• A L Klein, R A Grimm, I W Black, D Y Leung, M K Chung, S E Vaughn, R D Murray, D P Miller, and K L Arheart.
• Cleveland Clinic Foundation, Department of Cardiology, OH 44195, USA.
• Ann. Intern. Med. 1997 Feb 1;126(3):200-9.

BackgroundElectrical cardioversion in patients with atrial fibrillation is associated with an increased risk for embolic stroke. Screening for atrial thrombi with transesophageal echocardiography (TEE) before cardioversion should, in many patients, safely permit cardioversion to be done earlier than would be possible with prolonged conventional, anticoagulation therapy.ObjectiveTo compare the feasibility and safety of TEE-guided early cardioversion with those of conventional management of cardioversion in patients with atrial fibrillation.DesignRandomized, multicenter clinical trial.Setting10 hospitals in the United States, Europe, and Australia.Patients126 patients who had atrial fibrillation lasting longer than 2 days and were having electrical cardioversion.InterventionConventional therapy or early, TEE-guided cardioversion with short-term anticoagulation therapy.Outcome MeasuresFeasibility outcome variables were frequency of cardioversion and times to cardioversion and sinus rhythm. Safety outcomes were ischemic stroke, transient ischemic attack, systemic embolization, bleeding, and detected episodes of clinical hemodynamic instability occurring as long as 4 weeks after cardioversion.Results62 patients were randomly assigned to receive TEE-guided cardioversion; TEE was done in 56 (90%) of these patients. Atrial thrombi were detected in 7 patients (13%) and led to the postponement of cardioversion. Cardioversion was successful in 38 of 45 patients (84%) who had early cardioversion. No embolization occurred with this strategy. Of the 64 patients receiving conventional therapy, 37 (58%) had cardioversion, which was successful in 28 patients (76%). One patient had a peripheral embolic event. The time to cardioversion was shorter in the TEE group (0.6 weeks [95% CI, 0.3 to 0.9 weeks] compared with 4.8 weeks [CI, 3.8 to 5.7 weeks]; P < 0.01). The incidence of clinical hemodynamic instability and bleeding complications tended to be greater in the conventional therapy group.ConclusionsThese results suggest that TEE-guided cardioversion with short-term anticoagulation therapy is feasible and safe. The use of TEE may allow cardioversion to be done earlier, may decrease the risk for embolism associated with cardioversion, and may be associated with less clinical instability than conventional therapy. A large, multicenter study to confirm these findings is currently under way.

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