Audit of Change in Anticoagulation Practice Prior to Direct Current Cardioversion and Incidence of Left Atrial Thrombus on Transoesophageal Echocardiogram

Abstract

The use of anticoagulation with either warfarin or novel oral anticoagulants (NOAC) is routine prior to direct current cardioversion (DCCV) for atrial fibrillation or atrial flutter. Transoesophageal echocardiograms (TOE) may be performed to visually confirm and rule out LAA thrombus. We retrospectively reviewed the change in practice of anticoagulation and results of TOE prior to DCCV. 354 patients underwent DCCV from 2012 to August 2016 of which 238 had a TOE. 20 patients were lost to follow-up. The mean age was 63years (range 18-94). The mean CHADSVASC score was 2.04 (SD1.49). Warfarin usage was 75% in 2012 declining to 7% in 2016. NOAC use increased from 6% to 89% in 2016, rivaroxaban being the overwhelming choice with 73%. Of the 238 who underwent TOE, 6 had filling defects suggestive of LAA thrombus. All had ≥3 weeks of formal anticoagulation. 2 were on warfarin and had inadequate INR control. 1 patient was taking apixaban once a day. 3 were on rivaroxaban of which one TOE was re-reported as ‘suspicious’ on review. These patients were compliant and taking rivaroxaban with food. No patient had a stroke on follow-up. Our retrospective dataset shows the changing practise of clinicians, favouring NOAC over warfarin prior to DCCV. Rivaroxaban, whilst being the favoured NOAC had two confirmed LAA thrombus and one suspicious finding with no obvious cause for the failure of treatment. Whilst retrospective, this is a real-world experience and warrants further prospective evaluation.