Elective cardioversion of atrial fibrillation is safe without transesophageal echocardiography in patients treated with non-vitamin K antagonist oral anticoagulants: Multicenter experience.

BACKGROUND: Current guidelines recommend electrical cardioversion (ECV) in patients with atrial fibrillation (AF) after at least 3 weeks of adequate non-vitamin K antagonist oral anticoagulant (NOAC) treatment without prior transesophageal echocardiography (TEE). However, in clinical practice in some centres, TEE is performed before ECV in patients with AF. The aim of the study was to evaluate prevalence of thromboembolic and hemorrhagic complications in patients with AF treated with NOACs and undergoing ECV without prior TEE. METHODS: This observational, multicentre study included consecutive patients with AF treated with NOACs who were admitted for ECV without prior TEE. Thromboembolic events and major bleeding complications were investigated during a 30-day follow-up. RESULTS: In the study group there were 611 patients, mean age was 66.3 ± 9.2 years, 40% were women. 52 (8.5%) patients had a low thromboembolic risk, 148 (24.2%) patients had an intermediate thromboembolic risk and 411 (67.2%) patients had a high thromboembolic risk. In the study group 253 (41.4%) patients were treated with rivaroxaban, 252 (41.2%) patients were treated with dabigatran and 106 (17.3%) patients were treated with apixaban. Reduced doses of NOACs were administered to 113 (18.9%) patients. In the entire study group, there were no thromboembolic events or major bleeding complications during the in-hospital stay and the 30-day follow-up. CONCLUSIONS: In this "real-world" study of AF patients treated with NOACs, it was proved that ECV is safe without a preceding TEE, regardless of the risk of thromboembolic complications and of the type of NOAC used.

Factors determining elective cardioversion preceded by transesophageal echocardiography: experiences of 2 cardiology centers.

INTRODUCTION: Although guidelines endorse cardioversion after adequate non-vitamin K antagonist oral anticoagulant (NOAC) treatment without prior transesophageal echocardiography (TEE), the majority of patients still undergo this examination. OBJECTIVES: The aim of this study was to assess factors determining the decision to perform TEE in patients with atrial fibrillation (AF) who are eligible for elective cardioversion. PATIENTS AND METHODS: In this study, we evaluated the medical records of consecutive patients with AF who were admitted for elective cardioversion after prior NOAC treatment. RESULTS: Of a total of 668 patients included in the study, 362 individuals (54%) underwent TEE before cardioversion. In the univariable analysis, paroxysmal AF, hypertension, coronary artery disease (CAD), thromboembolic events, a history of percutaneous coronary intervention, a history of bleeding, left ventricular ejection fraction, left ventricular end­ diastolic diameter, a reduced dose of NOACs, hemoglobin levels, impaired renal filtration, and a high CHA2DS2­VASc score were significant predictors of the decision to perform TEE. In the multivariable logistic regression analysis, a history of CAD, bleeding, and stroke / transient ischemic attack / thromboembolism remained independent predictors of referring a patient for TEE (odds ratio [OR], 3.92, P <0.001; OR, 7.92, P <0.001; and OR, 2.36, P = 0.02, respectively). In contrast, paroxysmal AF (OR, 0.31; P = 0.02) and hypertension (OR, 0.28; P <0.001) were indicators of refraining from TEE. CONCLUSIONS: Transesophageal echocardiography before cardioversion was more frequently performed in patients with a history of CAD, bleeding, or thromboembolic events. Patients with paroxysmal AF and hypertension more often received cardioversion without prior TEE.

Sudden cardiac arrest in takotsubo cardiomyopathy - a case study.

We present a 59-year-old woman who was admitted to hospital after sudden cardiac arrest due to ventricular fibrillation. Finally takotsubo syndrome was diagnosed. In the acute phase of takotsubo syndrome life-threatening ventricular arrhythmias and significant hemodynamic disorders may occur due to strong adrenergic stimulation and myocardial ischemia. It has been proved that the occurrence of torsade de pointes tachycardia in the acute phase of takotsubo cardiomyopathy is associated with QT prolongation. There are no clear guidelines on pharmacological treatment and implantable cardioverter defibrillator implantation after a past takotsubo episode. Takotsubo cardiomyopathy has not been entirely explained as an etiological disease.