What is a reasonable length of time to pass before considering TEE guided DCCV for atrial fibrillation in a patient with a suspected acute cardioembolic stroke and concerns for tachycardia-mediated cardiomyopathy?

There are many issues to consider before proceeding with DCCV. We need to make sure the patient is neurologically stable following the stroke and can be anticoagulated. We seek the opinion of a knowledgeable stroke neurologist in that regard. As soon as anticoagulation can be initiated with a DOAC that provides immediate anticoagulation, a TEE-guided cardioversion is reasonable, keeping in mind the possible use of an antiarrhythmic drug to maintain sinus rhythm after the procedure, depending on the likelihood of IRAF or ERAF. If DCCV is not feasible or needs to be postponed for any reason, such as the presence of LAA clot, strict rate control will be critically important to prevent tachycardia-mediated cardiomyopathy.