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Medical Forum / General / Cardiology / February 2006Cardioversion without TEE
I am currently scheduled to be cardioverted at the end of February, for I believe the 4th time in 5 years (last time was July 2004). By the time of the cardioversion I will have been on coumadin for about 6 weeks. I am a little bit concerned because this time I don't think the doctor is planning on doing a TEE beforehand. Is the slight risk of skipping the TEE outweighed by the slight risks of the TEE procedure itself along with the sedation? I have not had a TEE since July 2004, and have not been on coumadin since September 2004. I was definitely not in a-fib as of October 2005 (EKG), but my best guess is that I was in it about 2 months before anti-coagulation started after my January EKG. I am 24 years old and have mildly high cholesterol, if that means anything. Should I press the TEE issue with the cardiologist? > I am currently scheduled to be cardioverted at the end of February, for > I believe the 4th time in 5 years (last time was July 2004). By the [quoted text clipped - 5 lines] > the TEE outweighed by the slight risks of the TEE procedure itself > along with the sedation? The benefit of TEE is that if there is a clot visualized, the cardioversion would be postponed in order to prevent a cardioembolic event which could be disastrous. > I have not had a TEE since July 2004, and > have not been on coumadin since September 2004. [quoted text clipped - 5 lines] > > Should I press the TEE issue with the cardiologist? Yes. Would be more than happy to "glow" and chat about this and other things like cardiology, diabetes, cooking and nutrition that interest those following this thread here during the next on-line chat happening now (02/02/06): http://tinyurl.com/cpayh For those who are put off by the signature, my advance apologies for how the LORD has reshaped me: http://tinyurl.com/bgfqt Prayerfully in Christ's love, Andrew http://tinyurl.com/8juld >>I am currently scheduled to be cardioverted at the end of February, for >>I believe the 4th time in 5 years (last time was July 2004). By the [quoted text clipped - 21 lines] > > Yes. Dr. Chung's commments notwithstanding, TEE is generally used as a way to avoid weeks of anticoagulation prior to cardioversion, not as an additional step in an anticoagulated patient. Is there any evidence that performing TEE prior to cardioversion in a patient who has been on therapeutic warfarin for six weeks is of some benefit?  SignatureDavid Rind drind@caregroup.harvard.edu > >>I am currently scheduled to be cardioverted at the end of February, for > >>I believe the 4th time in 5 years (last time was July 2004). By the [quoted text clipped - 33 lines] > David Rind > drind@caregroup.harvard.edu Thank you for the replies. As I said, for at least 2 of my 3 cardioversions I had a TEE the morning of the procedure, in addition to a month of anticoagulation. There might have been one where the doctor chose to skip the TEE, but I can't recall for sure. David, your question is basically what I wanted to know. I know that a TEE is often used as a substitute for anticoagulation in order to not delay the cardioversion, and that 3-4 weeks of anticoagulation before and after the cardioversion has been shown to have the same effect. However, I have not seen a study on whether or not taking BOTH precautions substantially decreases risk. > >>I am currently scheduled to be cardioverted at the end of February, for > >>I believe the 4th time in 5 years (last time was July 2004). By the [quoted text clipped - 25 lines] > avoid weeks of anticoagulation prior to cardioversion, not as an > additional step in an anticoagulated patient. However, here we are discussing a **specific** person who has had a TEE prior to each of three earlier cardioversions **after** coumadin anticoagulation. Now this person is older. Being older will not make it less likely for there to be an intraatrial clot as a consequence of the atrial fibrillation. > Is there any evidence that performing TEE prior to cardioversion in a > patient who has been on therapeutic warfarin for six weeks is of some > benefit? No. Will be available to "glow" and chat about this and other things like cardiology, diabetes, cooking and nutrition that interest those following this thread here during the next on-line chat (02/09/06) from 6 to 7 pm EST: http://tinyurl.com/cpayh For those who are put off by the signature, my advance apologies for how the LORD has reshaped me: http://tinyurl.com/bgfqt Prayerfully in Christ's love, Andrew http://tinyurl.com/8juld > However, here we are discussing a **specific** person who has had a TEE > prior to each of three earlier cardioversions **after** coumadin > anticoagulation. Now this person is older. Being older will not make > it less likely for there to be an intraatrial clot as a consequence of > the atrial fibrillation. I'm