In patients presenting to the hospital with atrial fibrillation of >/= 48 hours and are started on anticoagulation, provided they spontaneously convert with AV nodal blocking agents but then revert back into AF, would you need LAA imaging before a rhythm control strategy with AADs or cardioversion?

I would approach this the same way as if the patient had never spontaneously converted. There is a risk of stroke with chemical as well as electrical cardioversion, so should factor in CHA2DS2-VASc when making that decision. If CHA2DS2-VASc is 0 and no other high-risk features (rheumatic disease, HCM,..) and the patient is comfortable without imaging, then it is reasonable to proceed with rhythm control without further LAA imaging (although in some patients with significant concern for stroke due to family history, may consider imaging if it aligns with their values). For all other patients, I would generally image with TEE or CTA chest unless the patient has been on uninterrupted A/C for at least 3 weeks. We cannot control if a patient spo...