What evidence exists for the use of VKA in the TEE-guided approach?
The best data for the use of VKA in the TEE-guided approach are from the Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) RCT, which compared a TEE-guided strategy of abbreviated therapeutic anticoagulation with IV UFH (started 24 h before cardioversion) or warfarin (INR, 2.0-3.0) (started 5 days before cardioversion) vs a strategy of therapeutic anticoagulation for at least 3 weeks before Overall, the evidence is of low quality, and therefore the results are not conclusive with respect to either a benefit or harm with the TEE-guided strategy vs the conventional approach of 3 weeks of anticoagulation pre-cardioversion.