DOACs in elective electrical cardioversion 27 DOAC is important (10-18). Of these real-world studies, 2 single-center studies had a larger sample size than our study, however, in both studies approximately one-fifth of procedures were guided by TEE (11, 17). Coleman et al. retrospectively evaluated 4,647 cardioversions in the Cleveland Clinic (USA) in the period 2009 to 2013, of which only 20% were performed under DOAC (17). The thromboembolic event rate under DOAC was relatively high, 1.62% within 8 weeks of follow-up, but this was similar to the VKA group (0.97%, P=0.16). Frederiksen et al. retrospectively evaluated 2,150 cardioversions from the Regional Hospital Central Jutland (Denmark) in the period 2011 to 2016 (11). This study showed a low thromboembolic event rate within 60 days with either DOAC or VKA (0.15% versus 0.14%). Our study also demonstrates a low thromboembolic event rate in procedures performed under DOAC and VKA in a routinely non-TEE-guided strategy. 5. Study limitations The present study has the known limitations inherent to an observational study. Selection bias may play a role, as DOAC are not used in patients with severe renal dysfunction or mechanical valves. This is partly reflected by a higher proportion of patients with comorbidity in the VKA group. Furthermore, the low event rates precluded a thorough statistical analysis between groups. 6. Conclusions During the past years, DOAC has replaced VKA as the most commonly used oral anticoagulant in patients undergoing elective ECV for atrial tachyarrhythmias. The use of pericardioversion DOAC was associated with low rates of thromboembolic and bleeding complications (both <0.5%) and was comparable to the use of VKA in a real-world population without routine TEE. 2
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