE: transesophageal echocardiography.
In TEE group, thrombi or SEC were observed in 12 (7.2%) and 44 (26.3%) patients, respectively. LA size (p = 0.003) and CHA2DS2-VASc scores (p = b0.001) were significantly higher in patients with a thrombus or SEC. Likewise, prevalence of heart failure (p = 0.05), hypertension (p = b 0.001), and vascular disease (p b 0.001) were significantly higher in patients with a thrombus or SEC. However, no other parameters differed between two groups. Patients with a thrombus or SEC correlated well with the CHA2DS2-VASc scores (Fig. 1). All patients with thrombi on TEE had CHA2DS2-VASc scores of 2 or higher, and none of them had a score below 2. Cardioversion was not performed in 12 (7.2%) patients with thrombi and patients with only SEC underwent a cardioversion. A total of 1065 patients underwent cardioversion. LA appendage is an important source of cardiogenic emboli in 70%– 90% of cases with AF. The presence of a thrombus and SEC as well as low blood velocities as assessed by TEE may indicate an increased risk for cardioembolic strokes [5]. Therefore, a preprocedural TEE has been employed by many centers in an attempt to reduce a thromboembolism. However, to current knowledge the impact of using TEE to reduce embolic events from cardioversion of AF has not been assessed to date. Hospitalization for thromboembolism was less than 0.5% in this study, with no difference according to whether TEE was performed. Several
recent studies evaluated the role of TEE in well-anticoagulated patients before AF ablation [3,4]. However, relatively few studies evaluated the role of TEE in patients with adequate anticoagulation [6]. Some studies reported uncertain role of TEE in acute AF patients with a duration of less than 48 h and a low risk of cardioversion-related thromboembolism [7]. In this study, LA thrombus was detected in 7.2%. Prevalence of LA thrombi was increased in AF patients with an impaired LV function, enlargement of LA or LA appendage, and a higher CHADS2 score [8]. Consistently, LA thrombi or SEC were more frequently observed in patients with a high stroke risk. Especially, none of the patients with CHA2DS2-VASc 0 or 1 score had thrombi. The mechanism of thromboembolisms in AF patients is dislodgment of LA thrombi by synchronous atrial contractions during cardioversion. However, thromboembolism occurred in patients without LA thrombi on TEE before cardioversion in this study and many other studies [9,10]. Finally, in this study, strokes were observed during the first week in patients with INR less than 2 at the time of thromboembolism, supporting the role of an optimal INR control for more than 4 weeks following cardioversion of AF. In conclusion, therapeutic INR was maintained for more than 3 weeks for AF lasting for more than 48 h, thromboembolism and bleeding were
Fig. 1. Thrombi or spontaneous echo contrast (SEC) on the TEE according to the CHA2D2-VASc scores. The left and right panels present the number and ratio of patients with thrombi or SEC, respectively. Note that thrombi or SEC were more common as the stroke risk increased.
