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State of the Art in Management of Atrial Fibrillation

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (20 February 2024) | Viewed by 27048

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Special Issue Editors

Dr. Fabiana Lucà

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Guest Editor

Department of Cariology, Big Metropolitan Hospital of Reggio Calabria, 89129 Reggio Calabria, Italy
Interests: atrial fibrillation; supraventricular arrhythmias; ventricular arrhythmias; sudden cardiac death (SCD); acute and chronic heart failure; ischemic heart disease; pacemaker; cardiac resynchronization therapy (CRT); implantable cardioverter defibrillator (ICD)
Special Issues, Collections and Topics in MDPI journals

Dr. Matthias Unterhuber

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Guest Editor

Kardiologie Herzzentrum Leipzig, 04289 Leipzig, Germany
Interests: cardiology; heart failure and valvular disease; machine learning and electrophysiology; syncope

Special Issue Information

Dear Colleagues,

New knowledge suggests that atrial fibrillation (AF) plays a significant role in patient management and healthcare systems. Several researchers and practitioners have discussed the causes underlying AF, its natural history, effective treatments and new evidence. In general, they have agreed that the care of patients with AF in daily clinical practice is a challenging but essential requirement for effective management of AF. In summary, a comprehensive and multidisciplinary approach to the management of AF patients is needed and new evidence must be taken into account. The sharing of knowledge, in relation to competence, among cardiologists and cardiac surgeons with varying levels of subspecialty expertise, and between research sectors, is required to improve strategies and treatment of AF in clinical practice.

Dr. Fabiana Lucà
Dr. Matthias Unterhuber
Guest Editor

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Keywords

atrial fibrillation
cancer and atrial fibrillation
DOAC
hybrid approach of AF
ablation of AF
AF medical therapy

Published Papers (12 papers)

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10 pages, 635 KiB

Open AccessArticle

Esophageal Protection and Temperature Monitoring Using the Circa S-Cath™ Temperature Probe during Epicardial Radiofrequency Ablation of the Pulmonary Veins and Posterior Left Atrium

by Rani Kronenberger, Orlando Parise, Ines Van Loo, Sandro Gelsomino, Ashley Welch, Carlo De Asmundis and Mark La Meir

J. Clin. Med. 2022, 11(23), 6939; https://doi.org/10.3390/jcm11236939 - 25 Nov 2022

Cited by 1 | Viewed by 1206

Abstract

Although epicardial bipolar radiofrequency ablation should diminish the risk of esophageal thermal injury in comparison to an endocardial ablation, cases of lethal atrio-esophageal fistula have been reported. To better understand this risk and to reduce the possibility of a thermal injury, we monitored the esophageal temperature with the Circa S-Cath™ temperature probe during and immediately after the ablation while implementing three procedural safety measures. Twenty patients (15 males; 63 ± 10 years) were prospectively enrolled (November 2019–February 2021). All patients underwent an epicardial ablation procedure, including an antral left and right pulmonary vein isolation with bidirectional bipolar clamping, and a roof and inferior line using unidirectional bipolar radiofrequency. Three procedural preventive mitigations were implemented: (1) transesophageal echocardiographic visualization of the atrio-esophageal interface, with probe retraction before the energy delivery; (2) lifting the ablated tissue away from the esophagus during an energy application; and (3) a 30 s cool-off and irrigation period after the energy delivery. The esophageal temperature was recorded using an insulated multisensory intraluminal esophageal temperature probe (Circa S-Cath™). Of the 20 patients enrolled, 7 patients had paroxysmal atrial fibrillation (AF), 8 persistent AF and 5 longstanding persistent AF. The average maximum luminal esophageal temperature observed was 36.2 ± 0.7 °C (34.8–38.2 °C). In our clinical experience, no abrupt increase in the luminal esophageal temperature above the baseline was observed. Since no measurements exceeded the threshold of 39 °C, no prompt interruption of energy delivery was required. Intraluminal esophageal temperature monitoring is feasible and can be helpful in confirming correct catheter position and safe energy application in bipolar epicardial left atrial ablation. Intra-procedural preventive mitigations should be implemented to reduce the risk of esophageal temperature rises. Full article

(This article belongs to the Special Issue State of the Art in Management of Atrial Fibrillation)

