BACKGROUND:Electrical cardioversion in patients with atrial fibrillation (AF) is associated with an increased risk of stroke. We compared a transesophageal echocardiography (TEE)-guided strategy with a conventional strategy in patients with AF > 2 days' duration undergoing electrical cardioversion over a 6-month follow-up. METHODS:The ACUTE study was a multicenter, randomized, clinical trial, with 1222 patients. Six-month follow-up was available in 1034 patients (85%), 525 in the TEE group and 509 in the conventional group. The primary composite end points were cerebrovascular accident, transient ischemic attack, and peripheral embolism at 6 months, which was a prespecified time point. Secondary end points were hemorrhage, mortality, and sinus rhythm. RESULTS:At 6 months, there was no difference in composite embolic events between the TEE group and the conventional group (10 [2%] vs 4 [0.8%]; risk ratio (RR) 2.47, 95% CI 0.78-7.88; P = .11). However, the hemorrhagic rate was significantly lower in the TEE group (23 [4.4%] vs 38 [7.5%]; RR 0.58, 96% CI 0.35-0.97; P = .04). There was no difference between the 2 treatment groups in all-cause mortality (21 [4%] vs 14 [2.8%]; RR 1.48, 95% CI 0.76-2.92; P = .25) and in the occurrence of normal sinus rhythm between the 2 groups (305 [62.2%] vs 280 [58.1%]; P = .51). Sinus rhythm at 6 months was more common in the TEE-guided group, in those patients who had direct current cardioversion (238 [62.5%] vs 151 [53.9%]; P = .03). CONCLUSION:The TEE-guided strategy may be considered a clinically effective alternative to a conventional anticoagulation strategy for patients with AF of > 2 days' duration undergoing electrical cardioversion over a 6-month period.

Background The ACUTE Trial studied a transesophageal echocardiography (TEE)-guided strategy compared with a conventional strategy for management of patients with atrial fibrillation undergoing direct current cardioversion. The primary aim was to determine if patient functional capacity, measured by the Duke Activity Status Index (DASI), would differ between treatment strategies.Methods The DASI was self-administered at study enrollment and at 8-week follow-up in 1074 (88%) of 1222 total patients. Clinical outcomes associated with enrollment DASI scores and change in follow-up DASI scores were reviewed.Results There was no difference between the TEE-guided (n = 544) and conventional treatment (n = 530) groups for mean baseline and 8-week DASI scores, adjusting for baseline; however, patients who improved their DASI score were more likely to be in the TEE-guided group (P =.03). Pooled group data showed that the higher the enrollment DASI score, the more it tended to be positively related to maintenance of sinus rhythm (P =.06) at 8 weeks. The lower the enrollment DASI score, the more it was predictive of death (P =.03) and bleeding (P =.01) within 8 weeks. Patients with congestive heart failure (CHF) at enrollment showed greater improvement in DASI scores at 8 weeks compared with patients without CHF (DASI A 45.9% vs 31.6%, P <.001).Conclusions There was no difference in DASI scores between treatment groups. However, TEE-guided treatment was a predictor of improved DASI at follow-up, and subgroup analysis showed that patients with CHIF did show improvement in functional capacity with cardioversion.

The ACUTE trial randomly assigned patients who had atrial fibrillation (AF) of > 2 days' duration to a transesophageal echocardiographically guided or a conventional strategy before cardioversion. In the 571 patients who underwent transesophageal echocardiography (TEE) in the ACUTE trial, we assessed the relative predictive value of baseline data derived by history, transthoracic echocardiography, and TEE for prediction of thrombus and adjudicated embolism (thromboembolism) as a composite end point. TEE was performed at 70 centers in 571 patients, 549 in the transesophageal echocardiographically guided group and 22 crossovers in the conventional group. Six patients (1.1%) who had embolism and 79 (13.8%) who had thrombi were identified in this group. Thrombus was completely resolved in 76.5% of patients who had repeat transesophageal echocardiographic procedures after 31.7 +/- 7.5 days of anticoagulation. For patients who had embolic events, none had a transesophageal echocardiographically identified thrombus; 5 of 6 (83.3%) had >= 1 transesophageal echocardiographic risk factors (including spontaneous echocardiographic contrast, aortic atheroma, patent foramen ovale, atrial septal aneurysm, mitral valve strands), and 4 of 6 (66.66%) had subtherapeutic anticoagulation or no anticoagulation. Clinical, transthoracic echocardiographic, and transesophageal echocardiographic risk factors contributed significantly to the prediction of composite thrombus/embolism. However, transesophageal echocardiographic thromboembolic risk factors were the strongest predictors of thromboembolism and provided statistically significant incremental value (chi-square 38.0, p < 0.001) for identification of risk. Thus, in addition to thrombus identification, TEE has significant incremental value in the identification of patients who had high thromboembolic risk. In conclusion, this study supports the role of TEE and anticoagulation monitoring in patients who have atrial fibrillation and is useful for identifying thromboembolic risk factors. (c) 2005 Elsevier Inc. All rights reserved.

