REPLY
Transesophageal Echocardiography-Guided Cardioversion: Going for Broke?
Eric N. Prystowsky, MD
15 October 1997 | Volume 127 Issue 8 (Part 1) | Pages 652-653
IN RESPONSE:
The TEE-guided approach to cardioversion used by experts is safe, as shown by Manning and colleagues [1]. The ACUTE Pilot Study [2] compared the TEE-guided approach with the conventional approach to cardioversion. In my editorial, I suggested that a larger-scale clinical trial should provide valuable data about the risk for thromboembolism. However, I also questioned the "supposed" major limitations of the conventional approach, as outlined by Klein and coworkers [2]. The use of anticoagulation before cardioversion carries a risk for embolism of 1% or less. Thus, the data to date do not suggest a major risk for emboli with the conventional approach. Furthermore, the ACUTE Pilot Study showed no difference between approaches in the rate of successful cardioversion or the presence of sinus rhythm at follow-up [2]. Of note, most patients with atrial fibrillation have an indication for long-term anticoagulation [3]. In this setting, loss of a few weeks of anticoagulation before cardioversion seems meaningless.
In the hospitalized patient, the potential benefits of the TEE-guided approach are much more realistic. One can perform cardioversion quickly and initiate antiarrhythmic drug therapy while patients are still in the hospital, which will maximize safety with regard to potential proarrhythmic effects. This may preclude the need for rehospitalization.
Klein and coworkers paraphrase my initial query, "If it ain't broke, why fix it?" They suggest that we need to "go for broke." Indeed, this is exactly what we should avoid. In my opinion, the expense of using TEE as a routine procedure for all or most outpatient elective cardioversions for atrial fibrillation could add a major and possibly unnecessary financial burden to the health care system. Thus, I still favor judicious and individualized use of the TEE-guided approach for outpatient cardioversion until the final results of a large-scale prospective study suggest otherwise.
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Author and Article Information
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Northside Cardiology, P.C.; Indianapolis, IN 46260
1. Manning WJ, Silverman DI, Keighley CS, Oettgen P, Douglas PS. Transesophageal echocardiography facilitated early cardioversion from atrial fibrillation using short-term anticoagulation: final results of a prospective 4.5-year study. J Am Coll Cardiol. 1995; 25:1354-61.
2. Klein AL, Grimm RA, Black IW, Leung DY, Chung MK, Vaughn SE, et al. Cardioversion guided by transesophageal echocardiography: the ACUTE Pilot Study. A randomized, controlled trial. Ann Intern Med. 1997; 126:200-9.
3. Prystowsky EN, Benson DW Jr, Fuster V, Hart RG, Kay GN, Myerburg RJ, et al. Management of patients with atrial fibrillation. A statement for healthcare professionals. From the Subcommittee on Electrocardiography and Electrophysiology, American Heart Association. Circulation. 1996; 93:1262-77.
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