Related Experiment Video
Updated: Aug 23, 2026
Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure
Published on: February 8, 2022
Transthoracic echocardiography for precardioversion screening during atrial flutter/fibrillation in young patients
M Silvana Horenstein1, Peter P Karpawich, Michael L Epstein
1Division of Cardiology, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michigan 48201, USA.
Insights
Transthoracic echocardiography (TTE) may be sufficient for screening atrial flutter/fibrillation (AFF) patients with congenital heart disease before electric cardioversion. This approach avoids unnecessary transesophageal echocardiography (TEE) while ensuring patient safety and preventing thromboembolic events.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Cardiac Surgery
Background:
- Transesophageal echocardiography (TEE) is standard for detecting left atrial appendage thrombi before cardioversion in adults with atrial flutter/fibrillation (AFF).
- The necessity of routine TEE in young survivors of congenital heart disease (CHD) with AFF remains unestablished.
- Transthoracic echocardiography (TTE) has limitations in visualizing the left atrial appendage.
Purpose of the Study:
- To evaluate the safety and efficacy of using TTE for precardioversion thrombus screening in pediatric patients with AFF, particularly those with a history of CHD repair.
- To determine if TEE can be avoided in this specific patient population when TTE does not suggest intracardiac thrombus.
Main Methods:
- Retrospective chart review of patients undergoing electric cardioversion for AFF at a pediatric tertiary care center from 1997-2002.
- Analysis of TTE findings for suspected intracardiac thrombi prior to cardioversion.
- Correlation of TTE results with TEE findings when performed and assessment of thromboembolic events post-cardioversion.
Main Results:
- Of 35 patients (32 with CHD repair history), 110 episodes of AFF were treated with electric cardioversion.
- TTE was performed in 74 episodes; 10 were suspicious for thrombi, leading to TEE.
- TEE confirmed thrombi in 3 patients, who were treated with warfarin prior to cardioversion. No thromboembolic events occurred in any patient.
- The study included patients aged 3 months to 49 years, with 18 Fontan survivors.
Conclusions:
- Transthoracic echocardiography (TTE) appears to be an effective imaging modality for precardioversion screening in young patients with atrial flutter/fibrillation (AFF).
- This approach may reduce the need for routine transesophageal echocardiography (TEE) in survivors of congenital heart disease repair.
- Electric cardioversion for AFF is safe in this population when TTE does not indicate an intracardiac thrombus.
Background:
Transthoracic echocardiography (TTE) is reliable for detection of thrombi in the left ventricle and right atrium, but not in the left atrial appendage. Therefore, transesophageal echocardiography (TEE) is routinely performed in adults prior to electric cardioversion for atrial flutter/fibrillation (AFF). Whether young survivors of congenital heart disease repair with AFF need routine TEE prior to electric cardioversion is unknown.
Hypothesis:
Electric cardioversion for AFF is safe in survivors of congenital heart disease repair/palliation if an intracardiac thrombus is not suspected on TTE imaging.
Methods:
This study reports the outcome of patients in a pediatric tertiary care cardiac unit where electric cardioversion was performed if no intracardiac thrombus was suspected on TTE. We performed a retrospective chart review of all patients treated with electric cardioversion for AFF at Children's Hospital of Michigan during 1997-2002.
Results:
Of 35 patients who presented with 110 episodes of AFF requiring electric cardioversion during the study duration, 32 (age 3 months-49 years, median age 20.5 years, 104 AFF episodes) had previously undergone palliative surgery or repair of their congenital heart disease. Of these 32 patients, 18 were survivors of a Fontan palliation (for a single-ventricle variant) and the remaining 14 were survivors of other defects and repairs (septal defects, valve replacements, and tetralogy of Fallot). During 81% of the episodes, patients were receiving aspirin, warfarin, or heparin for anticoagulation at presentation. Transthoracic echocardiography was performed in 74 AFF episodes; of these, 10 TTE studies were suspicious for atrial thrombi. Transesophageal echocardiography confirmed the presence of a thrombus in 3 of these 10 patients. These patients received warfarin for 2 weeks and then underwent electric cardioversion. No thromboembolic events occurred immediately after or on follow-up in any patient.
Conclusions:
These findings suggest that TTE may be an effective imaging tool for precardioversion screening in young patients with AFF.
Related Concept Videos
01:30Dysrhythmias V: Evaluating Dysrhythmias
01:17Imaging Studies for Cardiovascular System I:Echocardiography
Indications: Echocardiography is utilized to diagnose heart failure, valve disorders, and myocardial infarction. It also assesses cardiac structures' size, shape, and motion, evaluates...
01:20Imaging Studies for Cardiovascular System II:Types of Echocardiography
Types of Echocardiography
Transthoracic Echocardiography (TTE)
TTE is the most common type of echocardiogram which involves placing a transducer on the patient's chest, emitting sound waves to create heart images. TTE is invaluable for evaluating the heart's size, structure, and motion, making it particularly useful for diagnosing...
01:17Assessment of apical pulse
Assessing the apical pulse is a critical nursing procedure, particularly indicated for:
01:25ECG Interpretation of Arrhythmias II: Atrial, Junctional and Ventricular Arrhythmias