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. In addition, a TEE-guided approach can be used to avoid prolonged VKA before cardioversion, which is a particular consideration in patients at increased risk for bleeding. The NOACs now offer an alternative to prolonged anticoagulation before cardioversion. However, a risk-based approach to anticoagulation should be used, and avoiding anticoagulation with a TEE-guided strategy should only be considered in the absence of stroke risk factors and a low risk of recurrent AF. For patients undergoing a TEE-guided approach, LMWH at full VTE treatment doses or IV UFH (to maintain an aPTT prolongation that corresponds to plasma heparin levels of 0.3-0.7 IU/mL anti-factor Xa activity) should be started at the time of TEE and cardioversion performed within 24 h of the TEE if no thrombus is seen. Observational data and 1 RCT show that LMWH has similar ef cacy compared with heparin or warfarin for immediate anticoagulation before In the outpatient setting, a TEE-guided approach should involve initiation of VKA (INR, 2.5; range, 2.0-3.0) followed by the TEE and subsequent cardioversion scheduled 5 days later (if the INR is in therapeutic range at that time). The NOACs again offer an alternative in outpatient treatment before TEE- guided cardioversion, with no bridging therapy necessary. Among AF patients undergoing TEE, 10% have LAA thrombus with a 3.5-fold increased risk of stroke/ but no speci c data are available in the context of cardioversion. 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. 