882
Correspondence
low. Although prevalence of thrombi was 7.2%, no patients with CHA2DS2-VASc score below 2 had thrombi. Pre-cardioversion TEE did not reduce the incidence of cardioversion-related thromboembolism and bleeding. Our data suggested that pre-cardioversion TEE might be an unnecessary attempt to reduce thromboembolism especially in patients with CHA2DS2-VASc score below 2. References [1] A. European Heart Rhythm, European Association for Cardio-Thoracic S, A.J. Camm, P. Kirchhof, G.Y. Lip, U. Schotten, et al., Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC), Europace 12 (2010) 1360–1420. [2] C.T. January, L.S. Wann, J.S. Alpert, H. Calkins, J.E. Cigarroa, J.C. Cleveland Jr., et al., 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society, J. Am. Coll. Cardiol. 64 (2014) e1–e76. [3] J.H. Han, D.H. Shin, H.J. Lee, Y.J. Kim, S.H. Lee, J. Shim, et al., Routine preprocedural transesophageal echocardiography might not be necessary for stroke prevention evaluation in AF patients on anticoagulation therapy, Int. J. Cardiol. 168 (2013) 1992–1996. [4] S.J. Hong, J.Y. Kim, J.B. Kim, J.H. Sung, D. Wook Kim, J.S. Uhm, et al., Multidetector computed tomography may be an adequate screening test to reduce periprocedural
[5]
[6]
[7]
[8] [9]
[10]
stroke in atrial fibrillation ablation: a multicenter propensity-matched analysis, Heart Rhythm. 11 (2014) 763–770. K. Ohara, T. Hirai, N. Fukuda, K. Sakurai, K. Nakagawa, T. Nozawa, et al., Relation of left atrial blood stasis to clinical risk factors in atrial fibrillation, Int. J. Cardiol. 132 (2009) 210–215. K. Seidl, M. Rameken, A. Drogemuller, M. Vater, A. Brandt, H. Schwacke, et al., Embolic events in patients with atrial fibrillation and effective anticoagulation: value of transesophageal echocardiography to guide direct-current cardioversion. Final results of the Ludwigshafen Observational Cardioversion Study, J. Am. Coll. Cardiol. 39 (2002) 1436–1442. M.M. Gallagher, B.J. Hennessy, N. Edvardsson, C.M. Hart, M.S. Shannon, O.A. Obel, et al., Embolic complications of direct current cardioversion of atrial arrhythmias: association with low intensity of anticoagulation at the time of cardioversion, J. Am. Coll. Cardiol. 40 (2002) 926–933. S. Ayirala, S. Kumar, D.M. O'Sullivan, D.I. Silverman, Echocardiographic predictors of left atrial appendage thrombus formation, J. Am. Echocardiogr. 24 (2011) 499–505. I.W. Black, D. Fatkin, K.B. Sagar, B.K. Khandheria, D.Y. Leung, J.M. Galloway, et al., Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study, Circulation 89 (1994) 2509–2513. E. Moreyra, R.S. Finkelhor, R.D. Cebul, Limitations of transesophageal echocardiography in the risk assessment of patients before nonanticoagulated cardioversion from atrial fibrillation and flutter: an analysis of pooled trials, Am. Heart J. 129 (1995) 71–75.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
The effect of transesophageal echocardiography on the incidence of thromboembolism after electrical cardioversion in atrial fibrillation: A multicenter analysis☆,☆☆,★ Dong Geum Shin a, Hee-Sun Mun b, Hye-Young Lee c, Eui Seock Hwang d, Jae-Sun Uhm a, Hui-Nam Pak a, Moon-Hyoung Lee a, Boyoung Joung a,⁎ a
Division of Cardiology, Yonsei University College of Medicine, Seoul, Republic of Korea Division of Cardiology, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Seoul, Republic of Korea c Division of Cardiology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea d Division of Cardiology, Myongji Hospital, Gyeonggi-do, Republic of Korea b
a r t i c l e
i n f o
Article history: Received 20 September 2015 Accepted 4 October 2015 Available online 9 October 2015 Keywords: Atrial fibrillation Transesophageal echocardiography Cardioversion Thromboembolism
Current guidelines advocate for patients with AF ≥ 48 h to achieve a therapeutic International Normalized Ratio (INR) 3 weeks prior to cardioversion and maintain anticoagulation for at least 4 weeks following cardioversion. If a patient did not receive anticoagulation for preceding 3 weeks, it is reasonable to perform a transesophageal echocardiography (TEE) prior to cardioversion [1,2]. However, whether TEE reduces thromboembolism during cardioversion in AF patients receiving guideline-oriented anticoagulation is still controversial. Recently, it was revealed that in AF patients with a low stroke risk, a routine TEE even before ablation might be unnecessary to decrease periprocedural stroke [3,4]. The aim of this study was to determine clinical impact of an additional pre-cardioversion TEE on the incidence of thromboembolism in patients with AF ≥ 48 h under adequate anticoagulation in realworld clinical practice. ☆ No conflicts of interest or relationship with industry. ☆☆ Sources of Funding: This study was supported in part by research grants from the Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education, Science and Technology (NRF-2012R1A2A2A02045367), and a grant of the Korean Healthcare technology R&D project funded by the Ministry of Health & Welfare (HI12C1552). ★ Disclosures: None. ⁎ Corresponding author at: Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 250 Seungsanno, Seodaemun-gu, Seoul 120-752, Republic of Korea. E-mail address: [email protected] (B. Joung).
http://dx.doi.org/10.1016/j.ijcard.2015.10.037 0167-5273/© 2015 Published by Elsevier Ireland Ltd.
