From the Guidelines
Routine transesophageal echocardiography (TEE) is not recommended for all patients with newly diagnosed atrial fibrillation, but rather should be reserved for specific clinical scenarios, such as suspicion of left atrial thrombus before cardioversion in patients who have been in atrial fibrillation for more than 48 hours or unknown duration and have not been adequately anticoagulated for at least 3-4 weeks 1. The evidence suggests that TEE is valuable in certain situations, but its routine use is not justified due to its semi-invasive nature, requirement for sedation, and associated procedural risks 1. For most patients with newly diagnosed atrial fibrillation, a transthoracic echocardiogram (TTE) is sufficient as the initial imaging study to assess cardiac structure and function 1. Some key points to consider when deciding on the use of TEE include:
- The patient's risk of thromboembolism
- The duration of atrial fibrillation
- Anticoagulation status
- Planned management strategy In patients undergoing cardioversion, TEE can be used to guide the procedure and minimize the risk of thromboembolism, especially if the patient has not been adequately anticoagulated for at least 3-4 weeks 1. However, the evidence is of low quality, and therefore the results are not conclusive with respect to either a benefit or harm with the TEE-guided strategy vs the conventional approach of 3 weeks of anticoagulation pre-cardioversion 1. A risk-based approach to anticoagulation can be recommended, and with respect to TEE, individualization of therapy on a case-by-case basis is proposed 1. It is essential to weigh the benefits and risks of TEE in each patient and to consider alternative approaches, such as the use of non-vitamin K antagonist oral anticoagulants (NOACs), which may offer a safer and more convenient alternative to warfarin in certain situations 1. Ultimately, clinical decision-making should be guided by patient-specific factors, and TEE should be used judiciously and only when necessary to minimize risks and improve outcomes 1.
From the Research
Routine TEE in Novel Atrial Fibrillation
- The use of transesophageal echocardiography (TEE) in patients with novel atrial fibrillation is a topic of ongoing debate 2, 3, 4, 5, 6.
- A study published in 1999 found that a follow-up TEE strategy may be more cost-effective than a no follow-up TEE strategy for patients with atrial fibrillation and left atrial thrombi detected on initial TEE 2.
- Another study published in 2017 suggested that the risk of thromboembolism associated with acute cardioversion of patients with atrial fibrillation estimated to be of less than 48 hours duration is low, but varies widely depending on patient characteristics 3.
- A prospective multicenter registry published in 2016 found that performing atrial fibrillation ablation while on uninterrupted novel oral anticoagulants without TEE is feasible and safe 4.
- A study published in 2012 found that fewer than 1% of patients with atrial fibrillation with negative results on baseline TEE had thrombi detected on repeat TEE before subsequent cardioversion or radiofrequency catheter ablation 5.
- A study published in 2006 found that TEE-guided cardioversion in patients with atrial fibrillation without previous anticoagulation can be considered a safe and effective method 6.
Evidence for Routine TEE
- The evidence suggests that routine TEE may not be necessary for all patients with novel atrial fibrillation, but rather should be guided by individual patient characteristics and risk factors 3, 4, 5, 6.
- The use of TEE should be considered on a case-by-case basis, taking into account the patient's overall risk of thromboembolism and the potential benefits and risks of the procedure 2, 3, 4, 5, 6.