Transesophageal echocardiographic-guided cardioversion

Abstract

The incidence and prevalence of atrial fibrillation (AF) continues to grow especially as the population ages. The uncoordinated atrial activation and subsequent ineffective atrial contraction is a strong stimulus for left atrial (LA) thrombus formation especially in the LA appendage. AF is associated with increased risk of stroke, heart failure, and all-cause mortality. The presence of LA thrombus in AF portends a poor prognosis. Direct current cardioversion (DCCV) is the most effective method of restoring sinus rhythm and, with it there is relief of symptoms, improved LV filling, reversed atrial remodeling, and possibly reduced cardio-embolic risk. However, there are significant risks of systemic embolization following DCCV if LA thrombus is present. Transesophageal echocardiography (TEE) is an ideal non-invasive imaging modality to detect thrombus in the LA and especially in the LA appendage. Its proper use can lead to earlier DCCV for AF and improve safety of DCCV in AF. A key part of this strategy is proper use of anticoagulation therapy. This chapter illustrates the important role of TEE in patient evaluation and risk stratification prior to cardioversion.