From 2005 through 2013, 1077 non-valvular AF patients at four tertiary hospitals in Korea were retrospectively analyzed. Patients with AF ≥ 48 h who underwent electric cardioversion were enrolled. Anticoagulation was performed following current guidelines. Cardiologists decided whether to perform TEE and performed within 24 h before cardioversion with a detailed evaluation of thrombi or spontaneous echo contrast (SEC). Cardioversion was canceled when TEE showed an evidence of thrombi. Physician decided whether to perform cardioversion in case of SEC. Study population was divided into two groups: group 1, patients with TEE and group 2, patients without TEE before cardioversion. The clinical outcomes during 30 days post-cardioversion were assessed for thromboembolism (stroke, transient ischemic attack, or systemic embolism) and bleeding (overt bleeding requiring admission including blood transfusion, decreased hemoglobin level ≥2.0 g/dL, or symptomatic bleeding in a critical organ). The mean duration of anticoagulation before cardioversion was 95 ± 52 days. Table 1 shows the comparisons in characteristics of study populations with TEE (n = 167) and no-TEE (n = 910). TEE group more frequently had heart failure (p = 0.04) and vascular disease (p = 0.002), and higher CHA2DS2-VASc (p b 0.001) and HAS-BLED (p = 0.04) scores. The left atrium (LA) size also was larger in TEE group. After propensity score matching, baseline characteristics were well matched and not differed between two groups (n = 306 vs n = 156). Two (1.2%) and 3 (0.3%) patients had thromboembolism in TEE and no-TEE group, respectively. The proportion of thromboembolisms did not differ between two groups (p = 0.17). Ironically, 2 patients in TEE group did not exhibit even SEC on TEE before cardioversion. The CHA2DS2-VASc score was above 2 in all 5 patients. The INR at the time of cardioversion was above 2 in all cases. However, three patients experienced thromboembolism within a week after cardioversion, and had an INR below 1.7. One (0.6%) and 4 (0.4%) patients were hospitalized for bleeding in TEE and no-TEE groups, respectively. There were no significant differences in the incidence of bleeding between two groups (p = 0.57). All patients with bleeding had a HAS-BLED score higher than 3. Only one patient, who was hospitalized for bleeding, had an INR higher than 3. After propensity score matching, there were 2 patients with thromboembolism in TEE group, and 1 patient with bleeding in both TEE and no-TEE groups without difference between two groups.
