Cardioversion + TEE: My EP has ordered a... - AF Association

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Cardioversion + TEE

GeorgeStevens profile image

My EP has ordered a cardioversion for me, my first since I was diagnosed with AF end of June 2021. What I didn’t know until I talked to the scheduler yesterday is that it will be preceded by a transesophageal echocardiogram (TEE). I also learned that my EP, who is the most experienced member of the team and also older, does not himself perform cardioversions when they are combined with TEE. (Is that because you need a steadier hand??) Since all this information is new to me, and because my anxiety level about the procedure increased exponentially when I found out the TEE involves sticking a tube with a camera down your throat, I’ve made a separate appointment to see my EP in the week before the procedure. Two questions:

1) Has anyway experienced a cardioversion immediately preceded by a TEE? Just how unpleasant is the TEE? I'm kind of worried about it, though I understand it's probably advisable to have it in order to make sure there are no clots before proceeding.

2) Any questions you can think of that I should ask my EP about either procedure? (FYI: I have persistent AF, and am asymptomatic. The main reason for doing the cardioversion is to see if I can be put back into normal rhythm. I’ve made some lifestyle changes since my diagnosis, so I’m somewhat hopeful it might be succcesful.)

Many thanks!

44 Replies

Hi George, I see that you are in the US. It is not normal in the UK for a TEE to be performed before cardioversion unless patient has not been properly anticiagulated beforehand or cardiologist has other concerns.( We call them TOE in the UK....TransOesophagealEcho) .I note from your previous post though that you are already taking Xarelto

I understand your reluctance !! I've had these 3 times before each of my first 3 ablations and have to say that before the first one I was more worried about the TEE than the actual ablation!

I'm not going to pretend that it's a pleasant experience because it's not but really nowhere near as bad as it sounds. I imagine you will be given an anaesthetic spray to the back of your throat, as in the UK, and possibly light sedation. It is all over very quickly. Just tell yourself how vital this procedure is for detecting clots.

The cardioversion itself should be a piece of cake and hopefully get you back into NSR

Wishing you well with both procedures!

PS....having reread your post after Bob's comment I see that you are having the TEE immediately prior to cardioversion so much of my comments may not apply ! You shouldn't be aware. Ablations are a bit different as only lightly sedated . I've left my comments in as may be of help to others.

BobD profile image
BobDVolunteer

The TOE (we spell oespohagus with an O here) is to check that there are no clots sitting in your heart waiting to fly out and cause a monumental stroke so actuallya good thing.

This suggests that you are not anticoagulated already and is a normal thing in such circumstances. Here in UK we would noramlly expect to be anticoagulated for at least a month prior to such procedure.

Since you will be deeply sedated for the DCCV anyway you won't know anything about it though may have a sligthly sore throat next day.

I’ve had a TOE immediately before a cardioverson and was under anaesthetic so didn't feel anything. I’ve also had TOEs before ablations. One time they found a blood clot so couldn’t go ahead with the procedure that day.

Jalia profile image
Jalia in reply to Kaz747

Relations?? ...a bit drastic😂😂😂. I'm sure you mean ablations 😁(hope so...)

Kaz747 profile image
Kaz747 in reply to Jalia

Indeed! Gotta love autocorrect 😂😂 Now edited - thanks.

Many thanks for your responses, Jalia, BobD, and Kaz747, and for letting me know the terminology for the procedure is different in the UK versus the US. Actually, I am on an anticoagulant: Xarelto, 20 mg, and have been so since July 12. I'm not sure why my EP ordered a TOE to be done prior. He didn't mention it when I saw him last. However, when I brought the matter up with the scheduler, she asked me whether I had missed any doses of my blood thinner, and I said "No." Actually, this was not quite true: About two weeks after I started, I missed one dose. In researching the procedure yesterday, I read that it is important not to "fib," as I did, since the consequences could be dire. I felt properly chastened and will make sure I am completely honest about everything when I see my EK in the week before the procedure.

I'm hoping that I will in fact be sedated (sufficiently) not to panic and gag as the tube is sent down my throat. It's something I'll ask my doctor about when I go in to see him. Your words-- of all three of you--have helped to allay some of my fears. Now I just have the worry that the young cardiologist who will perform the TOE won't inadvertently puncture something on the way down and back. Yet I realize that compared to the more invasive procedures, this one's a cakewalk!

