Correspondence

Cardioversion of Atrial Fibrillation

N Engl J Med 1999; 341:1313October 21, 1999

Article

To the Editor:

In the study by Oral and colleagues on the efficacy of ibutilide for facilitating transthoracic cardioversion of atrial fibrillation (June 17 issue),1 patients with atrial fibrillation of more than 48 hours' duration were excluded unless “cardioversion was preceded either by transesophageal echocardiography to rule out the possibility of intracardiac thrombi or by therapeutic anticoagulation . . . for at least three weeks.” Although we2 and others3 have advocated the use of transesophageal echocardiography to facilitate early and safe cardioversion, the weight of published data suggests that transesophageal echocardiography be performed only after complete anticoagulation with heparin or warfarin and that therapeutic anticoagulation be continued during cardioversion and for one month after cardioversion.2,3 Anticoagulation after cardioversion allows prophylaxis against thrombus formation during the recovery of atrial mechanical function4 and prevents new thrombus formation, should the rhythm revert to atrial fibrillation. Without such a strategy for anticoagulation, the risk of thromboembolism in patients with a “negative” transesophageal echocardiogram may be unacceptably high.5

Warren J. Manning, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 02215

David I. Silverman, M.D.
University of Connecticut Health Center, Farmington, CT 06030

5 References

1. 1

   Oral H, Souza JJ, Michaud GF, et al. Facilitating transthoracic cardioversion of atrial fibrillation with ibutilide pretreatment. N Engl J Med 1999;340:1849-1854
   Full Text | Web of Science | Medline

2. 2

   Manning WJ, Silverman DI, Gordon SPF, Krumholz HM, Douglas PS. Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi. N Engl J Med 1993;328:750-756
   Full Text | Web of Science | Medline

3. 3

   Klein AL, Grimm RA, Black IW, et al. Cardioversion guided by transesophageal echocardiography: the ACUTE Pilot Study: a randomized, controlled trial. Ann Intern Med 1997;126:200-209
   Web of Science | Medline

4. 4

   Manning WJ, Silverman DI, Katz SE, et al. Impaired left atrial mechanical function after cardioversion: relationship to the duration of atrial fibrillation. J Am Coll Cardiol 1994;23:1535-1540
   CrossRef | Web of Science | Medline

5. 5

   Black IW, Fatkin D, Sagar KB, et al. Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation: a multicenter study. Circulation 1994;89:2509-2513
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Although it was not stated in the Methods section of our report, all the patients in our study in whom transesophageal echocardiography was performed underwent therapeutic anticoagulation with either heparin or warfarin before the procedure and for one month afterward.

Hakan Oral, M.D.
Fred Morady, M.D.
University of Michigan, Ann Arbor, MI 48109

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