Electrical cardioversion of patients with atrial fibrillation (AF) is frequently performed to relieve symptoms and improve cardiac performance. Patients undergoing cardioversion are treated conventionally with therapeutic anticoagulation for three weeks before and four weeks after cardioversion to decrease the risk of thromboembolism. A transesophageal echocardiography (TEE)-guided strategy has been proposed as an alternative that may lower stroke and bleeding events. Patients without atrial cavity thrombus or atrial appendage thrombus by TEE are cardioverted on achievement of therapeutic anticoagulation, whereas cardioversion is delayed in higher risk patients with thrombus. The aim of this review is to discuss the issues and controversies associated with the management of patients with AF undergoing cardioversion. We provide an overview of the TEE-guided and conventional anticoagulation strategies in light of the recently completed Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) clinical trial. The two management strategies comparably lower the patient’s embolic risk when the guidelines are properly followed. The TEE-guided strategy with shorter term anticoagulation may lower the incidence of bleeding complications and safely expedite early cardioversion. The inherent advantages and disadvantages of both strategies are presented. The TEE-guided approach with short-term anticoagulation is considered to be a safe and clinically effective alternative to the conventional approach, and it is advocated in patients in whom earlier cardioversion would be clinically beneficial.

The relation between C-reactive protein, an inflammatory marker, and thromboembolic risk factors was investigated in 104 patients with atrial fibrillation. Tranesophageal echocardiography identified patients who had thromboembolic risk factors with greater C-reactive protein levels than those without (1.00 vs 0.302 mg/dl). C-reactive protein also correlated with clinical stroke risk factors. Increased C-reactive protein levels were also independently associated with transesophageal echocardiographic thromboembolic risk factors. (C) 2004 by Excerpta Medica, Inc.

OBJECTIVES This study was designed to determine the characteristics and outcomes of spontaneous conversion (SC) to sinus rhythm (SR) in patients with atrial fibrillation (AF) of more than two days.BACKGROUND The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) multicenter study was a prospective trial in which transesophageal echocardiography (TEE)-guided treatment was compared with conventional anticoagulation treatment for the management of patients with AF >2 days undergoing direct current cardioversion (DCC). In an ancillary analysis, we evaluated the baseline and outcome data in patients who under-went SC to SR before scheduled DCC.METHODS We identified 1,041 patients for this analysis after excluding patients on pre-existing antiarrhythmic agents. Patients with SC in the TEE-guided and conventional groups were first compared then pooled and compared with non-spontaneous conversion (No-SC) patients.RESULTS Overall, 167 of 1,041 (16%) patients underwent SC, with twice as many in the conventional compared with the TEE-guided group (110/523 [21%] vs. 57/518 [11%]. p < 0.001). When compared with No-SC patients, a higher proportion of SC patients maintained SR at eight weeks (87.2% vs. 48.9%, p < 0.001), without statistically significant differences in bleeding, thromboembolism or mortality. Multivariate predictors of SC were shorter duration of AF, New York Heart Association (NYHA) functional class 1 or 2, smaller left atrial size, and absence of left atrial spontaneous echo contrast.CONCLUSIONS Spontaneous conversion was associated with shorter duration of AF, lower NYHA class, smaller left atrial size, and absence of left atrial spontaneous echo contrast. There was a better SR outcome in the SR group, but no differences in the other clinical end points. The conventional treatment strategy allowed greater opportunity for SC. In the absence of favorable predictors of SC, the TEE-guided approach should be considered. (C) 2003 by the American College of Cardiology Foundation.

In a multicenter randomized trial, we studied a transesophageal echocardiography (TEE) guided strategy with short-term anticoagulation compared with a conventional strategy for patients with atrial fibrillation >2 days’ duration and undergoing cardioversion. Composite major and minor bleeding was a predetermined secondary end point of the study. The objective of the study was to assess the incidence, location, and predictors of bleeding in the 2 treatment groups. A total of 1,222 patients were assigned to a TEE guided or conventional strategy and followed over 8 weeks. We present data on major and minor adjudicated bleeding complications for the 2 study groups during the 8-week study period. Composite major and minor bleeding complications occurred in 51 of 1,222 patients (4.2%) and were significantly lower in the TEE guided group compared with the conventional group (2.9 vs 5.5%, p = 0.025). The TEE group had fewer cancellations of cardioversion as a result of bleeding (0% vs 0.7%, p = 0.003). Major (n = 14) and minor (n = 38) bleeding complications were predominantly gastrointestinal (71.4% and 31.6%, respectively) and were associated with warfarin use. Predictors of bleeding included patient age, conventional group assignment, inpatient status, and functional status. Thus, composite major and minor bleeding complications occurred in 4.2% of the 1,222 patients and were significantly lower in the TEE guided group compared with the conventional group. Treatment variables affecting length of anticoagulant therapy in the conventional arm combined with advancing age and functional status are important concerns in patients who undergo cardioversion of atrial fibrillation.

