TEE as a Guide to Anticoagulation
Prior to Electrical Cardioversion
by Karoon
Nititham , M.D.
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The standard of care for the elimination or control of atrial fibrillation has long been either antiarrhythmic drugs and/or electrical cardioversion. Because of the potential existence of thrombi and the risk of systemic embolization, patients about to undergo electrical cardioversion are usually anticoagulated with Coumadin® for 4-8 weeks prior to the procedure. Some patients may be able to endure the fatigue and palpitations frequently associated with atrial fibrillation during this waiting period. For others, their condition worsens.
A new standard of care for patients with atrial fibrillation is reducing the amount of time spent on anticoagulants by taking the guesswork out of determining whether or not a thrombus exists. Using transesophageal echocardiography (TEE) prior to cardioversion, cardiologists can now clearly visualize the left atrium and conclude whether or not a thrombus is present.
If a thrombus is found, anticoagulation would be prolonged and a subsequent TEE would determine whether residual thrombosis remained. If no thrombi are found, the patient can take a shorter course of anticoagulants and have the cardioversion performed much sooner than the typical 4-8 weeks. This is an important change for symptomatic patients.
In the case of J.D., since her atrial fibrillation was of acute onset, she was started on heparin and scheduled for electrical cardioversion. (See Case Study) To be safe, a TEE was performed immediately prior to the scheduled cardioversion. The TEE showed a thrombus in formation in the left atrial appendage. (See Figure 1.) The procedure was then postponed, and the patient was placed on Coumadin® for six weeks. A follow-up TEE showed that the thrombus had lysed, and a successful cardioversion was performed.
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Case
Study
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Patient: J.D., 62-year-old female from Evanston History: Uncomplicated CABG for treatment of progressive angina pectoris three months earlier Symptoms: Acute onset of dyspnea Tests: ECG Diagnosis: Atrial fibrillation, new onset Treatment: TEE (thrombus identified in left atrial appendage), 6 weeks of Coumadin®, repeat TEE (thrombus no longer present), electrical cardioversion |
Figure
1:
TEE view of thrombus in left atrial appendage just prior to Coumadin®
In this case,
the success lies not so much in the fact that J.D. is now symptom-free,
but in the fact that life-threatening systemic embolization was avoided.
Since TEE can be performed on an outpatient basis, it does not add to
a patient’s length of stay and, in fact, helps prevent a pro-longed complicated
hospitalization.
So far, none of the patients who have undergone pre-cardioversion TEE in the lab at St. Francis Hospital, Evanston have suffered a systemic embolic event.
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