Kaz747 profile image
Kaz747 in reply to GeorgeStevens

Hi George

I’m in Australia and we use English spelling, hence the TOE. My cardioversion was for Atrial Flutter (before I was diagnosed with AF and tachycardia) so I wasn't on anticoagulants then. I was on Xarelto when I went in for the ablation where they found the blood clot. I’d been asked to stop it 48 hours before the procedure and my EP said with my aggressive arrhythmias the clot must have formed quickly. That said he then tried me on Apixiban then Pradaxa but I had reactions to both of those so I’m back on Xarelto.

GeorgeStevens profile image
GeorgeStevens in reply to Kaz747

Interesting to know. Especially, as other people have said, the importance of not missing a single dose of Xarelto, or whatever bloodthinner you're on. Your case gives a concrete example of why. Thank you.

Yes you should be numbed & wont feel a thing!

I told the staff I am a "gagger".

I am in the US and had a TEE just prior to a a DCCV. I was sedated prior to both procedures and have no memory of either. I had no sore throat or any side effects from either. It would seem to me reckless not to do a TEE first to make sure there are no potential clots that could cause a stroke.

Thanks for your reply. I hope I find out that I'll be sedated for both procedures. And it would be nice to wake up with no memory of either or any other side effects.

Hi and good morning, nothing to worry about, you will not really feel anything as you will probably either be asleep or half asleep. Don't worry

Best of luck

Dave

As others have said, you need the TOE to check for clots. Tell them your concerns and ask about sedation etc. It's their job to reassure you.

Thanks, Singwell. What you write makes sense: "It's their job to reassure you."

The worst part of it was this banana spray to numb your throat. Trust me on this, worrying was the biggest mistake I made. I was frantic the night before the procedure. I'm embarrassed I was that terrified. You will get through this procedure and afterwards you will think to yourself it was nothing. Best of luck

Larry, I can so relate, both about being "frantic" the night before and then being "embarrassed" about being terrified. Before my diagnosis with AF I used to take 2.5 mg of alprazolam (Xanax) on an occasional basis if I was feeling especially anxious about something. I took one the night before my hernia operation (doc said it was ok). But given the fact that all benzodiazapines lower the heart rate, I don't have that recourse now. Anyway, thanks for your reassuring words.

Cookie341 profile image
Cookie341 in reply to Larry0304

Larry, me too! It was so fast ...I said "I could hear you all talking, I didnt even fall asleep"...they burst into laughter as anesthesiologist said "oh dear, you were so out of it you were drooling". lol! Be well~

Larry0304 profile image
Larry0304 in reply to Cookie341

I know I was out after the 3rd spray on my throat. The funny thing is when I woke up, I had this image in my brain of being hit across my chest with a 2x4. Strange how the brain deals with a catastrophic event.

Cookie341 profile image
Cookie341 in reply to Larry0304

True because mine blocks them completely out yet the day to day stuff I am a chronic worrier...omgBe well !!!

I had a TOE (UK version)before a cardioversion but not immediately, the CV was later in the day. I'd also had a toe before as an investigation which takes longer on that occasion I was sedated and just as it started to get unpleasant I woke up back on the ward. When I told the doc I hadn't known I would be unconscious he said I was awake throughout but the drug they use us an amnesiac so you don't remember a thing! It was great.Before the CV the procedure was very short, camera down, camera out and takes literally no time but again I didn't remember a thing! I'd said I'd only have it done if they gave me the amnesiac again which they did🤣. So please do not worry ( easier said than done, I know). The name of the amnesiac eludes me but begins with M

Jalia profile image
Jalia in reply to Jajarunner

Midazolam?

Jajarunner profile image
Jajarunner in reply to Jalia

Mmmm, that could be it. It matches my description but I don't remember (ha ha) for sure.

Thank you, Jaja. Especially reassuring is that the TOE is very quick. Probably nice too not to have any memory of it.

Hi GeorgeI’m in the uk and they don’t usually perform TOE here but a few years ago I had a stroke during an ablation. From then onwards I have always had a T O E with a cardio version. Please don’t be afraid of it. It is the best and safest way to do a cardioversion. From your point it’s a bit uncomfortable to have a small tube down your throat but that feeling lasts seconds. Good luck

Thanks, Sally, for pointing out the importance of having the TOE first.