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12 pages, 569 KiB

Open AccessArticle

Not to Rush—Laboratory Parameters and Procedural Complications in Patients Undergoing Left Atrial Appendage Closure

by David Zweiker, Lukas Fiedler, Gabor G. Toth, Andreas Strouhal, Georg Delle-Karth, Guenter Stix, Harald Gabriel, Ronald K. Binder, Martin Rammer, Michael Pfeffer, Paul Vock, Brigitte Lileg, Clemens Steinwender, Kurt Sihorsch, Florian Hintringer, Silvana Mueller, Fabian Barbieri, Martin Martinek, Wolfgang Tkalec, Nicolas Verheyen, Klemens Ablasser, Andreas Zirlik and Daniel Scherr Show full author list Hide full author list

J. Clin. Med. 2022, 11(21), 6548; https://doi.org/10.3390/jcm11216548 - 04 Nov 2022

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Abstract

Background: As a preventive procedure, minimizing periprocedural risk is crucially important during left atrial appendage closure (LAAC). Methods: We included consecutive patients receiving LAAC at nine centres and assessed the relationship between baseline characteristics and the acute procedural outcome. Major procedural complications were defined as all complications requiring immediate invasive intervention or causing irreversible damage. Logistic regression was performed and included age and left-ventricular function. Furthermore, the association between acute complications and long-term outcomes was evaluated. Results: A total of 405 consecutive patients with a median age of 75 years (37% female) were included. 47% had a history of stroke. Median CHA2DS2-VASc score was 4 (interquartile range, 3–5) and the median HAS-BLED score was 3 (2–4). Major procedural complications occurred in 7% of cases. Low haemoglobin (OR 0.8, 95% CI 0.65–0.99 per g/dL, p = 0.040) and end-stage kidney disease (OR 13.0, CI 2.5–68.5, p = 0.002) remained significant in multivariate analysis. Anaemia (haemoglobin < 12 and < 13 g/dL in female and male patients) increased the risk of complications 2.2-fold. Conclusions: The major complication rate was low in this high-risk patient population undergoing LAAC. End-stage kidney disease and low baseline haemoglobin were independently associated with a higher major complication rate. Full article

(This article belongs to the Special Issue State of the Art in Management of Atrial Fibrillation)

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13 pages, 1249 KiB

Open AccessArticle

Heart Team for Left Appendage Occlusion without the Use of Antithrombotic Therapy: The Epicardial Perspective

by Stefano Branzoli, Fabrizio Guarracini, Massimiliano Marini, Giovanni D’Onghia, Domenico Catanzariti, Elettra Merola, Luciano Annicchiarico, Giulia Casagranda, Chiara Stegagno, Mauro Fantinel and Mark La Meir

J. Clin. Med. 2022, 11(21), 6492; https://doi.org/10.3390/jcm11216492 - 01 Nov 2022

Cited by 5 | Viewed by 1401

Abstract

Background: Left atrial appendage occlusion is an increasingly proposed treatment for patients with atrial fibrillation and poor tolerance to anticoagulants. All endovascular devices require antithrombotic therapy. Anatomical and clinical variables predisposing to device-related thrombosis, as well as post-procedural peri-device leaks, could mandate the continuation or reintroduction of aggressive antithrombotic treatment. Because of the absence of foreign material inside the heart, epicardial appendage closure possibly does not necessitate antithrombotic therapy, but data of large series are missing. Methods: Multidisciplinary team evaluation for standalone totally thoracoscopic epicardial appendage closure was done in 180 consecutive patients with atrial fibrillation and poor tolerance to antithrombotic therapy. One hundred and fifty-two patients consented (male 66.1%, mean age 76.1 ± 7.4, CHA₂DS₂VASc mean 5.3 ± 1.6, HASBLED mean 3.8 ± 1.1). Indications were cerebral hemorrhage (48%), gastro-intestinal bleeding (33.3%), and other bleeding (20.7%). No antithrombotic therapy was prescribed from the day of surgery to the latest follow up. Results: Procedural success was 98.7%. At a mean follow up of 38.2 ± 18.8 months, cardioembolic and bleeding events were 1.3% and 0.6%, respectively. Among patients with a history of blood transfusions (41.1%), none needed further transfusions or treatment post procedure. Conclusion: Epicardial appendage occlusion without any antithrombotic therapy appears to be safe and effective. This strategy could be advised when minimization of bleeding risk concomitant to stroke prevention is needed. Full article

(This article belongs to the Special Issue State of the Art in Management of Atrial Fibrillation)

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10 pages, 774 KiB

Open AccessArticle

Persistent Atrial Fibrillation in Elderly Patients: Limited Efficacy of Pulmonary Vein Isolation

by Andreas A. Boehmer, Moritz Rothe, Celine Zezyk, Christina M. Soether, Bianca C. Dobre, Bernhard M. Kaess and Joachim R. Ehrlich

