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Previous Volume 328:750-755 March 18, 1993 Number 11 Next

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ABSTRACT

Background Because atrial thrombi are poorly detected by conventional noninvasive techniques such as transthoracic echocardiography, patients with prolonged atrial fibrillation usually receive several weeks of oral anticoagulation therapy before cardioversion is attempted. We wondered whether transesophageal echocardiography, an accurate method of detecting atrial thrombi, would allow early cardioversion to be performed safely if no thrombi were identified.

Methods A total of 669 consecutive patients admitted with the diagnosis of atrial fibrillation were screened. Patients were excluded if they were receiving long-term anticoagulation, if the duration of atrial fibrillation was two days or less, if they were not candidates for cardioversion, or if transesophageal echocardiography was contraindicated. Of 119 qualifying patients, 94 agreed to participate; the average duration of atrial fibrillation was 4.5 weeks. Participating patients underwent transthoracic echocardiography and transesophageal echocardiography followed by cardioversion if no thrombi were seen. Short-term anticoagulation with heparin was used in 80 patients before cardioversion, and 60 patients received warfarin for one month after cardioversion.

Results Fourteen atrial thrombi were identified in 12 patients (13 percent), and 12 of the 14 thrombi were visualized only on transesophageal echocardiography. Cardioversion was deferred in all 12 patients. Two of these 12 patients died suddenly; 4 of the 10 surviving patients underwent uneventful cardioversion after prolonged oral anticoagulation. Seventy-eight of the 82 patients without thrombi underwent successful cardioversion to sinus rhythm (47 by means of antiarrhythmic drugs and 31 by electrical cardioversion), all without long-term oral anticoagulation. None of these patients (95 percent confidence interval, 0 to 4.6 percent) had an embolic event.

Conclusions In patients with atrial fibrillation of unknown or prolonged duration who are not receiving long-term anticoagulation, atrial thrombi are detected by transesophageal echocardiography in only a small minority (13 percent in our study). Our preliminary data suggest that if transesophageal echocardiography excludes the presence of thrombi, early cardioversion can be performed safely without the need for prolonged oral anticoagulation before the procedure.

Source Information

From the Charles A. Dana Research Institute and the Harvard-Thorndike Laboratory of the Department of Medicine, Cardiovascular Division, Beth Israel Hospital and Harvard Medical School, Boston (W.J.M., S.P.F.G., H.M.K., P.S.D.), and the University of Connecticut Health Center, Cardiology Division, Farmington (D.I.S.).

Address reprint requests to Dr. Manning at the Cardiovascular Division, Beth Israel Hospital, 330 Brookline Ave., Boston, MA 02215.

Full Text of this Article

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Transesophageal Echocardiography before Cardioversion
Grimm R. A., Black I. W., Klein A. L., Manning W. J., Silverman D. I., Douglas P. S.
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N Engl J Med 1993; 329:577-578, Aug 19, 1993. Correspondence

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