Original Articles
Use of transesophageal contrast echocardiography for excluding left atrial appendage thrombi in patients with atrial fibrillation before cardioversion

https://doi.org/10.1067/mje.2002.123961Get rights and content

Abstract

Transesophageal echocardiographic (TEE) guidance of cardioversion in patients with atrial fibrillation is an alternative method to conventional anticoagulation. Although TEE is considered the gold standard for excluding left atrial (LA) thrombi, in some patients dense spontaneous echo contrast (SEC) and artifacts may hamper the identification or exclusion of LA thrombi. Often those patients are refused cardioversion. The purpose of this study was to determine whether the application of echo contrast (Optison, Mallinckrodt, San Diego, Calif) facilitates the exclusion of LA appendage thrombi in this patient group and allows for safer cardioversion. Forty-one patients with atrial fibrillation and dense SEC or inconclusive TEE findings were given echo contrast. Fourteen patients with sinus rhythm served as control participants. Echo contrast completely reduced artifacts in 13 of 22 patients. In 12 of 19 patients with SEC, the LA appendage was completely filled after the application of echo contrast and, thus, SEC was completely suppressed. In 13 of 41 patients, it was filled incompletely and in 9 of 41 patients, a new mass resembling a thrombus was detected. In total, of 25 of 41 patients with inconclusive TEE findings an atrial thrombus was definitively excluded. Those patients underwent cardioversion. None of those patients had a cerebral embolic complication as assessed by cranial magnetic resonance imaging. Thus, the application of echo contrast may facilitate the TEE exclusion of LA appendage thrombi and, hence, improve the safety of TEE-guided cardioversion. (J Am Soc Echocardiogr 2002;15:1256-61.)

Section snippets

Study patients

The study was conducted as a prospective study at a tertiary cardiac referral center. Between January 1999 and September 2000, 121 patients underwent TEE for the exclusion of LA thrombi before cardioversion. In 41 of 121 patients exclusion of LA appendage thrombi was difficult because of either dense SEC (n = 19) or artifacts in the LA appendage (n = 22). Those patients formed the study group and were investigated by contrast TEE to evaluate the use of echo contrast on excluding LA appendage

Patients

During the study period, 121 patients underwent TEE for the exclusion of LA appendage thrombi before cardioversion. Sixty-six patients (55%) had previous cardioversion attempts, 75 patients (61%) had a duration of AF more than 3 months. In 13 of the 121 patients (11%), a LA appendage thrombus was identified. In 41 patients (34%; 33 men, age: 66.2 ± 9.5 years old), ambiguous findings lead to inclusion in the study group. Of those, 23 patients had coronary artery disease, 7 patients had a

Discussion

TEE-guided cardioversion of AF is an alternative approach to conventional anticoagulation. However, a potential clinical problem is the definitive exclusion of LA thrombi in patients with dense SEC or in patients with artifacts in the LA appendage. This is the first study to investigate the use of echo contrast for excluding LA appendage thrombi in patients with AF scheduled for cardioversion. The results of our study show that the application of intravenous echo contrast during the TEE study

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Reprint requests: Heyder Omran, MD, Department of Medicine - Cardiology, University of Bonn, Sigmund-Freud-Str. 25, D 53105 Bonn, Germany (E-mail: [email protected]).

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