LAA Thrombus Deferring Cardioversion — EECC MCQ
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Correct answer: D — Cardioversion must be deferred; intensify anticoagulation and repeat TOE in 3-6 weeks — if thrombus has resolved, cardioversion can proceed; if thrombus persists, cardioversion should not be performed and long-term rhythm control strategy should be reconsidered
LAA thrombus on TOE is an absolute contraindication to cardioversion. The risk of embolisation (stroke) during cardioversion with a pre-existing thrombus is unacceptably high. The 2024 ESC AF Guidelines recommend: (1) defer cardioversion; (2) ensure therapeutic anticoagulation — if on DOAC, assess adherence (consider switching to warfarin with INR monitoring for more reliable anticoagulation); if on warfarin, ensure INR 2-3; (3) repeat TOE in 3-6 weeks; (4) if thrombus resolved: proceed with cardioversion; (5) if thrombus persists: cardioversion should not be performed — consider alternative strategies (pharmacological rate control, acceptance of permanent AF, or continued rhythm control attempts without cardioversion). Importantly, post-cardioversion anticoagulation for ≥4 weeks is mandatory even after thrombus resolution, and long-term OAC based on CHA₂DS₂-VA score.
Reference: ESC (2024): AF Guidelines