Chapter 2 22 2. Methods 2.1 Study cohort We retrospectively evaluated all consecutive adult patients who underwent an elective ECV for sustained atrial tachyarrhythmia (>48 hours) from January 2013 to February 2020 at the department of Cardiology of the Erasmus MC, University Medical Center Rotterdam, the Netherlands. Atrial tachyarrhythmias comprised atrial fibrillation, atrial flutter and atrial tachycardia. Patients who had an emergency ECV or received an ECV for an atrial tachyarrhythmia with a duration <48 hours were not included in the study. Patients were identified by screening all scheduled ECV procedures in the study period. If the patient did not undergo an ECV for any reason, then this patient was excluded from the final analysis. Furthermore, patients who had <60 days of follow-up after the procedure, except when death occurred, were excluded. Data were collected from the electronic medical records. 2.2 Anticoagulation regimen All patients required therapeutic oral anticoagulation for at least 3 weeks prior to ECV. In patients using VKA, the International Normalized Ratio (INR) level had to be in the therapeutic range (≥2.0) in the 3 weeks prior to the procedure. The INR was rechecked on the day of the procedure. Patients using DOAC had to use them continuously for at least 3 weeks. Compliance was evaluated by asking the patient whether they did not miss a dose in the previous 3 weeks. If abovementioned conditions were not met, we usually postponed the procedure. If required (e.g., inadequate INR, doubt about DOAC adherence, symptom-driven), a TEE-guided ECV was performed. Thus, not all patients with an inadequate oral anticoagulation received a TEE. Patients continued their oral anticoagulation for a minimum of 4 weeks after the ECV procedure. Continuation of oral anticoagulation after this 4-week period was based on the CHADS-VASc score or other indication for oral anticoagulation (e.g., mechanical heart valves). 2.3 Electrical cardioversion Electrical cardioversion was performed in the holding area or on the ward under the supervision of a nurse practitioner or cardiologist. The procedures were performed under monitored anaesthesia care. The placement of the external patches was usually posterior-anterior. For patients in atrial fibrillation a synchronized ECV was
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