Early cardioversion of atrial fibrillation and atrial flutter guided by transoesophageal echocardiography - A single centre 8 center dot 5-year experience

Aims To analyse the safety and impact on maintenance of sinus rhythm of tra nsoesophageal echocardiographically guided early cardioversion associated w ith short-term anticoagulation in a large series of patients with atrial fi brillation and atrial flutter. Methods and Results Patients who were candidates for cardioversion were eli gible for inclusion if they had atrial fibrillation or atrial flutter lasti ng longer than 2 days or of unknown duration. Patients received short-term anticoagulation with warfarin or heparin and underwent transthoracic echoca rdiography followed by transoesophageal echocardiography. Early cardioversi on was performed if no thrombus was seen on the transoesophageal study. War farin was maintained for 1 month after cardioversion. In patients with atri al thrombi, cardioversion was deferred and prolonged anticoagulation was pr escribed. The study population included 183 patients. One hundred and sixty nine patients without atrial thrombi underwent early cardioversion. Fourte en patients with atrial thrombi (7.6%) underwent a second transoesophageal echocardiogram after a median of 4 weeks of oral warfarin, and cardioversio n was performed if clot regression was documented. No patient in our study population had a clinical thromboembolic event at 1 month follow-up (95% C. I. 0-0016). The immediate success rate of cardioversion was better among pa tients with atrial fibrillation <4 weeks duration compared with patients wi th atrial fibrillation of longer or of unknown duration: 96.6% vs 85%, resp ectively (P=0.014). At 1 month follow-up, the percentage of arrhythmia rela pses in patients with initially successful cardioversion was similar in the two groups (29% vs 26%, P=ns), thus the initial better outcome in patients with recent-onset arrhythmia was not lost. Conclusion Transoesophageal echocardiography-guided early cardioversion in concert with short-term anticoagulation is safe. This approach permits abbr eviation of the overall duration of atrial fibrillation and has a better im pact on the maintenance of sinus rhythm for patients in whom the duration o f atrial fibrillation is <4 weeks. (Europace 2000; 2: 119-126) (C) 2000 The European Society of Cardiology.