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Cardioversion Guided by Transesophageal Echocardiography: The ACUTE Pilot Study: A Randomized, Controlled Trial

Allan L. Klein, MD; Richard A. Grimm, DO; Ian W. Black, MD; Dominic Y. Leung, MB, BS; Mina K. Chung, MD; Susan E. Vaughn, RN; R. Daniel Murray, PhD; Dave P. Miller, MS; and Kristopher L. Arheart, EdD
[+] Article, Author, and Disclosure Information

For the ACUTE Investigators Acknowledgments: The authors thank Yolonda E. Simpson for typing the manuscript, Paula Shalling for preparing the figures, and Tom Lang for editorial assistance. Requests for Reprints: Allan L. Klein, MD, the Cleveland Clinic Foundation, Department of Cardiology, Desk F15, 9500 Euclid Avenue, Cleveland, OH 44195. Current Author Addresses: Drs. Klein, Grimm, Leung, Chung, and Murray and Ms. Vaughn: The Cleveland Clinic Foundation, Department of Cardiology, Desk F15, 9500 Euclid Avenue, Cleveland, OH 44195.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1997;126(3):200-209. doi:10.7326/0003-4819-126-3-199702010-00004
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Background: Electrical 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.

Objective: To compare the feasibility and safety of TEE-guided early cardioversion with those of conventional management of cardioversion in patients with atrial fibrillation.

Design: Randomized, multicenter clinical trial.

Setting: 10 hospitals in the United States, Europe, and Australia.

Patients: 126 patients who had atrial fibrillation lasting longer than 2 days and were having electrical cardioversion.

Intervention: Conventional therapy or early, TEE-guided cardioversion with short-term anticoagulation therapy.

Outcome Measures: Feasibility 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.

Results: 62 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.

Conclusions: These 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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Figure 1.
The ACUTE (Assessment of Cardioversion Using Transesophageal Echocardiography) study protocol.

Patients with atrial fibrillation were randomly assigned to receive either cardioversion with conventional therapy or cardioversion guided by transesophageal echocardiography (TEE) with brief anticoagulation therapy. The conventional therapy group received warfarin therapy for 3 weeks before and 4 weeks after cardioversion. In the TEE group, patients were stratified according to whether a thrombus was detected in either the left atrium or the left atrial appendage. Patients in the TEE group were fully anticoagulated at the time of cardioversion and for 4 weeks after cardioversion. LA = left atrial; LAA = left atrial appendage.

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Figure 2.
Outcome of the 62 patients in the group assigned to receive transesophageal echocardiography-guided cardioversion.

Numbers in parentheses are numbers of patients.

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Figure 3.
Transesophageal echocardiograms. Top.arrowBottom.arrow

An 8.5-mm protruding thrombus ( ) in the right atrial appendage of a 53-year-old man. A 9-mm left atrial appendage thrombus ( ) in a 70-year-old man. LAA = left atrial appendage; RAA = right atrial appendage.

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Figure 4.
Outcome of the 64 patients assigned to receive conventional therapy.

Numbers in parentheses are numbers of patients.

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