Management of Blood Thinners in Patients Undergoing Transesophageal Echocardiogram
For patients on anticoagulation therapy undergoing TEE, anticoagulation should be held for at least 24 hours before the scheduled procedure for low-to-moderate bleeding risk TEE, and 48-72 hours for high bleeding risk TEE to minimize bleeding complications. 1
General Principles for Anticoagulation Management Before TEE
Vitamin K Antagonists (e.g., Warfarin)
- Hold warfarin 5 days before the procedure 1
- Check INR on the day of procedure
- Target INR < 1.5 for safe TEE procedure 2
- No bridging therapy is required for most patients with low-moderate thrombotic risk
Direct Oral Anticoagulants (DOACs)
- Apixaban: Hold for 24-48 hours before TEE (longer with renal impairment) 1
- Rivaroxaban: Hold for 24-48 hours before TEE (longer with renal impairment) 1
- Dabigatran: Hold for 24-72 hours before TEE (longer interval with decreased renal function) 1
- Edoxaban: Hold for 24-48 hours before TEE 1
- No bridging therapy is required for DOACs 3
Antiplatelet Agents
- Aspirin: Can be continued for routine TEE 2
- Clopidogrel: Hold for 5 days before TEE if high bleeding risk is anticipated 2
- Prasugrel: Hold for 7 days before TEE if high bleeding risk is anticipated 2
- Ticagrelor: Hold for 3 days before TEE if high bleeding risk is anticipated 2
Special Considerations for TEE-Guided Cardioversion
For patients undergoing TEE-guided cardioversion for atrial fibrillation:
- Patients should be on therapeutic anticoagulation before the procedure if AF duration is >48 hours or unknown 2
- After a thrombus-negative TEE, cardioversion should be performed within 24 hours 1
- For patients on warfarin, target INR should be 2.0-3.0 before cardioversion 2
- For patients on DOACs, they should have been on the medication for at least 3 weeks before cardioversion 1
High Thrombotic Risk Patients
For patients with high thrombotic risk (recent VTE <3 months, mechanical heart valves, active cancer):
- Consider bridging therapy with LMWH if warfarin is interrupted 2
- For mechanical heart valves: Use unfractionated heparin or LMWH bridging 2
- For recent VTE (<3 months): Minimize time off anticoagulation; consider LMWH bridging 1
- For active cancer: Higher thrombotic risk; minimize time off anticoagulation 1
Resuming Anticoagulation After TEE
- Warfarin: Resume same day as procedure if no bleeding complications 1
- DOACs: Resume approximately 24 hours after procedure 1
- For high thrombotic risk patients: Resume as soon as hemostasis is assured 1
- For patients undergoing TEE-guided cardioversion: Continue anticoagulation for at least 4 weeks after cardioversion regardless of rhythm outcome 2
Safety Considerations
- TEE can be safely performed by trained physicians even in patients with coagulopathy and thrombocytopenia with minimal complications 4
- The risk of upper esophageal bleeding during TEE in patients with high bleeding risk is approximately 4%, which is not significantly different from patients with low bleeding risk 4
- For patients undergoing AF ablation on uninterrupted NOACs, TEE may not be mandatory as demonstrated in a prospective multicenter registry 5
Common Pitfalls and Caveats
- Failure to assess both bleeding and thrombotic risks before TEE
- Inappropriate bridging in low-risk patients, which may increase bleeding risk
- Not accounting for renal function when determining DOAC interruption timing
- Delaying anticoagulation resumption unnecessarily after uncomplicated TEE
- Not considering the indication for anticoagulation when making management decisions
Following these guidelines will help optimize patient safety by balancing the risks of thromboembolism against the risks of bleeding during and after TEE procedures.