sorry, but this answer makes no sense. Either performing a TEE is useful or it isn't. That someone chose to perform one previously has no bearing on the situation. >>Is there any evidence that performing TEE prior to cardioversion in a >>patient who has been on therapeutic warfarin for six weeks is of some >>benefit? > > No. SignatureDavid Rind drind@caregroup.harvard.edu > > However, here we are discussing a **specific** person who has had a TEE > > prior to each of three earlier cardioversions **after** coumadin [quoted text clipped - 5 lines] > useful or it isn't. That someone chose to perform one previously has no > bearing on the situation. It is not wise to ignore a patient's past medical history. It is possible that the patient has a huge left atrial appendage with slow flow velocities and past visualization of intraatrial clot despite adequate anticoagulation justifying TEE prior to every subsequent cardioversion. Will be available to "glow" and chat about this and other things like cardiology, diabetes, cooking and nutrition that interest those following this thread here during the next on-line chat (02/09/06) from 6 to 7 pm EST: http://tinyurl.com/cpayh For those who are put off by the signature, my advance apologies for how the LORD has reshaped me: http://tinyurl.com/bgfqt Prayerfully in Christ's love, Andrew http://tinyurl.com/8juld Andrew, But it appears he was cardioverted each and every time--therefore there was no intraatrial clot visualized on any of the attempts, judging by John's words. If there had been a clot visualized, then I can understand the concern--but if no clot visualized on the prior 3 times, why pursue another? > Andrew, > > But it appears he was cardioverted each and every time Yes. > --therefore there > was no intraatrial clot visualized on any of the attempts, judging by > John's words. There may have been "smoke." > If there had been a clot visualized, then I can > understand the concern--but if no clot visualized on the prior 3 times, > why pursue another? Large atrial appendage, slow flow velocities, and the presence of "smoke" would have me be concerned. Will be available to "glow" and chat about this and other things like cardiology, diabetes, cooking and nutrition that interest those following this thread here during the next on-line chat (02/09/06) from 6 to 7 pm EST: http://tinyurl.com/cpayh For those who are put off by the signature, my advance apologies for how the LORD has reshaped me: http://tinyurl.com/bgfqt Prayerfully in Christ's love, Andrew http://tinyurl.com/8juld > > Andrew, > > [quoted text clipped - 14 lines] > Large atrial appendage, slow flow velocities, and the presence of > "smoke" would have me be concerned. Dr. Chung - as far as I know, there was never any indication of any type of clot or high risk of clotting for me, and I think one of the three cardioversions might have been without a TEE anyway. I'd feel a lot safer with a TEE in addition to my current anticoagulation, but according to a response from you earlier in the thread, there is no evidence to support any benefit of doing both. Why is this the case? Since warfarin does not break down clots, it would seem obvious that 4 weeks of anticoagulation would not be enough of a defense if the patient was in a-fib for months prior to the start of warfarin. > Will be available to "glow" and chat about this and other things like > cardiology, diabetes, cooking and nutrition that interest those [quoted text clipped - 12 lines] > Andrew > http://tinyurl.com/8juld > > > Andrew, > > > [quoted text clipped - 24 lines] > > Why is this the case? Absence of proof is not proof of absence. > Since warfarin does not break down clots, it > would seem obvious that 4 weeks of anticoagulation would not be enough > of a defense if the patient was in a-fib for months prior to the start > of warfarin. The indication here for TEE would be your doubt and apprehension. If you were my patient expressing these concerns to me, I would do the TEE for you prior to the cardioversion. LORD willing, will be available to "glow" and chat about this and other things like cardiology, diabetes, cooking and nutrition that interest those following this thread here during the next on-line chat now (02/09/06): http://tinyurl.com/cpayh For those who are put off by the signature, my advance apologies for how the LORD has reshaped me: http://tinyurl.com/bgfqt Prayerfully in Christ's love, Andrew http://tinyurl.com/8juld > > > > Andrew, > > > > [quoted text clipped - 52 lines] > Andrew > http://tinyurl.com/8juld Dr. Chung - thanks for the answers. I asked the doctor's secretary to tell the doctor that I would be more comfortable with a TEE. I was afraid that, since he isn't very accessible for questions/concerns like this, it just wouldn't wind up happening. But I called again just now and was told that there is no problem and they will order the TEE. Thanks again. John > > > > > Andrew, > > > > > [quoted text clipped - 60 lines] > > Thanks again. You are welcome, John :-) Will be available to "glow" and chat about this and other things like cardiology, diabetes, Bird Flu, cooking and nutrition that interest those following this thread here during the next on-line chat (02/16/06) from 6 to 7 pm EST: http://tinyurl.com/8w7uq For those who are put off by the signature, my advance apologies for how the LORD has reshaped me: http://tinyurl.com/bgfqt Prayerfully in Christ's love, Andrew http://tinyurl.com/8juld > Andrew, > [quoted text clipped - 3 lines] > understand the concern--but if no clot visualized on the prior 3 times, > why pursue another? Erskine, I have not been on warfarin continually since my past TEE's. I was off of the drug for over a year and a half, and went back into a-fib for probably a month or two before restarting it recently. Would this change your apparent belief that it would be redundant to pursue another TEE? John, No, that would not change my belief. If you have been successfully anticoagulated for the past 6 weeks, then you can pursue CV without a TEE. The original studies for TEE with cardioversion were to evaluate quickly CV someone--without waiting the 6 weeks--and were compared to studies were patients were fully anticoagulated and then cardioverted without a TEE. There has been no study, in my knowledge, to look at the benefit of TEE after 6 weeks of anticoagulation on the decision to cardiovert. The atria are going to be stunned anyways for about 6 weeks afterwards approximately. Andrew, when you said "There may have been "smoke." ", I do not know about your practice, but I NEVER cardiovert someone if I am doing a TEE and see "smoke." It is just as likely to predict an event in afib as is a atrial thrombus--so when the cardiologist had proceeded with CV, I assumed there was no smoke, or thrombus. Erskine, I know there has been no study on doing both, but doesn't it logically seem like anticoagulation plus TEE is the absolute safest route? If the patient had a TEE 2 years ago, why couldn't a clot have formed since then? Six weeks of warfarin won't break apart that clot, am I right? Am I not understanding something about the way warfarin works? What effect does the atria being stunned for 6 weeks afterwards have in this regard? > Erskine, > [quoted text clipped - 3 lines] > since then? Six weeks of warfarin won't break apart that clot, am I > right? Am I not understanding something about the way warfarin works? Warfarin stops new clot from forming. Without new clot formation any existing clot tends to stabilize so that it won't break off (this seems to happen pretty quickly) and also the body tends to start breaking down clot that is already there. Although you can imagine theoretical reasons why treating with warfarin for six weeks might or might not work, we know from studies that it does work. A TEE is not perfectly safe (though, obviously, not very risky), so unless it really can further decrease the risk of stroke it could conceivably be a bad idea. > What effect does the atria being stunned for 6 weeks afterwards have in > this regard? There's an ongoing risk of stroke after cardioversion because the atria aren't contracting normally and clot can form. I think his point was that if you don't trust the warfarin to work before cardioversion, that you then wouldn't trust it to work after cardioversion. (Again, we know from studies that warfarin really does work to decrease stroke both before and after cardioversion.) SignatureDavid Rind drind@caregroup.harvard.edu John, David answered this very well, probably better than I could, so see his post. One question in terms of all of these cardioversions, is just how symptomatic are you during atrial fibrillation. The reason I am asking this is that in case you have not read the AFFIRM study, I highly recommend you read it. It really surprised a lot of cardiologists in term of rate management versus rhythm management. > John, > [quoted text clipped - 11 lines] > about your practice, but I NEVER cardiovert someone if I am doing a TEE > and see "smoke." Neither do I. However, this does not mean that others won't. > It is just as likely to predict an event in afib as is > a atrial thrombus--so when the cardiologist had proceeded with CV, I > assumed there was no smoke, or thrombus. It would be wise not to assume the best case scenario but default to the worst case scenario. Will be available to "glow" and chat about this and other things like cardiology, diabetes, Bird Flu, cooking and nutrition that interest those following this thread here during the next on-line chat (02/16/06) from 6 to 7 pm EST: http://tinyurl.com/8w7uq For those who are put off by the signature, my advance apologies for how the LORD has reshaped me: http://tinyurl.com/bgfqt Prayerfully in Christ's love, Andrew http://tinyurl.com/8juld |
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