Is transesophageal echocardiography necessary before electrical cardioversion in patients treated with non-vitamin K antagonist oral anticoagulants? Current evidence and practical approach

According to current guidelines, non-vitamin K antagonist oral anticoagulants (NOACs) should be used at least 3 weeks before planned electrical cardioversion. In accordance with international atrial fibrillation (AF) guidelines, transesophageal echocardiography (TEE) is a pre-procedural examination recommended as an alternative to adequate oral anticoagulation. The strategy related to qualifying patients treated with NOACs for pre-procedural TEE differs in individual centers. Therefore, it is necessary to create an algorithm that will standardize estimation of left atrial appendage thrombus (LAAT) prevalence risk and thereby qualify NOAC-treated patients to TEE in the most effective way. We assessed the available studies on LAAT predictors. Risk factors for LAAT formation are not necessarily the same as the risk factors for thromboembolic events in patients with AF. The main risk factor for LAAT are as follows: previous intracardiac thrombus, irregular use of NOAC, inappropriate dose reduction of NOAC, previous stroke, CHA2DS2-VASc score >= 3 points, glomerular filtration rate < 60 mL/min/1.73 m2 , reduced left ventricular ejection fraction, or left atrial enlargement. Based on available evidence, we proposed algorithm guarantees more systematic approach to performing TEE in patients undergoing electrical cardioversion.