Atrial fibrillation and NOAC therapy: do we need transoesophageal echocardiography before cardioversion?

Atrial fibrillation is a common cause of stroke. In particular, patients without adequate anticoagulation are at increased risk of thromboembolic events (approximately 5-7%). There is an association between cardioversions (CV) and embolic events. Oral anticoagulation (OAC) with non-Vitamin K antagonist (NOAC) can reduce this risk to less than 1%. There are two different strategies for cardioversion. CV can be performed after 3 weeks of effective anticoagulation without further imaging or without delay but after ruling out intracardiac thrombus formation by TOE. In AF, effective anticoagulation should be given for at least 4 weeks after CV regardless of CHA(2)DS(2)VASc score. TOE is recommended if the duration of effective anticoagulation is shorter than 3 weeks, if there remains any uncertainty regarding daily intake of anticoagulation or in patients at high risk of left atrial thrombus formation.