Usefulness of transesophageal echocardiography using a combined probe when converting atrial fibrillation to sinus rhythm

We studied the feasibility and efficacy of transesophageal echocardiography (TEE) combined with transesophageal cardioversion (TEC). Secondary aims were to study left atrial flow velocities before and 1 and 5 minutes after TEC, biochemical markers of myocardial damage, and patient tolerability. TEC after a short period of anticoagulation and exclusion of a clot with TEE was safe. TEC was well tolerated and efficacious. The use of a combined probe for TEE and TEC therefore can save time and be more effective. A custom-made probe for combined TEE plus TEC was used. TEC was performed with a step-up protocol (20 J to between 30 and 50 J) and with biphasic shocks. Presence of spontaneous echo contrast was scored. Cumulative energy needed to achieve sinus rhythm was calculated. Discomfort was scored on a scale of 0 to 10. Twenty-six patients underwent combined TEE/TEC. Sinus rhythm was achieved in 24 of 26 patients (92%) with a mean cumulative energy of 42.3 J. Sixteen of 26 patients were cardioverted with a 20-J shock, and 6 of these patients had early recurrence of atrial fibrillation. All biochemical markers were unaffected, and TEE/TEC was well tolerated. Left atrial appendage velocity decreased significantly after TEC. Thus, the use of a TEE/TEC probe offers effective cardioversion with low energy levels, is well tolerated, and hemodynamics during and immediately after cardioversion can be monitored. Early cardioversion after exclusion of a clot with this combined probe is time saving and cost effective.