Background: Respiratory variation of the pulmonary venous (PV) peak flow velocities can be used to distinguish constrictive pericarditis (constriction) from restrictive cardiomyopathy (restriction). Rapid volume expansion has been used successfully to enhance diastolic pressure equalization in occult constriction. The effect of volume on the respiratory variation in constriction has not been studied previously. This study assessed the utility of volume in enhancing the PV respiratory variation of constriction to further separate it from restriction. Methods: The study population consisted of 15 patients referred to the echocardiography laboratory for further evaluation of clinically suspected diastolic dysfunction. Pulsed-Doppler transesophageal echocardiography (TEE) of the left or right upper pulmonary vein and mitral inflow was performed with respiratory monitoring before and after infusion of 1 liter of normal saline over 5 to 10 minutes. The classification of patients as constriction (n = 8) or restriction (n = 7) was confirmed independently by cardiac catheterization or surgery. Peak velocities of the PV systolic and diastolic waves and the mitral inflow E were measured during inspiration and expiration. A mean of 3-6 respiratory cycles was obtained for each value before and after volume loading. The percent change from expiration to inspiration (FOE) was calculated using the formula %E = expiration - inspiration/expiration. Results: At baseline, patients with constrictive pericarditis can be separated reliably from those with restrictive cardiomyopathy based on a higher systolic/diastolic ratio and greater respiratory variation of their PV diastolic flow velocity. There were no complications in any patient due to volume expansion. Although the change from baseline to volume expansion was not statistically significant in either constriction or restriction, the %E of the PV diastolic wave became significantly higher in constriction than in restriction (P < 0.05). Conclusions: Rapid volume expansion is relatively safe during TEE and can be used for further separation of constrictive pericarditis from restrictive cardiomyopathy by significantly enhancing the respiratory variation of the PV diastolic flow velocity in constrictive pericarditis.

Acute stress and ventricular arrhythmias a need to compare the already evaluated methods of mental stress testing [1,5,6] in order to better select patients for stress therapy.Furthermore, intervention trials should not only focus on beta-adrenergic blockers but evaluate the efficacy of relaxation techniques and stress reduction programmes in cardiac patients at risk.This will hopefully be useful in closing the gap between theory and clinical practice in stress-reduction treatments in patients with coronary artery disease.

Background: Previous studies have reported the clinical and echocardiographic findings of patients with left atrial spontaneous echo contrast (SEC) and thrombi. We sought to study these characteristics in patients with right atrial SEC and thrombi. Methods: We reviewed 580 consecutive patients from the ACUTE (Assessment of Cardioversion Using Transesophageal Echocardiography) Registry and found 79 patients (14%, aged 67 ±; 13 years, 67 male) with transesophageal echocardiography (TEE) findings of right atrial SEC or thrombi (group 1). This group was compared with a control group of 75 consecutive patients (group 2) (aged 68 ± 13 years, P = not significant; 49 male, P <.005) from the registry with no TEE findings of SEC or thrombi in the left or right atrium. Results: Atrial fibrillation was present in 60 of 79 group 1 patients (76%). Five right atrial (6%) and 11 left atrial (14%) thrombi were identified. Both left ventricular ejection fraction (39% ±; 16% versus 47% ±; 14%; P =.0005) and presence of right ventricular dysfunction (n = 44 versus 18; P =.0001) differed significantly between groups 1 and 2, respectively. Right atrial area (24 ±; 6 cm2 versus 22 ±; 6 cm2; P =.02) was larger in patients in group 1. Left atrial SEC was present in 68 of 79 group 1 patients (86%). Patients with right atrial thrombi and right atrial SEC had a longer duration of arrhythmia (524 ±; 812 days versus 147 ±; 368 days, P <.05) than patients with right atrial SEC only. Conclusions: Right atrial SEC has a prevalence of 14% in patients with atrial arrhythmia who undergo TEE-guided cardioversion. Right atrial thrombi are a rare finding and were seen in fewer than 1% (5/580) of patients with atrial arrhythmia. Right atrial thrombi among patients on anticoagulation therapy were not associated with clinically significant pulmonary embolism. (J Am Soc Echocardiogr 2001;14:122-7.)