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Transesophageal Echocardiography-Guided Cardioversion: Going for Broke?
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
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Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
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IN RESPONSE:
The TEE-guided approach to cardioversion used by experts is safe, as shown by Manning and colleagues [1]. The ACUTE Pilot Study [2] compared the TEE-guided approach with the conventional approach to cardioversion. In my editorial, I suggested that a larger-scale clinical trial should provide valuable data about the risk for thromboembolism. However, I also questioned the “supposed” major limitations of the conventional approach, as outlined by Klein and coworkers [2]. The use of anticoagulation before cardioversion carries a risk for embolism of 1% or less. Thus, the data to date do not suggest a major risk for emboli with the conventional approach. Furthermore, the ACUTE Pilot Study showed no difference between approaches in the rate of successful cardioversion or the presence of sinus rhythm at follow-up [2]. Of note, most patients with atrial fibrillation have an indication for long-term anticoagulation [3]. In this setting, loss of a few weeks of anticoagulation before cardioversion seems meaningless.
In the hospitalized patient, the potential benefits of the TEE-guided approach are much more realistic. One can perform cardioversion quickly and initiate antiarrhythmic drug therapy while patients are still in the hospital, which will maximize safety with regard to potential proarrhythmic effects. This may preclude the need for rehospitalization.
Klein and coworkers paraphrase my initial query, “If it ain't broke, why fix it?” They suggest that we need to “go for broke.” Indeed, this is exactly what we should avoid. In my opinion, the expense of using TEE as a routine procedure for all or most outpatient elective cardioversions for atrial fibrillation could add a major and possibly unnecessary financial burden to the health care system. Thus, I still favor judicious and individualized use of the TEE-guided approach for outpatient cardioversion until the final results of a large-scale prospective study suggest otherwise.
Eric N. Prystowsky, MD
Northside Cardiology, P.C.; Indianapolis, IN 46260
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