Correspondence
881
Table 1 Characteristics of the study population. Total population
Age, years Sex, male Heart failure Hypertension Diabetes mellitus History of stroke/TIA Vascular disease CHA2DS2-VASc score HAS-BLED score Echocardiographic value LV ejection fraction, % LA diameter (AP), mm LAVI, mL/m2 INR at cardioversion Cardioversion success Outcome Thromboembolism Bleeding
Propensity score-matched population
Overall (n = 1077)
No-TEE (n = 910)
TEE (n = 167)
p-Value
No-TEE (n = 306)
TEE (n = 156)
p-Value
60 ± 11 804 (75) 161 (15) 681 (64) 261 (24) 150 (14) 48 (5) 2.0 ± 1.5 2.0 ± 1.2
60 ± 11 683 (75) 125 (14) 564 (62) 215 (24) 125 (14) 33 (4) 1.9 ± 1.4 1.9 ± 1.2
62 ± 12 122 (73) 36 (22) 117 (71) 46 (28) 25 (15) 15 (9) 2.4 ± 1.7 2.1 ± 1.1
0.09 0.58 0.009 0.06 0.28 0.67 0.002 b0.001 0.04
61 ± 10 226 (74) 51 (17) 206 (67) 97 (32) 55 (18) 9 (3) 2.2 ± 1.5 2.1 ± 1.2
61 ± 12 117 (75) 28 (18) 107 (69) 39 (25) 21 (14) 8 (5) 2.2 ± 1.5 2.1 ± 1.2
0.85 0.79 0.73 0.78 0.13 0.21 0.24 0.94 0.92
61 ± 10 47 ± 7 46 ± 17 2.5 ± 0.9 928 (87)
61 ± 9 46 ± 7 45 ± 16 2.5 ± 0.9 799 (88)
60 ± 12 48 ± 7 50 ± 22 2.5 ± 0.9 129 (83)
0.17 0.005 0.008 0.46 0.11
62 ± 9 47 ± 7 46 ± 17 2.5 ± 0.9 269 (88)
60 ± 12 48 ± 7 49 ± 23 2.5 ± 0.9 120 (83)
0.23 0.08 0.15 0.93 0.14
5 (0.5) 5 (0.5)
3 (0.3) 4 (0.4)
2 (1.2) 1 (0.6)
0.17 0.57
0 (0) 1 (0.3)
2 (1.3) 1 (0.6)
0.11 1.0
The numbers in parentheses represent percentages. CHA2DS2-VASc: congestive heart failure, hypertension, age ≥75 (doubled), diabetes mellitus, and prior ischemic stroke, transient ischemic attack or thromboembolism (doubled), vascular disease, age 65 to 74, sex category (female); HAS-BLED: hypertension, abnormal renal/liver function, stroke, bleeding tendency or predisposition, labile INR, elderly (eg. N65), drugs (eg. aspirin, clopidogrel or non-steroidal anti-inflammatory drug) or alcohol abuse; LA: left atrium; LAVI: left atrium volume index; LV: left ventricle; INR: International Normalized Ratio; TEE: transesophageal echocardiography.
In TEE group, thrombi or SEC were observed in 12 (7.2%) and 44 (26.3%) patients, respectively. LA size (p = 0.003) and CHA2DS2-VASc scores (p = b0.001) were significantly higher in patients with a thrombus or SEC. Likewise, prevalence of heart failure (p = 0.05), hypertension (p = b 0.001), and vascular disease (p b 0.001) were significantly higher in patients with a thrombus or SEC. However, no other parameters differed between two groups. Patients with a thrombus or SEC correlated well with the CHA2DS2-VASc scores (Fig. 1). All patients with thrombi on TEE had CHA2DS2-VASc scores of 2 or higher, and none of them had a score below 2. Cardioversion was not performed in 12 (7.2%) patients with thrombi and patients with only SEC underwent a cardioversion. A total of 1065 patients underwent cardioversion. LA appendage is an important source of cardiogenic emboli in 70%– 90% of cases with AF. The presence of a thrombus and SEC as well as low blood velocities as assessed by TEE may indicate an increased risk for cardioembolic strokes [5]. Therefore, a preprocedural TEE has been employed by many centers in an attempt to reduce a thromboembolism. However, to current knowledge the impact of using TEE to reduce embolic events from cardioversion of AF has not been assessed to date. Hospitalization for thromboembolism was less than 0.5% in this study, with no difference according to whether TEE was performed. Several
recent studies evaluated the role of TEE in well-anticoagulated patients before AF ablation [3,4]. However, relatively few studies evaluated the role of TEE in patients with adequate anticoagulation [6]. Some studies reported uncertain role of TEE in acute AF patients with a duration of less than 48 h and a low risk of cardioversion-related thromboembolism [7]. In this study, LA thrombus was detected in 7.2%. Prevalence of LA thrombi was increased in AF patients with an impaired LV function, enlargement of LA or LA appendage, and a higher CHADS2 score [8]. Consistently, LA thrombi or SEC were more frequently observed in patients with a high stroke risk. Especially, none of the patients with CHA2DS2-VASc 0 or 1 score had thrombi. The mechanism of thromboembolisms in AF patients is dislodgment of LA thrombi by synchronous atrial contractions during cardioversion. However, thromboembolism occurred in patients without LA thrombi on TEE before cardioversion in this study and many other studies [9,10]. Finally, in this study, strokes were observed during the first week in patients with INR less than 2 at the time of thromboembolism, supporting the role of an optimal INR control for more than 4 weeks following cardioversion of AF. In conclusion, therapeutic INR was maintained for more than 3 weeks for AF lasting for more than 48 h, thromboembolism and bleeding were
Fig. 1. Thrombi or spontaneous echo contrast (SEC) on the TEE according to the CHA2D2-VASc scores. The left and right panels present the number and ratio of patients with thrombi or SEC, respectively. Note that thrombi or SEC were more common as the stroke risk increased.
