How should cardioversion be approached in AF patients with contraindication to long-term anticoagulation?

• A. Proceed with immediate cardioversion without imaging
• B. Delay for 6 weeks with imaging
• C. Perform TEE-guided cardioversion to exclude left atrial thrombus or delay until safe anticoagulation is possible
• D. Use rate control rather than cardioversion

Answer: (C)

When long-term anticoagulation isn’t an option, the priority is to restore rhythm without dislodging any existing left atrial thrombus. Transesophageal echocardiography (TEE) allows direct, sensitive visualization of the left atrial appendage to rule out thrombus before cardioversion. If the TEE shows no thrombus, cardioversion can be performed with short-term anticoagulation or bridging as appropriate, restoring sinus rhythm while avoiding long-term anticoagulation risks. If a thrombus is detected, cardioversion should be postponed and anticoagulation optimized, with rate control used in the meantime if needed. This approach reduces the risk of embolic stroke during cardioversion and provides a safe pathway when chronic anticoagulation is not possible.