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Fig. 9. Midesophageal view of right atrial appendage at omni-plane 137°. Less than 10% of all atrial thrombi occur on the right. Note the broader neck of the right appendage compared to the left.

Fig. 9. Midesophageal view of right atrial appendage at omni-plane 137°. Less than 10% of all atrial thrombi occur on the right. Note the broader neck of the right appendage compared to the left.

anticoagulation in this manner is intended to minimize the formation of microthrombi, and to prevent thrombi from forming during the postcardioversion period. It has been demonstrated that during the immediate post-cardioversion period, electrical, pharmacological, and even spontaneous conversion to sinus rhythm is associated with relatively depressed atrial appendage mechanical function. The peri-cardioversion period, therefore, appears to be one in which a patient is at somewhat increased risk for new thrombus formation and physicians should be especially vigilant regarding therapeutic anticoagulation.

At least four prospective studies have examined the safety of a TEE-guided approach to early cardioversion of AF of 2 days or longer duration. These studies demonstrate that 12% of patients will have TEE evidence of atrial thrombi. This apparent discrepancy between the 12% prevalence of atrial thrombus on TEE and the 6% historical rate of clinical thrombo-embolism for nonanticoagulated patients is likely explained by (1) the imperfect specificity of TEE; (2) the likelihood that not all thrombi migrate after cardioversion; and (3) not all thrombus migration is associated with clinical thromboembolism. TEE evidence for atrial thrombus is associated with spontaneous echo contrast, prior thromboembolism, and left ventricular systolic dysfunction.

Using the anticoagulation strategy described in Fig. 10, and based on almost 2000 prospectively studied patients, clinical thromboembolism has been reported in less than 0.5% of patients following a "negative" TEE for atrial

Echocardiography Images

Fig. 10. Transesophageal echocardiography-guided cardioversion strategy in atrial fibrillation. Management of patients presenting with atrial fibrillation of unknown or more than 2 d duration. Patients with a thrombus on the initial transesphageal echocardiography (TEE) should received 1 mo of warfarin followed by a TEE to document complete thrombus resolution before elective cardioversion. (From Seto TB et al. Cost-effectiveness of transesophageal echocardiography guided cardioversion for hospitalized patients with atrial fibrillation. J Am Cardiol 1997;29:122-130.

Fig. 10. Transesophageal echocardiography-guided cardioversion strategy in atrial fibrillation. Management of patients presenting with atrial fibrillation of unknown or more than 2 d duration. Patients with a thrombus on the initial transesphageal echocardiography (TEE) should received 1 mo of warfarin followed by a TEE to document complete thrombus resolution before elective cardioversion. (From Seto TB et al. Cost-effectiveness of transesophageal echocardiography guided cardioversion for hospitalized patients with atrial fibrillation. J Am Cardiol 1997;29:122-130.

thrombus. The largest reported series is the multicenter 1222 patient Assessment of Cardioversion Using Transesophageal Echocardiography trial in which patients were randomized to a conservative approach of 1 mo of warfarin or the TEE-facilitated approach. This study confirmed the "equivalence" of the expedited TEE and the conventional approaches. Optimal patients for TEE expedited cardioversion likely include those with a relatively brief (<1 mo) duration of AF, or those with an increased risk of hemorrhagic complications. Assuming expeditious performance of TEE and cardioversion, thereby not prolonging the initial hospitalization, the TEE approach has been shown to be cost effective for inpa-tients and for enhancing long-term maintenance of sinus rhythm. At our Center, TEE-facilitated cardioversion is offered for nearly all inpatients. For outpatients, TEE is only generally offered to those patients at increased risk for a warfarin complication or those who are highly symptomatic. Other sites equally offer the TEE strategy to inpatients and outpatients.

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