Cardioversion guided by transesophageal echocardiography

The ACUTE Pilot Study: A randomized, controlled trial

Allan L. Klein, Richard A. Grimm, Ian W. Black, Dominic Y. Leung, Mina K. Chung, Susan E. Vaughn, R. Daniel Murray, Dave P. Miller, Kristopher Arheart

Research output: Contribution to journalArticle

205 Citations (Scopus)

Abstract

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.

Original languageEnglish
Pages (from-to)200-209
Number of pages10
JournalAnnals of Internal Medicine
Volume126
Issue number3
StatePublished - Feb 13 1997
Externally publishedYes

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Electric Countershock
Transesophageal Echocardiography
Randomized Controlled Trials
Atrial Fibrillation
Multicenter Studies
Thrombosis
Therapeutics
Hemodynamics
Stroke
Hemorrhage
Safety

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Klein, A. L., Grimm, R. A., Black, I. W., Leung, D. Y., Chung, M. K., Vaughn, S. E., ... Arheart, K. (1997). Cardioversion guided by transesophageal echocardiography: The ACUTE Pilot Study: A randomized, controlled trial. Annals of Internal Medicine, 126(3), 200-209.

Cardioversion guided by transesophageal echocardiography : The ACUTE Pilot Study: A randomized, controlled trial. / Klein, Allan L.; Grimm, Richard A.; Black, Ian W.; Leung, Dominic Y.; Chung, Mina K.; Vaughn, Susan E.; Murray, R. Daniel; Miller, Dave P.; Arheart, Kristopher.

In: Annals of Internal Medicine, Vol. 126, No. 3, 13.02.1997, p. 200-209.

Research output: Contribution to journalArticle

Klein, AL, Grimm, RA, Black, IW, Leung, DY, Chung, MK, Vaughn, SE, Murray, RD, Miller, DP & Arheart, K 1997, 'Cardioversion guided by transesophageal echocardiography: The ACUTE Pilot Study: A randomized, controlled trial', Annals of Internal Medicine, vol. 126, no. 3, pp. 200-209.
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. Annals of Internal Medicine. 1997 Feb 13;126(3):200-209.
Klein, Allan L. ; Grimm, Richard A. ; Black, Ian W. ; Leung, Dominic Y. ; Chung, Mina K. ; Vaughn, Susan E. ; Murray, R. Daniel ; Miller, Dave P. ; Arheart, Kristopher. / Cardioversion guided by transesophageal echocardiography : The ACUTE Pilot Study: A randomized, controlled trial. In: Annals of Internal Medicine. 1997 ; Vol. 126, No. 3. pp. 200-209.
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abstract = "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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AU - Leung, Dominic Y.

AU - Chung, Mina K.

AU - Vaughn, Susan E.

AU - Murray, R. Daniel

AU - Miller, Dave P.

AU - Arheart, Kristopher

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N2 - 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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