Patel S V, Flaker Greg
Department of Internal Medicine, Mercer University School of Medicine, Macon, Georgia 31201, USA.
Clin Cardiol. 2008 Apr;31(4):148-52. doi: 10.1002/clc.20172.
The 2006 American Heart Association guidelines for management of patients with atrial fibrillation state "For patients with no identifiable thrombus in the left atrium (LA) or left atrial appendage (LAA), cardioversion (CV) is reasonable immediately after anticoagulation with unfractionated heparin. Thereafter, continuation of oral anticoagulation is reasonable for an anticoagulation period of at least 4 weeks". For patients with thrombus identified by transesophageal echocardiography, guidelines recommend therapeutic oral anticoagulation for 3 weeks prior to and 4 weeks after elective cardioversion. Patients with spontaneous echo contrast (SEC) identified by TEE have a high risk of thromboembolic events,1-8 however, the guidelines do not address whether patients with SEC without thrombus can be safely cardioverted. This paper reviews the literature describing the pathogenesis of SEC, how it is detected, and whether elective cardioversion is safe. On the basis of our review, we believe that the risk of cardioembolic stroke after cardioversion of a patient with SEC is low, regardless of anticoagulation. The safe conclusion is that patients with SEC on TEE should receive therapeutic anticoagulation prior to cardioversion if possible and early cardioversion is not contraindicated.
2006年美国心脏协会房颤患者管理指南指出：“对于左心房（LA）或左心耳（LAA）未发现明确血栓的患者，在使用普通肝素抗凝后立即进行心脏复律（CV）是合理的。此后，持续口服抗凝至少4周是合理的”。对于经食管超声心动图发现有血栓的患者，指南建议在择期心脏复律前3周和复律后4周进行治疗性口服抗凝。经食管超声心动图发现有自发显影（SEC）的患者发生血栓栓塞事件的风险很高，1 - 8然而，指南并未提及无血栓的SEC患者是否能安全地进行心脏复律。本文回顾了描述SEC发病机制、检测方法以及择期心脏复律是否安全的文献。基于我们的综述，我们认为无论是否抗凝，SEC患者心脏复律后发生心脏栓塞性卒中的风险都很低。安全的结论是，经食管超声心动图显示有SEC的患者，如果可能应在心脏复律前接受治疗性抗凝，且早期心脏复律无禁忌证。