J. Clin. Med. 2022, 11(20), 6070; https://doi.org/10.3390/jcm11206070 - 14 Oct 2022

Cited by 3 | Viewed by 1082

Abstract

(1) Background: Cryoballoon pulmonary vein isolation (cryoPVI) is established for symptomatic paroxysmal atrial fibrillation (AF) treatment, but its value in persistent AF is less clear. In particular, limited data are available on its efficacy in elderly patients (≥75 years) with persistent AF. Age is an important modifier of AF progression and represents a risk-factor for AF recurrence. (2) Methods: Prospective, single-center observational study to evaluate the impact of age on efficacy and safety of cryoPVI in elderly patients. Primary efficacy endpoint was symptomatic AF recurrence after 90-day blanking period. Primary safety endpoints were death from any cause, procedure-associated complications or stroke/transient ischemic attack. Median follow-up was 17 months (range 3–24). (3) Results: We included 268 patients with persistent AF (94 ≥ 75 years of age). Multivariate Cox regression analysis identified age as the only independent factor influencing AF recurrence in the overall cohort (p = 0.006). To minimize confounding bias in efficacy and safety analysis of cryoPVI, we matched younger and elderly patients with respect to baseline characteristics. At 24 months, primary efficacy endpoint occurred in 13/69 patients <75 years and 31/69 patients ≥75 years of age (24 months Kaplan–Meier event-rate estimates, HR 0.34; 95% CI, 0.19 to 0.62; log-rank p = 0.0004). No differences were observed in the occurrence of safety end points. (4) Conclusions: Elderly (≥75 years) patients with persistent AF undergoing cryoPVI had an approximately threefold higher risk of symptomatic AF recurrence than matched younger patients. Accordingly, other treatment modalities may be evaluated in this population. Full article

(This article belongs to the Special Issue State of the Art in Management of Atrial Fibrillation)

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12 pages, 16517 KiB

Open AccessArticle

Heart Team for Left Atrial Appendage Occlusion: A Patient-Tailored Approach

by Stefano Branzoli, Fabrizio Guarracini, Massimiliano Marini, Giovanni D’Onghia, Daniele Penzo, Silvio Piffer, Dimitri Peterlana, Angelo Graffigna, Michele Massimo Gulizia, Sandro Gelsomino and Mark La Meir

J. Clin. Med. 2022, 11(1), 176; https://doi.org/10.3390/jcm11010176 - 29 Dec 2021

Cited by 5 | Viewed by 1768

Abstract

Background and Purpose: Left atrial appendage occlusion (LAAO) is an accepted therapeutic option for stroke prevention; however, the ideal technique and device have not yet been identified. In this study we evaluate the potential role of a heart team approach for patients contraindicated for oral anticoagulants and indicated for left atrial appendage closure, to minimize risk and optimize benefit in a patient-centered decision-making process. Methods: Forty patients were evaluated by the heart team for appendage occlusion. Variables considered were CHA₂DS₂VASc, HASBLED, documented blood transfusions, comorbidities, event forcing anticoagulant interruption, past medical history, anatomy of the left atrial appendage, and patient quality of life. Twenty patients had their appendage occluded percutaneously (65% male, mean age 72.3 ± 7.5, mean CHA₂DS₂VASc 4.2 ± 1.5, mean HASBLED 3.5 ± 1.1). The other twenty underwent thoracoscopic occlusion (65% male, mean age of 74.9 ± 8, mean CHA₂DS₂VASc 6.0 ± 1.5, HASBLED mean 5.4 ± 1.4). Percutaneous patients were on dual antiplatelet therapy for the first three months and aspirin thereafter, whereas the others received no anticoagulant/antiplatelet therapy from the day of surgery. Follow up included TEE, CT scan, and periodical clinical evaluation. Results: Mean duration of procedures and hospital stay were comparable. All patients had complete exclusion of the appendage; at a mean follow up of 33.1 ± 14.1 months, no neurological or hemorrhagic events were reported. Conclusions: A heart team approach may improve the decision-making process for stroke and hemorrhage prevention, where LAAO is a therapeutic option. Percutaneous and thoracoscopic appendage occlusion seem to be comparably safe and effective. An epicardial LAAO could be advisable in patients for whom the risk of bleeding is estimated as being too high for post-procedural antiplatelet therapy. Full article

