Given the need for accurate visualization of thrombus, the TEE-guided strategy requires an experienced 1164 Evidence-Based Medicine [ 1 5 4 # 5 C H E S T N O V E M B E R 2 0 1 8 ] echocardiographer. 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 bene t or harm with the TEE-guided strategy vs the conventional approach of 3 weeks of anticoagulation pre-cardioversion. For NOACs vs warfarin in the TEE-guided approach, our review found an existing systematic review and An updated search of this systematic review identi ed 1 additional study. Pooled results found that the relative RR for stroke/thromboembolism was 0.33 (95% CI, 0.06-1.68) for NOACs vs warfarin (e- Fig 3, e-Table 18). Although these data indicate safety and probable equivalence of NOACs in the TEE-guided approach vs VKA, the trials were underpowered to show ef cacy, and therefore the evidence is of low quality (e- Table 18). The advantage of NOACs is that their mode of action is quicker than VKA, and therefore there is no delay in waiting for a therapeutic INR. However, the need for strict adherence to the NOAC therapy must be emphasized to patients, particularly in the post- cardioversion period. Individuals who are very symptomatic due to AF may gain greatest bene t from the TEE-guided approach since cardioversion can be expedited by a thrombus- negative TEE. 