I am in Dallas & I've had 2 cardioversions that had to be canceled, right now because of Delta Covid. The TEE is worse than the cardioversion because I'm told afterwards it's just like how you feel after they take the tube out after surgery. Any cardiologist who doesn't perform a TEE is one you need to run from. You will be be out, they give you something similar to when you have a colonscopy. The TEE is not a camera but it looks for clots. If you have been on a blood thinner there should be no problem. The cardioversion then takes a few minutes & most of the time it gets you back in sinus rhythm & you will feel so much better. I wish I was you.

Thanks, Camille. You write that they cancelled your cardioversions "because of Delta Covid." Was that because they didn't have sufficient beds/space for elective procedures, or because there was concern about contagion? I'm in Berkeley, California and so far I haven't heard anything about hospital cancellations here.

Concern about Covid. Day procedures are not in the same part of the hospital as Covid patients. Things are spread thin here due to Covid, but it's the rural areas that have it worse.

I've too many cardioversions to count. Only had TEE for the first. Felt no discomfort. After that is was anticoagulant time and they stopped with the TEE/TOE (take your pick). Bob is right, making sure you're not pooling blood in the bottom of your left atria is far better than tossing a clot and having a stroke.

GeorgeStevens profile image
GeorgeStevens in reply to indy64

Interesting. The scheduler told me that since my cardioversion is scheduled later than my EP originally planned, he may decide to forgo the TEE. (Because I'll have been on the anti-coagulant for a longer time.) Now, after reading everybody's comments, I'm actually hoping that they WILL include the TEE/TOE !!

I've been on Eliquis over a year & the chances of me having a clot are almost zero, but I still get a TEE. The TEE is more of a procedure than the cardioversion. Not doing a TEE is for the doctor, not he patient.

Cookie341 profile image
Cookie341 in reply to indy64

Same exact story as my husband...be well~

Camille777 profile image
Camille777 in reply to indy64

No cardioversions are done here without a TEE. That's what I was told by 3 cardiologist.

I too was more afraid of the TEE than the cardioversion a few years back. The patient in the bed next to me in the waiting area for cardioversions had the TEE performed right then and there, but I didn't. I was able to hear what was going on, and it seemed to be a very quick procedure. I remember the doctor saying, "That wasn't so bad, was it?" -- and the patient replied no, it wasn't.

Good to know about the brevity of the procedure, though I'd prefer not to be hearing the sounds of the patient ahead of me getting theirs done. I'm imagining howls, then gagging and gurgling, then silence and a loud zap!, followed by flailing limbs whipping the air as the doctor calls out "Nurse, restrain this patient!!" and some large matron comes in with a straitjacket. 😱😀

Sometimes having imagination is not an asset.

Ha!! Yes indeed, that's how my imagination went too! There was a little cough, and after that silence until the TEE was finished on that patient. The cardioversion room was next for both of us then. And that was actually fun!

Hi GeorgeHubby has had TEE prior to 1st cardioversion for a fib. I did not i opted for 6 weeks on blood thinner 1st. Its going in and out of a fib that can "throw a clot". So, the TEE makes sure there is not one already formed as you mentioned. Yes a TEE needs a steady hand. My husband and I only reasons for not wanting TEE was the longer time for procedure. He has had 4 cardioversions & thus all the experience. You will be fine and its good you are asymptomatic. You should convert & hopefully it lasts a while. My 1st one last a year, same w/husband. We both need one now...waiting for covid to slow down a bit. Be well, take care & enjoy every day!! It will be over before you know it!!

Thanks for the encouragement, Cookie. Good luck to you and your husband on your future CVs.

It is likely that you will be sedated for both procedures. The process with me took only 20 minutes. I awakened to learn that in my case the team tried twice and my body could not convert to sinus rhythm.Then I was left with meds until I finally tried Cryoablation four months ago.

That worked for me and I'm grateful everyday. Stay with it George

Thank you. Very interesting to know.

Not directly connected to your question but it would be interesting to find out some statistics about how many cases with clots were actually found in the two groups: anticoagulated and not. A comparison.

Yes, it would be interesting to have that information. But here in the US, as I understand it, they won't do a cardioversion if you haven't been on anticoagulants for at least 6 weeks.

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