Introduction/Hypothesis
Direct current cardioversion of atrial fibrillation/flutter is frequently preceded by transesophageal echocardiography (TOE) which usually are performed as two separate procedures. TOE is often performed under sedation with midazolam by a cardiologist without assistance from an anesthetist. Subsequently, when the patient has awakened, cardioversion is performed with propofol-sedation with assistance from an anesthetist. In this case presentation, a novel timesaving patient-friendly combined 2-in-1 procedure of TOE and cardioversion without anesthesiology assistance is presented.

Methods
CASE
A 72-year-old male without any previous cardiac disease apart from dyslipidemia was admitted due to several weeks history of dyspnea. On admission blood pressure was 164/123 mmHg, heart rate was 145 BPM. ECG showed atrial flutter with 2:1 conduction with a rate of 143 BPM. An echocardiogram showed left ventricular ejection fraction of 25%, enlarged left atrium and modest mitral- and tricuspid- regurgitation and a dilated inferior vena cava (> 30 mm). Treatment with intravenous furosemide, and per oral ramipril, metoprolol and rivaroxaban was initiated. Digoxin was later added for rate control. On the second day of admission, the patient had lost 2,6 kg of bodyweight, dapaglifozin was started and metoprolol dose was increased. Intravenous furosemide was discontinued and treatment with per oral furosemide was stated. On the third day, due to insufficient rate control of atrial flutter, TOE and cardioversion was scheduled.

Results
PROCEDURE
A combined 2-in-1 procedure of TOE and cardioversion without anesthesiology assistance was undertaken. The patient was in a fasting state. TOE was performed with the use intravenous midazolam 2,5 mg; the left atrium and auricle was inspected with 2D and 3D ultrasound images and found to be without any signs of thrombi. Prior to performing the TOE, cardioversion electrodes were attached to the patient. After finishing the TOE, the ultrasound probe was retracted and an additional dose of intravenous midazolam of 5 mg was administered. Sufficient sedation was confirmed with the absence of glabellar and ciliary reflex. Direct current cardioversion was performed with one synchronized shock of 50 J biphasic upon which sinus rhythm was restored. The procedural sedation was reversed with a dose of intravenous flumazenil (0,5 mg) upon which the patient was fully awake.
The combined 2-in-1 procedure of TOE and cardioversion was performed by a cardiology nurse and a cardiologist alone without any anesthesiology assistance and the procedure lasted a total of 15 minutes.

EPILOGUE
During sinus rhythm an echocardiogram showed left ventricular ejection fraction of 40%. The patient was referred to elective atrial flutter ablation and a cardiac CT-scan to rule-out coronary disease and discharged later on the same day of the combined 2-in-1 procedure to outpatient follow-up.

Conclusion
SUMMARY
The combined 2-in-1 procedure of TOE and cardioversion has several advantages:
Can be performed by a nurse and a cardiologist alone
No anesthetist is needed because the procedure is competed with midazolam
Patient-friendly: no need to undergo two separate procedures and avoid two different sedation-drugs
Can be performed in as little as 15 minutes
Saves time, resources and may reduce length of hospital stay
The combined 2-in-1 TOE and cardioversion-procedure has by colleagues been named a "Double Løfgren" and the procedure is currently used on a daily basis in our clincal practice.

**Introduction/Hypothesis**
Direct current cardioversion of atrial fibrillation/flutter is frequently preceded by transesophageal echocardiography (TOE) which usually are performed as two separate procedures. TOE is often performed under sedation with midazolam by a cardiologist without assistance from an anesthetist. Subsequently, when the patient has awakened, cardioversion is performed with propofol-sedation with assistance from an anesthetist. In this case presentation, a novel timesaving patient-friendly combined 2-in-1 procedure of TOE and cardioversion without anesthesiology assistance is presented.

**Methods**
**CASE**
A 72-year-old male without any previous cardiac disease apart from dyslipidemia was admitted due to several weeks history of dyspnea. On admission blood pressure was 164/123 mmHg, heart rate was 145 BPM. ECG showed atrial flutter with 2:1 conduction with a rate of 143 BPM. An echocardiogram showed left ventricular ejection fraction of 25%, enlarged left atrium and modest mitral- and tricuspid- regurgitation and a dilated inferior vena cava (> 30 mm). Treatment with intravenous furosemide, and per oral ramipril, metoprolol and rivaroxaban was initiated. Digoxin was later added for rate control. On the second day of admission, the patient had lost 2,6 kg of bodyweight, dapaglifozin was started and metoprolol dose was increased. Intravenous furosemide was discontinued and treatment with per oral furosemide was stated. On the third day, due to insufficient rate control of atrial flutter, TOE and cardioversion was scheduled.

**Results**
**PROCEDURE**
A combined 2-in-1 procedure of TOE and cardioversion without anesthesiology assistance was undertaken. The patient was in a fasting state. TOE was performed with the use intravenous midazolam 2,5 mg; the left atrium and auricle was inspected with 2D and 3D ultrasound images and found to be without any signs of thrombi. Prior to performing the TOE, cardioversion electrodes were attached to the patient. After finishing the TOE, the ultrasound probe was retracted and an additional dose of intravenous midazolam of 5 mg was administered. Sufficient sedation was confirmed with the absence of glabellar and ciliary reflex. Direct current cardioversion was performed with one synchronized shock of 50 J biphasic upon which sinus rhythm was restored. The procedural sedation was reversed with a dose of intravenous flumazenil (0,5 mg) upon which the patient was fully awake.
The combined 2-in-1 procedure of TOE and cardioversion was performed by a cardiology nurse and a cardiologist alone without any anesthesiology assistance and the procedure lasted a total of 15 minutes.

**EPILOGUE**
During sinus rhythm an echocardiogram showed left ventricular ejection fraction of 40%. The patient was referred to elective atrial flutter ablation and a cardiac CT-scan to rule-out coronary disease and discharged later on the same day of the combined 2-in-1 procedure to outpatient follow-up.

**Conclusion**
**SUMMARY**
The combined 2-in-1 procedure of TOE and cardioversion has several advantages:
- Can be performed by a nurse and a cardiologist alone
- No anesthetist is needed because the procedure is competed with midazolam
- Patient-friendly: no need to undergo two separate procedures and avoid two different sedation-drugs
- Can be performed in as little as 15 minutes
- Saves time, resources and may reduce length of hospital stay

The combined 2-in-1 TOE and cardioversion-procedure has by colleagues been named a "Double Løfgren" and the procedure is currently used on a daily basis in our clincal practice.

Transesophageal Echocardiography And Cardioversion: A 2-in-1 15 minute Clinical Procedure Without Anesthesiology Assistance – A Case Report