Background

Patients with atrial fibrillation (AF) are at high risk for thromboembolic stroke. For prevention, oral anticoagulation (OAC) is recommended after risk assessment by CHA₂DS₂-VASc score. Transesophageal echocardiography (TEE) to exclude thrombus may be omitted before electrocardioversion if OAC has been taken continuously for at least 4 weeks. No standardized approach has been established before pulmonary vein isolation (PVI), and often TEE is performed in all patients before PVI regardless of stroke risk.

Objectives

To define a standardized protocol for TEE before PVI and to prospectively analyze the safety of this approach.

Methods

We prospectively analyzed consecutive patients who underwent PVI in a single-center cohort between 2019 and 2023. PVI was performed in a standardized fashion and OAC was “minimally” interrupted on the morning of PVI. TEE was performed in patients who were in AF before the procedure, who had not consistently taken OAC in the previous 3 weeks or who had previously experienced stroke or atrial thrombus (figure). In patients in sinus rhythm and OAC > 3 weeks TEE was performed only if stroke/atrial thrombus had occurred (figure). Endpoints were thromboembolic stroke or peripheral arterial embolism at 30 days after procedure.

Results

Of 690 patients undergoing PVI 340 (49.3%) underwent TEE before procedure (164 due to AF before PVI, 133 due to OAC < 3 weeks, 31 due to previous stroke/ atrial thrombus, 12 due to AF and previous stroke / atrial thrombus). In two patients, a thrombus was detected by TEE and PVI was accordingly not performed. One TEE patient (0.3%) experienced a stroke within 30 days after procedure while no endpoint was met in patients not receiving TEE (0.3% vs. 0%, p=0.31).

Conclusion

A standardized, risk-stratified approach to TEE before PVI is safe and can prevent unnecessary examinations.