Combined transesophageal echocardiography and transesophageal cardioversion probe: technical aspects

Esophageal electrical cardioversion of atrial fibrillation: when esophagus gives a help to cardiologists

Atrial fibrillation is a common clinical disease especially in the elderly and in patients with organic heart disease. Electrical cardioversion is the first choice therapeutic approach for patients in which sinus rhythm could improve the quality of life and where the maintenance of sinus rhythm is considered likely. There are different techniques to perform an electrical cardioversion, each with specific indications, advantages, and limitations. The method most frequently used to restore sinus rhythm is external direct current cardioversion; however, this technique has some disadvantages, since it requires a high energy and usually general anesthesia. Esophageal cardioversion is an alternative method to obtain restoration of sinus rhythm, warranting acute and long-term results absolutely comparable with those obtained by the conventional transthoracic technique, especially in obese and COPD patients with high thoracic impedance for whom the standard technique may be less effective.

Single-step atrial thrombus exclusion and transesophageal cardioversion in atrial fibrillation

Atrial fibrillation (AF), the most common arrhythmia, has a major impact on both patient morbidity and healthcare economics. Hospital admissions due to AF have risen by two-thirds in the last 20 years. This is due mainly to an aging population and an increasing prevalence of chronic heart disease. Strategies for the management of AF include prevention of thromboembolism, rate control and correction of the arrhythmia. Electrical cardioversion as one component of the treatment of AF requires the absence of atrial thrombi. Transesophageal echocardiography is used routinely for exclusion of atrial thrombi prior to cardioversion in many hospitals. This review presents preliminary data on the clinical use of devices for simultaneous transesophageal echocardiography and transesophageal cardioversion.

Simultaneous transesophageal cardioversion and echocardiography: feasibility and safety

BACKGROUND

Transesophageal echocardiography (TEE) is routinely used to exclude atrial thrombus prior to cardioversion of atrial fibrillation (AF). Because the TEE probe lies adjacent to the atria, cardioversion using an electrode attached to the TEE probe should allow for immediate low-energy transesophageal cardioversion.

OBJECTIVE

The purpose of this study was to evaluate a cardioversion electrode sheath that can be affixed to conventional TEE probes for simultaneous thrombus exclusion and cardioversion of AF.

METHODS

A thin electrode was integrated into a latex or polyurethane sheath covering a conventional TEE probe. TEE thrombus exclusion and biphasic transesophageal cardioversion using a step-up protocol were performed during deep sedation. Esophagoscopy was performed immediately after cardioversion and after 1 week.

RESULTS

TEE was performed in 27 patients. One patient showed left atrial thrombi. Transesophageal cardioversion was successful in 25 of the remaining 26 patients. Mean atrial cardioversion threshold was 63 +/- 48 J. Transesophageal cardioversion restored sinus rhythm in two patients with unsuccessful transthoracic cardioversion. Transesophageal cardioversion in deep sedation was well tolerated. Esophagoscopy revealed slight mucosal damage in three patients at the site of shock application; two of these patients showed signs of gastroesophageal reflux disease. Mucosal damage unrelated to the site of shock delivery was noted in three patients.

CONCLUSION

Atrial thrombus exclusion and transesophageal cardioversion of AF via a disposable cardioversion sheath offers the opportunity to perform transesophageal cardioversion and TEE thrombus exclusion during one sedation. It may not be suitable for use in patients with gastroesophageal reflux disease. Transesophageal cardioversion may establish sinus rhythm in selected patients refractory to transthoracic cardioversion.