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17 pages, 8953 KiB

Open AccessArticle

Pulmonary Vein Isolation Outcome Degree Is a New Score for Efficacy of Atrial Fibrillation Catheter Ablation

by Ruzica Jurcevic, Lazar Angelkov, Nebojsa Tasic, Milosav Tomovic, Dejan Kojic, Petar Otasevic and Milovan Bojic

J. Clin. Med. 2021, 10(24), 5827; https://doi.org/10.3390/jcm10245827 - 13 Dec 2021

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Abstract

This study introduces the pulmonary vein isolation outcome degree (PVIOD) as a new semiquantitative measure for the efficacy of atrial fibrillation (AF) catheter ablation and reports the determination of predictors associated with PVIOD. The median follow-up periods of 117 patients after the first and last ablation were, respectively, 82 (IQR 15) and 72 (IQR 30) months. PVIOD 1 included 32.5% of patients, those with successful single pulmonary vein isolation (PVI); PVIOD 2 included 29.1% of subjects, those with success after multiple procedures; PVIOD 3 comprised 14.5% of patients, those with clinical success; and PVIOD 4 included 23.9% of cases, those with procedural and clinical failure. In the multivariate ordinal logistic regression analysis, PVIOD 1–4 were independently associated with longstanding persistent AF with paroxysmal AF as the referent category (odds ratio (OR), 3.5; 95% confidence interval (95% CI), 1.1–10.7 (p = 0.031)), left atrial (LA) diameter (OR, 1.2; 95% CI, 1.1–1.3 (p = 0.001)) and left ventricular ejection fraction (LVEF) (OR, 0.9; 95% CI, 0.86–1.0 (p = 0.038)). LA size > 41 mm, LVEF ≤ 50% and longstanding persistent AF are strong predictors of AF recurrence. PVIOD 1–4 offer the most exact long-term prognosis of PVI. The purpose of the present article is to expand the quantitative measure of procedural success in the medical and biological fields. Full article

(This article belongs to the Special Issue State of the Art in Management of Atrial Fibrillation)

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8 pages, 519 KiB

Open AccessArticle

Left Atrial Pressure as a Predictor of Success in Catheter Ablation of Atrial Fibrillation in a Real-Life Cohort

by Massimiliano Manfrin, Giacomo Mugnai, Werner Rauhe, Vedran Velagic and Matthias Unterhuber

J. Clin. Med. 2021, 10(15), 3208; https://doi.org/10.3390/jcm10153208 - 21 Jul 2021

Cited by 3 | Viewed by 1470

Abstract

Aims: The clinical role of the left atrial (LA) hypertension in patients with atrial fibrillation (AF) and its role as predictor in those undergoing pulmonary vein (PV) isolation is still unknown. The aim of the present study was to analyze the role of LA pressure in patients with nonvalvular AF who underwent PV isolation and its implication for AF catheter ablation. Methods: Consecutive patients with drug resistant AF who underwent PV isolation at San Maurizio Regional Hospital of Bolzano (Italy) as index procedure were included in this analysis. Results: A total of 132 consecutive patients (97 males, 73%; mean age 58.0 ± 13.2 years) were included in the analysis. Eleven patients (8%) underwent radiofrequency ablation and 121 (92%) cryoballoon ablation. Higher LA pressures were found in 54 patients (40.9%). At a mean follow up of 14.3 ± 8.2 months (median 12 months), the success rate without antiarrhythmic therapy was 65.9% (87/132; considering the blanking period). Female gender and continuous mean LA pressure were significantly associated with AF recurrence and remained significant on multivariable Cox analysis (respectively, HR 1.845, 1.00–3.40, p = 0.05 and HR 1.066, 1.002–1.134, p = 0.04). We identified a LA mean pressure of >15 mmHg as ideal cutoff and constructed a model to predict AF recurrence which fitted with a concordance index (C-index) of 0.65 (95% CI 0.56–0.75), logrank score p = 0.003. Full article

(This article belongs to the Special Issue State of the Art in Management of Atrial Fibrillation)

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Review

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14 pages, 1796 KiB

Open AccessReview

Breast Cancer and Atrial Fibrillation

by Emanuela Mauro, Fabiana Lucà, Cecilia Tetta, Orlando Parise, Iris Parrini, Gianmarco Parise, Carmelo Massimiliano Rao, Francesco Matteucci, Linda Renata Micali, Michele Massimo Gulizia, Mark La Meir and Sandro Gelsomino

