The optimal treatment for patients who have TEE evidence of atrial thrombi has not been identified. Despite therapeutic heparin or warfarin and avoidance of cardioversion, these patients remain at increased risk for adverse events. As illustrated in Fig. 10, we believe it is most prudent to perform a follow-up TEE (after >4 wk of warfarin) to document complete thrombus resolution before elective cardioversion. If residual thrombus is present, we do not advise cardioversion, although this area is controversial.
TEE Facilitated Cardioversion Without Anticoagulation
In the absence of the anticoagulation strategy outlined in Fig. 10, several centers have reported clinical thromboembolism following a "negative TEE" for atrial thrombus. The mechanism of these adverse events is unknown and may be related to thrombi not visualized by TEE or to thrombi that form during the pericar-dioversion period. Because of these reports, we strongly encourage the use of systemic anticoagulation at the time of TEE and extending to 1 mo after cardioversion. For the patient with nonvalvular AF in whom warfarin is contraindicated, we offer the option of full-dose heparin anticoagulation (partial thromboplastin time 50-70 s) at the time of TEE and extending to at least 24 h after cardioversion. Although unproven, this approach is likely to be preferred to "blind" cardioversion.
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