Circulation, Vol 89, 2509-2513, Copyright © 1994 by American Heart Association
IW Black, D Fatkin, KB Sagar, BK Khandheria, DY Leung, JM Galloway, MP Feneley, WF Walsh, RA Grimm and C Stollberger
BACKGROUND: Transesophageal echocardiography (TEE) has been used recently
to detect atrial thrombi before cardioversion of atrial arrhythmias. It has
been assumed that embolic events after cardioversion result from embolism
of preexisting atrial thrombi that are accurately detected by TEE. This
study examined the clinical and echocardiographic findings in patients with
embolism after cardioversion of atrial fibrillation despite exclusion of
atrial thrombi by TEE. METHODS AND RESULTS: Clinical and echocardiographic
data in 17 patients with embolic events after TEE-guided electrical (n =
16) or pharmacological (n = 1) cardioversion were analyzed. All 17 patients
had nonvalvular atrial fibrillation, including four patients with lone
atrial fibrillation. TEE before cardioversion showed left atrial
spontaneous echo contrast in five patients and did not show atrial thrombus
in any patient. Cardioversion resulted in return to sinus rhythm without
immediate complication in all patients. Thirteen patients had cerebral
embolic events and four patients had peripheral embolism occurring 2 hours
to 7 days after cardioversion. None of the patients were therapeutically
anticoagulated at the time of embolism. New or increased left atrial
spontaneous echo contrast was detected in four of the five patients
undergoing repeat TEE after cardioversion including one patient with a new
left atrial appendage thrombus. CONCLUSIONS: Embolism may occur after
cardioversion of atrial fibrillation in inadequately anticoagulated
patients despite apparent exclusion of preexisting atrial thrombus by TEE.
These findings suggest de novo atrial thrombosis after cardioversion or
imperfect sensitivity of TEE for atrial thrombi and suggest that screening
by TEE does not obviate the requirement for anticoagulant therapy at the
time of and after cardioversion. A randomized clinical trial is needed to
compare conventional anticoagulant management with a TEE-guided strategy
including anticoagulation after cardioversion.
ARTICLES
Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study
Department of Cardiology, Cleveland Clinic Foundation, OH 44195.
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