J. Clin. Med. 2022, 11(5), 1417; https://doi.org/10.3390/jcm11051417 - 04 Mar 2022

Cited by 5 | Viewed by 2765

Abstract

This study aims to establish the incidence of atrial fibrillation (AF) in breast cancer (BC) patients, focusing on staging and anti-cancer treatment. A meta-analysis was conducted to investigate the incidence of AF in BC patients and compare this incidence to other cancers. Furthermore, we evaluated the occurrence of AF as an adverse effect of biological therapies vs. non-biological therapies vs. biological therapies + non-biological therapies in BC. Finally, we compared the incidence of AF in early BC and metastatic BC. Thirty studies were included. Twenty-two studies focused on BC, encompassing 166,271 patients. In the BC group, 2.7% of patients developed AF, while in the “all cancer” group, 5.8% of patients developed AF. In addition, there was no difference between different types of therapies (p = 0.61) and between early and metastatic BC (p = 0.57). The type of anti-cancer therapy and the staging of BC does not influence AF’s occurrence in this neoplastic disease. Full article

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12 pages, 962 KiB

Open AccessReview

Antithrombotic Strategies in Patients with Atrial Fibrillation and Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention

by Leonardo De Luca, Raffaella Mistrulli, Francesco Antonio Veneziano, Francesco Grigioni, Massimo Volpe, Francesco Musumeci and Domenico Gabrielli

J. Clin. Med. 2022, 11(3), 512; https://doi.org/10.3390/jcm11030512 - 20 Jan 2022

Cited by 7 | Viewed by 3106

Abstract

Patients with atrial fibrillation (AF) are at increased risk for coronary artery disease (CAD). After percutaneous coronary intervention (PCI), the antithrombotic therapy consists of a combination of anticoagulant and antiplatelet agents to reduce the ischemic and thromboembolic risk, at the cost of increased bleeding events. In the past few years, several randomized clinical trials involving over 12,000 patients have been conducted to compare the safety of vitamin K antagonist (VKA) and direct-acting oral anticoagulants (DOACs) in association with a single- or double-antiplatelet agent, in the so-called dual- (DAT) or triple-antithrombotic therapy (TAT). These studies and several meta-analyses showed a consistent benefit for reducing bleeding events of DAT over TAT and of DOAC over VKA, without concerns about ischemic endpoints, except for a trend for increased stent thrombosis risk. The present paper examines current international guidelines’ recommendations and reviews clinical trials, meta-analyses, and observational studies conducted on AF patients treated with DAT or TAT after PCI for acute coronary syndromes. Full article

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13 pages, 2828 KiB

Open AccessReview

Catheter Ablation for Atrial Fibrillation in Patients with Heart Failure with Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

by Emmanuel Androulakis, Catrin Sohrabi, Alexandros Briasoulis, Constantinos Bakogiannis, Bunny Saberwal, Gerasimos Siasos, Dimitris Tousoulis, Syed Ahsan and Nikolaos Papageorgiou

J. Clin. Med. 2022, 11(2), 288; https://doi.org/10.3390/jcm11020288 - 06 Jan 2022

Cited by 13 | Viewed by 2507

Abstract

Background: Catheter ablation (CA) for atrial fibrillation (AF) has been proposed as a means of improving outcomes among patients with heart failure and reduced ejection fraction (HFrEF) who are otherwise receiving appropriate treatment. Unlike HFrEF, treatment options are more limited in patients with preserved ejection fraction (HFpEF) and the data pertaining to the management of AF in these patients are controversial. The aim of this systematic review and meta-analysis was to investigate the effects of CA on outcomes of patients with AF and HFpEF, such as functional status, post-procedural complications, hospitalization, morbidity and mortality, based on data from observational studies. Methods: We systematically searched the electronic databases MEDLINE, PUBMED, EMBASE and the Cochrane Library for Central Register of Clinical Trials until May 2020. Results: Overall, the pooling of our data showed that sinus rhythm was achieved long-term in 58.0% (95% CI 0.44–0.71). Long-term AF recurrence was noticed in 22.3% of patients. Admission for HF occurred in 6.2% (95% CI 0.04–0.09) whilst all-cause mortality was identified in 6.3% (95% CI 0.02–0.13). Conclusion: This meta-analysis is the first to focus on determining the benefits of a rhythm control strategy for patients with AF and HFpEF using CA, suggesting it may be worthwhile to investigate the effects of a CA rhythm control strategy as the default treatment of AF in HFpEF patients in randomized trials. Full article

(This article belongs to the Special Issue State of the Art in Management of Atrial Fibrillation)

