Indications for TEE Before Cardioversion for Atrial Fibrillation: Implications for Appropriateness Criteria
Author + information
- Gaganpreet K. Grewal, BS⁎,
- Tristan B. Klosterman, BS⁎,
- Kevin Shrestha, BS⁎,
- Hirad Yarmohammadi, MD⁎,
- Andrew O. Zurick, MD⁎,
- Brandon C. Varr, MD†,
- W.H. Wilson Tang, MD⁎,
- Bruce D. Lindsay, MD⁎ and
- Allan L. Klein, MD⁎,⁎ (kleina{at}ccf.org)
- ↵⁎Reprint requests and correspondence:
Dr. Allan L. Klein, Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, Ohio 44195
Abstract
The purpose of this study was to evaluate appropriateness of transesophageal echocardiography (TEE) before direct current cardioversion (DCC), investigate indications for TEE, and analyze if indications are predictive of outcome. According to American College of Cardiology Foundation/American Society of Echocardiography 2011 Appropriateness Criteria, TEE is appropriate in the evaluation of patients with atrial fibrillation (AF) to facilitate clinical decision making with regards to anticoagulation and/or DCC. However, it is unclear in which instances physicians utilize TEE. We reviewed 671 TEE studies in 604 AF patients (age 66 ± 13 years, 67% male) in which TEE was performed before DCC for left atrial thrombus (LAT)/sludge. Studies were divided by the main indication for TEE into the following 8 categories: 1) congestive heart failure (CHF)/hemodynamic compromise; 2) symptomatic; 3) new onset AF; 4) hospitalized and symptomatic; 5) high stroke risk; 6) subtherapeutic anticoagulation; 7) miscellaneous; and 8) inappropriate for TEE. The main indications for TEE before DCC were symptomatic (26.4%) and CHF/hemodynamic compromise (26.1%). We deemed 2.7% of the studies as inappropriate. LAT/sludge was found in 8.2% of studies. Incidence of LAT/sludge differed significantly between indications (p = 0.0021) and the highest incidences occurred in the high stroke risk (17.6%) and hospitalized and symptomatic (14.1%) categories. No LAT/sludge was found in the miscellaneous or inappropriate groups. Stroke occurred in 2.5% (n = 15) of all patients and in all groups except for miscellaneous and inappropriate (p = 0.3). TEE is appropriately used prior to DCC for patients with the main indications of symptomatic and CHF/hemodynamic compromise. In a minority of studies, TEE utilization was inappropriate. Incidence of LAT/sludge differed between indications.
Footnotes
Dr. Tang is a consultant for Medtronic Inc. and St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 18, 2011.
- Revision received November 7, 2011.
- Accepted December 22, 2011.
- American College of Cardiology Foundation
