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Post-cardioversion transesophageal echocardiography (POSTEC) strategy with the use of enoxaparin for brief anticoagulation in atrial fibrillation patients: the multicenter POSTEC trial (a pilot study)

Sorino, Margherita; Colonna, Paolo; De Luca, Leonardo; Carerj, Scipione; Oliva, Esmeralda; De Tommasi, Salvatore M; Conti, Umberto; Iacopi, Flaviano; D'Agostino, Carlo; D'Amato, Nicola; Pettinati, Giacinto; Montericcio, Vincenzo; Cualbu, Annamaria; De Luca, Italo

Journal of Cardiovascular Medicine: December 2007 - Volume 8 - Issue 12 - p 1034–1042
doi: 10.2459/JCM.0b013e32803cab11
Original articles

Objectives In patients with atrial fibrillation (AF), we sought to evaluate the feasibility and safety of a new transesophageal echocardiography (TEE)-guided strategy, aimed at selecting, 7 days post-cardioversion, those patients who are at low risk (i.e. who can terminate anticoagulation after a second TEE) and those at high risk (i.e. who have to continue it).

Methods We enrolled 206 patients with non-valvular AF into a randomized, multicenter clinical trial. Group A patients underwent a TEE-guided cardioversion with heparin and at least 4 weeks of oral anticoagulation therapy (OAT) after cardioversion. Group B patients received enoxaparin and underwent a TEE-guided cardioversion. After 7 days, a second TEE was carried out. In the absence of TEE thromboembolic risk factors and left atrial appendage (LAA) dysfunction anticoagulation was discontinued.

Results In group A, 88 out of 102 patients underwent TEE and cardioversion was efficacious in 77 of 78. In group B, 100 out of 104 patients underwent TEE and cardioversion was efficacious in 80 of 87 patients; 55 patients underwent the second TEE and enoxaparin was stopped in 50 without LAA dysfunction. In group A, one transient ischemic attack and one sudden cardiac death occurred. In group B, one patient with complex aortic plaques suffered a stroke during enoxaparin. There was a minor hemorrhage in groups A and B, and a severe hemorrhage in a patient during OAT because of persistent atrial stunning. Hospitalization length and duration of anticoagulation were significantly shorter in group B.

Conclusions The pre/post-cardioversion TEE strategy with enoxaparin in AF may constitute a feasible and safe approach in selecting patients at low thromboembolic risk who can benefit from precocious termination of anticoagulation (7 days after cardioversion). It may be also useful to identify those patients in whom a life-lasting anticoagulation could be beneficial. A larger trial to confirm these findings is under way.

aDivision of Cardiology, Policlinico Hospital of Bari, Bari, Italy

bDivision of Cardiology, Policlinico Hospital, Messina, Italy

cDivision of Cardiology, Hospital S. Chiara, Pisa, Italy

dDivision of Cardiology, Hospital of Faenza, Italy

eDivision of Cardiology, Di Venere Hospital, Carbonara Bari, Italy

fDivision of Cardiology, Hospital of Casarano, Italy

gCardiology, Policlinico San Donato Hospital, Milan, Italy

hDivision of Cardiology, SS Trinita Hospital of Cagliari, Italy

Received 13 August, 2006

Revised 4 December, 2006

Accepted 7 December, 2006

Correspondence and requests for reprints to Italo De Luca, Cardiology Hospital Department, Policlinico of Bari, Piazza G. Cesare 11, 70124 Bari, Italy Tel: +39 080 5592424; fax: +39 080 5575729; e-mail: i_deluca@tin.it,baricard@tin.it

© 2007 Italian Federation of Cardiology. All rights reserved.