If atrial thrombus is seen on TEE, then there is heterogeneity in current clinical practice regarding both when or whether to perform the TEE again, as well as subsequent management of anticoagulation. There is no evidence to support re- imaging, although it is a reasonable strategy. Although current practice favors not performing cardioversion if re-imaging shows thrombus due to the presumed high risk of thromboembolism, there is a lack of direct data about the safety of cardioversion in the presence of thrombus. Taken together, a risk-based approach to anticoagulation can be recommended and with respect to TEE, individualization of therapy on a case-by-case basis is proposed. It should be noted that in a multicenter registry of AF patients undergoing catheter ablation, TEE-guided cardioversion did not show a bene t compared with uninterrupted NOAC therapy.257 Although there is no direct evidence to guide decision- making about long-term management of anticoagulation in patients who appear to be in sinus rhythm at 4 weeks after cardioversion, indirect evidence suggests strongly that long-term anticoagulation should be based on the risk of stroke rather than the apparent success of the cardioversion procedure. First, recurrence of AF at 1 year after cardioversion occurs in approximately one- half of patients, and therefore long-term stroke risk is Second, the Atrial Fibrillation Follow- up Investigation of Sinus Rhythm Management (AFFIRM) study, in which many patients stopped anticoagulation after initial (apparently) successful restoration of sinus rhythm, demonstrated similar rates of thromboembolism with a rhythm control strategy compared with a rate control strategy.262 Third, patients with paroxysmal AF are often asymptomatic during episodes of AF recurrence, with 1 series suggesting that only 1 in every 12 paroxysms are symptomatic.263 Recommendation 12. 