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Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi.

Publication ,  Journal Article
Manning, WJ; Silverman, DI; Gordon, SP; Krumholz, HM; Douglas, PS
Published in: N Engl J Med
March 18, 1993

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.

Duke Scholars

Published In

N Engl J Med

DOI

ISSN

0028-4793

Publication Date

March 18, 1993

Volume

328

Issue

11

Start / End Page

750 / 755

Location

United States

Related Subject Headings

  • Warfarin
  • Middle Aged
  • Male
  • Humans
  • Heparin
  • Heart Atria
  • General & Internal Medicine
  • Female
  • Electric Countershock
  • Echocardiography
 

Citation

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Manning, W. J., Silverman, D. I., Gordon, S. P., Krumholz, H. M., & Douglas, P. S. (1993). Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi. N Engl J Med, 328(11), 750–755. https://doi.org/10.1056/NEJM199303183281102
Manning, W. J., D. I. Silverman, S. P. Gordon, H. M. Krumholz, and P. S. Douglas. “Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi.N Engl J Med 328, no. 11 (March 18, 1993): 750–55. https://doi.org/10.1056/NEJM199303183281102.
Manning, W. J., et al. “Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi.N Engl J Med, vol. 328, no. 11, Mar. 1993, pp. 750–55. Pubmed, doi:10.1056/NEJM199303183281102.
Manning WJ, Silverman DI, Gordon SP, Krumholz HM, Douglas PS. Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi. N Engl J Med. 1993 Mar 18;328(11):750–755.
Journal cover image

Published In

N Engl J Med

DOI

ISSN

0028-4793

Publication Date

March 18, 1993

Volume

328

Issue

11

Start / End Page

750 / 755

Location

United States

Related Subject Headings

  • Warfarin
  • Middle Aged
  • Male
  • Humans
  • Heparin
  • Heart Atria
  • General & Internal Medicine
  • Female
  • Electric Countershock
  • Echocardiography