882
Correspondence
low. Although prevalence of thrombi was 7.2%, no patients with CHA2DS2-VASc score below 2 had thrombi. Pre-cardioversion TEE did not reduce the incidence of cardioversion-related thromboembolism and bleeding. Our data suggested that pre-cardioversion TEE might be an unnecessary attempt to reduce thromboembolism especially in patients with CHA2DS2-VASc score below 2. References [1] A. European Heart Rhythm, European Association for Cardio-Thoracic S, A.J. Camm, P. Kirchhof, G.Y. Lip, U. Schotten, et al., Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC), Europace 12 (2010) 1360–1420. [2] C.T. January, L.S. Wann, J.S. Alpert, H. Calkins, J.E. Cigarroa, J.C. Cleveland Jr., et al., 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society, J. Am. Coll. Cardiol. 64 (2014) e1–e76. [3] J.H. Han, D.H. Shin, H.J. Lee, Y.J. Kim, S.H. Lee, J. Shim, et al., Routine preprocedural transesophageal echocardiography might not be necessary for stroke prevention evaluation in AF patients on anticoagulation therapy, Int. J. Cardiol. 168 (2013) 1992–1996. [4] S.J. Hong, J.Y. Kim, J.B. Kim, J.H. Sung, D. Wook Kim, J.S. Uhm, et al., Multidetector computed tomography may be an adequate screening test to reduce periprocedural
[5]
[6]
[7]
[8] [9]
[10]
stroke in atrial fibrillation ablation: a multicenter propensity-matched analysis, Heart Rhythm. 11 (2014) 763–770. K. Ohara, T. Hirai, N. Fukuda, K. Sakurai, K. Nakagawa, T. Nozawa, et al., Relation of left atrial blood stasis to clinical risk factors in atrial fibrillation, Int. J. Cardiol. 132 (2009) 210–215. K. Seidl, M. Rameken, A. Drogemuller, M. Vater, A. Brandt, H. Schwacke, et al., Embolic events in patients with atrial fibrillation and effective anticoagulation: value of transesophageal echocardiography to guide direct-current cardioversion. Final results of the Ludwigshafen Observational Cardioversion Study, J. Am. Coll. Cardiol. 39 (2002) 1436–1442. M.M. Gallagher, B.J. Hennessy, N. Edvardsson, C.M. Hart, M.S. Shannon, O.A. Obel, et al., Embolic complications of direct current cardioversion of atrial arrhythmias: association with low intensity of anticoagulation at the time of cardioversion, J. Am. Coll. Cardiol. 40 (2002) 926–933. S. Ayirala, S. Kumar, D.M. O'Sullivan, D.I. Silverman, Echocardiographic predictors of left atrial appendage thrombus formation, J. Am. Echocardiogr. 24 (2011) 499–505. I.W. Black, D. Fatkin, K.B. Sagar, B.K. Khandheria, D.Y. Leung, J.M. Galloway, et al., Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study, Circulation 89 (1994) 2509–2513. E. Moreyra, R.S. Finkelhor, R.D. Cebul, Limitations of transesophageal echocardiography in the risk assessment of patients before nonanticoagulated cardioversion from atrial fibrillation and flutter: an analysis of pooled trials, Am. Heart J. 129 (1995) 71–75.