Ineffektive Antikoagulation vor elektiver elektrischer Kardioversion von Vorhofflimmern

Hintergrund und Fragestellung: Eine 3- bis 4-wöchige Antikoagulation (AC) vor elektiver elektrischer Kardioversion von Vorhofflimmern gilt als anerkannte Maßnahme zur Reduktion thrombembolischer Ereignisse. In dieser Phase treten jedoch häufig Perioden ineffektiver AC auf. Der Einfluss der Dauer einer ineffektiven AC auf den Nachweis von Vorhofthromben (LAT) oder das staseinduzierte Phänomen des spontanen Echokontrastes (SEC) mittels transösophagealer Echokardiographie (TEE) sollte untersucht werden.

Patienten und Methodik: 56 konsekutive Patienten (39 Männer) im mittleren Alter von 64 ± 9 Jahren mit nicht-rheumatischem Vorhofflimmern, bei denen eine elektrische Kardioversion nach einer mindestens 3-wöchigen AC geplant und eine ineffektive AC dokumentiert war, wurden mittels TEE untersucht. Die Kardioversion erfolgte nach LAT-Ausschluss oder bei Nachweis von LAT nach einer 4-wöchigen Phase der AC und neuerlicher TEE. Nach Kardioversion erfolgte eine mindestens 4-wöchige AC und Nachbeobachtung. Echokardiographische, demographische und klinische sowie die verfügbaren Gerinnungsparameter wurden erfasst.

Ergebnisse: Bei 5/56 (9 %) der Patienten war ein LAT, bei zehn (18 %) ein SEC nachweisbar, in keinem Fall beide Befunde. Bezüglich der Dauer der ineffektiven AC unterschied sich die Gruppe mit LAT mit im Mittel 15 ± 10 Tagen (Spanne 5 - 28) nicht signifikant zur Patientengruppe mit unauffälliger TEE (17 ± 8 Tage; Spanne 0 - 28) und zur Gruppe mit SEC (23 ± 6 Tage; Spanne 12 - 28). Es bestand zwischen den drei Gruppen kein signifikanter Unterschied bezüglich der untersuchten klinischen, demographischen und anamnestischen Parameter. Thrombembolische Ereignisse traten nicht auf.

Folgerung: Im untersuchten Kollektiv mit kleinen Fallzahlen innerhalb der einzelnen Gruppen ließen weder die Dauer der ineffektiven AC noch klinische, epidemiologische oder echokardiographische Parameter Rückschlüsse auf das Vorkommen eines LAT zu. Bei ineffektiver AC sollte daher eine TEE vor Kardioversion erfolgen. Patienten mit SEC hatten in unserer Untersuchung kein erhöhtes Embolierisiko.

Background and objective: Anticoagulation (AC) should be given for 3 to 4 weeks before elective electrical cardioversion to reduce thromboembolic events. During this period ineffective AC is a common problem. The aim of our study was to investigate the influence of the duration of ineffective AC on the incidence of left atrial thrombi (LAT) or spontaneous echocontrast (SEC) induced by hemostasis detected by transesophageal echocardiography (TEE).

Patients and methods: 56 consecutive patients (39 men) at the age of 64 ± 9 years with non-rheumatic atrial fibrillation who were scheduled for electrical cardioversion after 3 to 4 weeks of AC and a documented ineffective AC underwent TEE. Cardioversion was performed after exclusion of a LAT by TEE or in patients with LAT after 4 more weeks of AC and repeated TEE. All patients received AC and were observed for at least 4 weeks after cardioversion. Echocardiographic, demographic and clinical parameters and available values of AC were recorded.

Results: In 5/56 (9 %) patients a LAT, in 10 (18 %) patients SEC was detected. No patient had both. In patients with LAT the duration of ineffective AC was 15 ± 10 days (range 5 - 28) and did not differ significantly from patients without LAT (17 ± 8 days; range 0 - 28) or to the group with SEC (23 ± 6 days; range 12 - 28). There was no significant difference of demographic, echocardiographic and clinical parameters between these groups. There was no embolic event during follow-up.

Conclusions: Neither the duration of ineffective AC nor clinical, epidemiologic or echocardiographic parameters could differentiate patients with or without LAT in our observed groups with small numbers of patients. In case of an ineffective AC patients who are to undergo electrical cardioversion should have TEE. In our study patients with SEC were not at a higher thromboembolic risk.

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