Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation

Electrical cardioversion of patients with atrial fibrillation (AF) is frequ ently performed to relieve symptoms and improve cardiac performance. Patien ts undergoing cardioversion are treated conventionally with therapeutic ant icoagulation for three weeks before and four weeks after cardioversion to d ecrease the risk of thromboembolism. A transesophageal echocardiography (TE E)-guided strategy has been proposed as an alternative that may lower strok e and bleeding events. Patients without atrial cavity thrombus or atrial ap pendage thrombus by TEE are cardioverted on achievement of therapeutic anti coagulation, whereas cardioversion is delayed in higher risk patients with thrombus. The aim of this review is to discuss the issues and controversies associated with the management of patients with AF undergoing cardioversio n. We provide an overview of the TEE-guided and conventional anticoagulatio n strategies in light of the recently completed Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) clinical trial. The two man agement strategies comparably lower the patient's embolic risk when the gui delines are properly followed. The TEE-guided strategy with shorter term an ticoagulation may lower the incidence of bleeding complications and safely expedite early cardioversion. The inherent advantages and disadvantages of both strategies are presented. The TEE-guided approach with short-term anti coagulation is considered to be a safe and clinically effective alternative to the conventional approach, and it is advocated in patients in whom earl ier cardioversion would be clinically beneficial. (J Am Coil Cardiol 2001;3 7:691-704) (C) 2001 by the American College of Cardiology.