Transesophageal Echocardiography-Guided Cardioversion: Going for Broke?
Transesophageal Echocardiography-Guided Cardioversion: Going for Broke?
复制标题
经食管超声心动图引导心脏复律：破产了吗？
DOI：
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发表时间：
1997
影响因子：
39.2
通讯作者：
John Burnum
中科院分区：
文献类型：
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作者：
John Burnum
致编辑：Prystowsky博士在其最近的社论[1]中讨论了ACUTE（使用经食管超声心动图评估心脏复律）初步研究[2]。他对该研究的不满似乎源于常规管理的局限性，包括直流电复律（DCC）延迟、出血风险增加、DCC再入院不便、尽管抗凝仍发生卒中以及缺乏显示疗效的对照研究[2]。Prystowsky为传统的方法辩护，并问如果它没有坏，为什么要修复它[1]。Prystowsky指出，使用传统的3周抗凝期是有充分依据的，并且可以在DCC之前解决大多数血栓。相反，我们认为，传统方法不仅延迟DCC，因为亚治疗的国际标准化比率和出血并发症，但也允许心脏复律的患者与未解决的血栓，谁可以避免DCC的风险，否则通过使用经食管超声心动图（TEE）。我们同意，ACUTE初步研究没有能力确定疗效，但它确实强调了大多数患有DCC而无血栓的患者（84%）可以在无栓塞的情况下成功进行早期DCC [2]。该研究的目的是比较TEE引导心脏复律与房颤患者心脏复律的传统抗凝管理策略的可行性和安全性。我们认为，传统的方法没有根据风险对患者进行分层，从未在随机试验中进行过测试，并且在临床实践中没有统一遵循[3]。相比之下，TEE引导的方法解决了血栓栓塞的风险，可能允许更早和更方便的DCC，并且可能更具成本效益[4，5]。然而，这两种方法的相对益处只能通过大型临床试验来确定。我们不应该质疑传统的治疗方法是否有问题，而应该大胆尝试，科学地测试这两种治疗方法的临床疗效和成本效益。
TO THE EDITOR: In his recent editorial [1], Dr. Prystowsky discusses the ACUTE (Assessment of Cardioversion Using Transesophageal Echocardiography) Pilot Study [2]. His dissatisfaction with the study seems to stem from the stated limitations of conventional management, which include the delay of direct-current cardioversion (DCC), the increased risk for bleeding, the inconvenience of readmission for DCC, the occurrence of strokes despite anticoagulation, and the lack of controlled studies showing efficacy [2]. Prystowsky defends the conventional approach and asks If it ain't broke, why fix it [1]. Prystowsky indicates that use of the conventional 3-week anticoagulation period is well founded and allows for the resolution of most thrombi before DCC. Conversely, we believe that the conventional approach not only delays DCC because of subtherapeutic international normalized ratios and bleeding complications but also allows cardioversion of patients with unresolved thrombi, who may have otherwise avoided the risks of DCC through the use of transesophageal echocardiography (TEE). We agree that the ACUTE Pilot Study did not have the power to establish efficacy, but it did emphasize that most patients (84%) who have DCC without thrombi can have successful early DCC without embolization [2]. The purpose of the study was to compare the feasibility and safety of TEE-guided cardioversion with the conventional anticoagulation management strategy for cardioversion in patients with atrial fibrillation. We contend that the conventional approach does not stratify patients by risk, has never been tested in a randomized trial, and is not uniformly followed in clinical practice [3]. In contrast, the TEE-guided approach addresses the risk for thromboembolism, may allow earlier and more convenient DCC, and may be more cost-effective [4, 5]. However, the relative benefit of the two approaches can be established only with a large clinical trial. Rather than questioning whether the conventional approach ain't broke, we need to go for broke and scientifically test the clinical efficacy and cost-effectiveness of both management approaches.