Black I W, Fatkin D, Sagar K B, Khandheria B K, Leung D Y, Galloway J M, Feneley M P, Walsh W F, Grimm R A, Stollberger C
Department of Cardiology, Cleveland Clinic Foundation, OH 44195.
Circulation. 1994 Jun;89(6):2509-13. doi: 10.1161/01.cir.89.6.2509.
Transesophageal echocardiography (TEE) has been used recently to detect atrial thrombi before cardioversion of atrial arrhythmias. It has been assumed that embolic events after cardioversion result from embolism of preexisting atrial thrombi that are accurately detected by TEE. This study examined the clinical and echocardiographic findings in patients with embolism after cardioversion of atrial fibrillation despite exclusion of atrial thrombi by TEE.
Clinical and echocardiographic data in 17 patients with embolic events after TEE-guided electrical (n = 16) or pharmacological (n = 1) cardioversion were analyzed. All 17 patients had nonvalvular atrial fibrillation, including four patients with lone atrial fibrillation. TEE before cardioversion showed left atrial spontaneous echo contrast in five patients and did not show atrial thrombus in any patient. Cardioversion resulted in return to sinus rhythm without immediate complication in all patients. Thirteen patients had cerebral embolic events and four patients had peripheral embolism occurring 2 hours to 7 days after cardioversion. None of the patients were therapeutically anticoagulated at the time of embolism. New or increased left atrial spontaneous echo contrast was detected in four of the five patients undergoing repeat TEE after cardioversion including one patient with a new left atrial appendage thrombus.
Embolism may occur after cardioversion of atrial fibrillation in inadequately anticoagulated patients despite apparent exclusion of preexisting atrial thrombus by TEE. These findings suggest de novo atrial thrombosis after cardioversion or imperfect sensitivity of TEE for atrial thrombi and suggest that screening by TEE does not obviate the requirement for anticoagulant therapy at the time of and after cardioversion. A randomized clinical trial is needed to compare conventional anticoagulant management with a TEE-guided strategy including anticoagulation after cardioversion.
最近经食管超声心动图（TEE）已被用于在房性心律失常转复前检测心房血栓。一直以来人们认为，转复后发生的栓塞事件是由TEE准确检测出的先前存在的心房血栓栓塞所致。本研究调查了尽管TEE排除了心房血栓，但房颤转复后发生栓塞的患者的临床和超声心动图表现。
分析了17例在TEE引导下进行电转复（n = 16）或药物转复（n = 1）后发生栓塞事件患者的临床和超声心动图数据。所有17例患者均为非瓣膜性房颤，其中4例为孤立性房颤。转复前TEE显示5例患者左心房有自发显影，所有患者均未显示心房血栓。所有患者转复后均恢复窦性心律且无即刻并发症。13例患者发生脑栓塞事件，4例患者在转复后2小时至7天发生外周栓塞。栓塞发生时，无一例患者接受治疗性抗凝。在转复后接受重复TEE检查的5例患者中，有4例检测到新的或增强的左心房自发显影，其中1例患者有新的左心耳血栓形成。
尽管TEE明显排除了先前存在的心房血栓，但未充分抗凝的患者在房颤转复后仍可能发生栓塞。这些发现提示转复后新发心房血栓形成或TEE对心房血栓的敏感性欠佳，并提示TEE筛查不能免除转复时及转复后抗凝治疗的必要性。需要进行一项随机临床试验，以比较传统抗凝管理与包括转复后抗凝在内的TEE引导策略。
