Early cardioversion of atrial fibrillation facilitated by transesophageal echocardiography: Short-term safety and impact on maintenance of sinus rhythm at 1 year

BACKGROUND: For patients presenting with atrial fibrillation of only a few weeks duration, the use of transesophageal echocardiography offers the oppo rtunity to markedly abbreviate the duration of atrial fibrillation before c ardioversion. We sought to determine if the shorter duration of atrial fibr illation allowed by a transesophageal echocardiography strategy had an impa ct on the recurrence of atrial fibrillation and prevalence of sinus rhythm during the first year following cardioversion. METHODS: Transesophageal echocardiography was attempted in 539 patients (29 2 men, 247 women; 71.6 +/- 13.0 years.) with atrial fibrillation greater th an or equal to2 days (66.1% <3 weeks) or of unknown duration before electiv e cardioversion of atrial fibrillation. Therapeutic anticoagulation at the time of transesophageal echocardiography was present in 94.6% of patients, and 73.4% of subjects were discharged on warfarin. RESULTS: Atrial thrombi were identified in 70 (13.1%) patients. Successful cardioversion in 413 patients without evidence of atrial thrombi was associ ated with clinical thromboembolism in 1 patient (0.24%, 95% confidence inte rval: 0.0-0.8%). In patients with atrial fibrillation <3 weeks at the time of cardioversion (a duration incompatible with conventional therapy of 3 to 4 weeks of warfarin before cardioversion), the 1-year atrial fibrillation recurrence rate was lower (41.1% vs. 57.9%, P <0.01), and the prevalence of sinus rhythm at 1 year was increased (65.8% vs. 51.3%, P <0.03). No other clinical or echocardiographic index was associated with recurrence of atria l fibrillation or sinus rhythm at 1 year. CONCLUSIONS: Early cardioversion facilitated by transesophageal echocardiog raphy has a favorable safety profile and provides the associated benefit of reduced recurrence of atrial fibrillation for patients in whom the duratio n of atrial fibrillation is <3 weeks. Am J Med. 2001;110:694-702. (C) 2001 by Excerpta Medica, Inc.