Usefulness of transesophageal echocardiography before cardioversion in atrial arrhythmias
Abstract
Background: Although many thromboembolism risk factors are well defined, formation of thrombus or
dense spontaneous contrast (sludge) in the left atrium remains enigmatic and confounding. Exclusion
of the thrombus is extremely important with respect to planned reversal of sinus rhythm. Data regarding
the routine transesophagal echocardiography (TEE) before cardioversion are inconclusive. The authors
focused on analyzing the usefulness of TEE before cardioversion by assessment of factors influencing the
risk of thrombus and/or dense spontaneous echo contrast with the intention of extending indications for
TEE in the group with a high risk of thrombus or to forgo TEE in the low risk group.
Methods: Two hundred sixty-nine consecutive patients with persistent (> 48 h) atrial fibrillation
or atrial flutter, in whom a direct current cardioversion was planned, were undergoing TEE for the
detection of the left atrial thrombus or dense spontaneous echo contrast. Additional clinical and echocardiographic data were collected. The relationship between both thrombus and dense spontaneous echo contrast and covariates was analyzed with the use of binary logistic regression.
Results: Left atrium (LA) appendage (LAA) thrombus and/or sludge were detected in 79 (29%)
patients. Signs of dementia in mini-mental state examination (hazard ratio [HR]: 1.16; p = 0.005),
low velocities in LAA (HR: 3.38; p = 0.032); presence of spontaneous echo contrast in LA (HR: 3.38;
p = 0,003) consecutive episode of AF (HR: 2.27; p = 0,046); longer duration of atrial fibrillation (HR:
1.009; p = 0.022); were significant predictors of thrombus and/or dense spontaneous echo contrast.
None of the patients with a CHA2DS2VASc score ≤ 1 had thrombus or sludge in the LAA. Among patients
with a CHA2DS2VASc score > 1, the prevalence of thrombus or sludge in LAA was independent
of the CHA2DS2VASc score value.
Conclusions: Amongst many factors, including an established as risk for thromboembolism only
a few of them increased the risk for the presence of thrombus in LAA: low velocities in LAA, presence
of spontaneous echo contrast, longer duration of arrhythmia, consecutive (not first) arrhythmia episode
and signs of dementia from a mini-mental state examination questionnaire. It was believed that there
could be a need for an extension of indications of TEE in vast majority of the patients with atrial arrhythmias, due most often to an unpredictable occurrence of thrombus and potentially disastrous
thromboembolism. The only exception could have been the group of the patients with a CHA2DS2VASc
score ≤ 1.
Keywords: left atrial appendage thrombussludgeatrial fibrillationatrial fluttercardioversiontransesophagal echocardiography
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