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11 pages, 3538 KiB

Open AccessReview

Direct Oral Anticoagulants versus Warfarin in Octogenarians with Nonvalvular Atrial Fibrillation: A Systematic Review and Meta-Analysis

by Clara Bonanad, Sergio García-Blas, Javier Torres Llergo, Rosa Fernández-Olmo, Pablo Díez-Villanueva, Albert Ariza-Solé, Manuel Martínez-Sellés, Sergio Raposeiras, Ana Ayesta, Vicente Bertomeu-González, Francisco Tarazona Santabalbina, Lorenzo Facila, David Vivas, Ana Gabaldón-Pérez, Vicente Bodi, Julio Nuñez and Alberto Cordero

J. Clin. Med. 2021, 10(22), 5268; https://doi.org/10.3390/jcm10225268 - 12 Nov 2021

Cited by 10 | Viewed by 3068

Abstract

Direct oral anticoagulants (DOACs) have been demonstrated to be more effective and safer than vitamin-K antagonist (VKA) for stroke prevention in patients with nonvalvular atrial fibrillation (AF). This meta-analysis aims to assess the effect of DOACS vs. VKA in patients ≥ 80 and AF. Primary endpoints were stroke or systemic embolism and all-cause death. Secondary endpoints included major bleeding, intracranial bleeding, and gastrointestinal bleeding. A random-effects model was selected due to significant heterogeneity. A total of 147,067 patients from 16 studies were included, 71,913 (48.90%) treated with DOACs and 75,154 with VKA (51.10%). The stroke rate was significantly lower in DOACs group compared with warfarin group (Relative risk (RR): 0.72; 95% confidence interval (CI): 0.63–0.82; p < 0.001). All-cause mortality was significantly lower in DOACs group compared with warfarin group (RR: 0.82; 95% CI: 0.70–0.96; p = 0.012). Compared to warfarin, DOACs were not associated with reductions in major bleeding (RR: 0.85, 95% CI 0.69–1.04; p = 0.108) or gastrointestinal bleeding risk (RR: 1.08, 95% CI 0.76–1.53; p = 0.678) but a 43% reduction of intracranial bleeding (RR: 0.47, IC 95% 0.36–0.60; p < 0.001) was observed. Our meta-analysis demonstrates that DOACs are effective and safe with statistical superiority when compared with warfarin in octogenarians with AF. Full article

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17 pages, 1430 KiB

Open AccessReview

Anticoagulation in Atrial Fibrillation Cardioversion: What Is Crucial to Take into Account

by Fabiana Lucà, Simona Giubilato, Stefania Angela Di Fusco, Laura Piccioni, Carmelo Massimiliano Rao, Annamaria Iorio, Laura Cipolletta, Emilia D’Elia, Sandro Gelsomino, Roberta Rossini, Furio Colivicchi and Michele Massimo Gulizia

J. Clin. Med. 2021, 10(15), 3212; https://doi.org/10.3390/jcm10153212 - 21 Jul 2021

Cited by 7 | Viewed by 3762

Abstract

The therapeutic dilemma between rhythm and rate control in the management of atrial fibrillation (AF) is still unresolved and electrical or pharmacological cardioversion (CV) frequently represents a useful strategy. The most recent guidelines recommend anticoagulation according to individual thromboembolic risk. Vitamin K antagonists (VKAs) have been routinely used to prevent thromboembolic events. Non-vitamin K antagonist oral anticoagulants (NOACs) represent a significant advance due to their more predictable therapeutic effect and more favorable hemorrhagic risk profile. In hemodynamically unstable patients, an emergency electrical cardioversion (ECV) must be performed. In this situation, intravenous heparin or low molecular weight heparin (LMWH) should be administered before CV. In patients with AF occurring within less than 48 h, synchronized direct ECV should be the elective procedure, as it restores sinus rhythm quicker and more successfully than pharmacological cardioversion (PCV) and is associated with shorter length of hospitalization. Patients with acute onset AF were traditionally considered at lower risk of thromboembolic events due to the shorter time for atrial thrombus formation. In patients with hemodynamic stability and AF for more than 48 h, an ECV should be planned after at least 3 weeks of anticoagulation therapy. Alternatively, transesophageal echocardiography (TEE) to rule out left atrial appendage thrombus (LAAT) should be performed, followed by ECV and anticoagulation for at least 4 weeks. Theoretically, the standardized use of TEE before CV allows a better stratification of thromboembolic risk, although data available to date are not univocal. Full article

(This article belongs to the Special Issue State of the Art in Management of Atrial Fibrillation)

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