Ahmed Hasaan, Ismayl Mahmoud, Palicherla Anirudh, Heppler Miranda, Petraskova Terezia, Kousa Omar, Vargha Jalal
Department of Medicine, Division of Internal Medicine.
Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.
Ann Med Surg (Lond). 2024 Jan 22;86(3):1729-1733. doi: 10.1097/MS9.0000000000001735. eCollection 2024 Mar.
Current guidelines recommend proceeding with cardioversion, without the explicit need for preprocedural transesophageal echocardiography (TEE), in patients compliant with oral anticoagulation for at least 3 weeks. The relevance of these guidelines remains unclear in those undergoing repeat cardioversion.
A 66-year-old male with a history of atrial fibrillation (AF) and a left atrial appendage occlusion (LAAO) device, compliant with apixaban, presented with dyspnea and lightheadedness. He was cardioverted into sinus rhythm, 10 days before symptom onset, with TEE unremarkable at the time. An ECG revealed that the patient converted back into AF and a repeat cardioversion was scheduled. At the patient's request, a TEE was obtained, revealing a new 2 cm×1 cm thrombus in the left atrium above the WATCHMAN device. Cardioversion was canceled and the patient was hospitalized for AF management.
Cardioverted patients are at risk for thrombus formation due to atrial stunning, a transitory dysfunction of the atrial appendage and atrium, which occurs immediately after cardioversion and can persist for several weeks. The likelihood of a thrombus is further propagated by individual risk factors for stroke.
Anticoagulation does not eliminate the risk of thrombus formation in those with increased risk factors for stroke. Further studies are warranted to assess the need for routine TEE, after cardioversion, in those with stroke risk factors on anticoagulation or who have LAAO.
当前指南建议，对于口服抗凝治疗至少3周的患者，进行心脏复律时无需明确进行术前经食管超声心动图（TEE）检查。对于接受重复心脏复律的患者，这些指南的相关性仍不明确。
一名66岁男性，有房颤（AF）病史且植入了左心耳封堵（LAAO）装置，服用阿哌沙班，出现呼吸困难和头晕。症状出现前10天，他被转复为窦性心律，当时TEE检查未见异常。心电图显示患者又转为房颤，计划进行重复心脏复律。应患者要求，进行了TEE检查，结果显示在WATCHMAN装置上方的左心房有一个新的2cm×1cm血栓。心脏复律取消，患者因房颤管理住院。
心脏复律后的患者因心房顿抑有血栓形成风险，心房顿抑是心房附件和心房的短暂性功能障碍，在心脏复律后立即发生，可持续数周。中风的个体危险因素会进一步增加血栓形成的可能性。
抗凝并不能消除中风风险增加患者的血栓形成风险。有必要进行进一步研究，以评估在接受抗凝治疗或植入LAAO且有中风危险因素的患者心脏复律后进行常规TEE检查的必要性。
