Related Experiment Video
Updated: Jan 23, 2026
Optimization of Transesophageal Atrial Pacing to Assess Atrial Fibrillation Susceptibility in Mice
Published on: June 29, 2022
Usefulness of transesophageal echocardiography before cardioversion in atrial arrhythmias
Katarzyna Kosmalska1, Małgorzata Rzyman2, Paweł Miękus2
1St Vincent Hospital in Gdynia, Wójta Radtkego1, 81-348 Gdynia, Poland. katarzyn5@wp.pl.
Insights
Transesophageal echocardiography (TEE) can identify left atrial thrombus before cardioversion. Dementia, low LAA velocity, spontaneous echo contrast, and longer atrial fibrillation duration predict thrombus formation.
Area of Science:
- Cardiology
- Medical Imaging
- Thrombosis Research
Background:
- Left atrial thrombus formation is not fully understood, despite known thromboembolism risk factors.
- Transesophageal echocardiography (TEE) is crucial for detecting left atrial thrombus before cardioversion.
- Current data on routine TEE before cardioversion are inconclusive, necessitating further analysis of its utility.
Purpose of the Study:
- To assess the usefulness of TEE in predicting left atrial thrombus and spontaneous echo contrast before cardioversion.
- To identify factors influencing the risk of thrombus formation.
- To refine indications for TEE in patients undergoing cardioversion.
Main Methods:
- 269 patients with persistent atrial fibrillation/flutter undergoing cardioversion were studied.
- Transesophageal echocardiography (TEE) was used to detect left atrial thrombus or dense spontaneous echo contrast.
- Binary logistic regression analyzed the relationship between thrombus/contrast and clinical/echocardiographic covariates.
Main Results:
- Left atrial appendage (LAA) thrombus/sludge detected in 29% of patients.
- Predictors of thrombus/sludge included dementia signs, low LAA velocity, spontaneous echo contrast, consecutive AF episodes, and longer AF duration.
- No thrombus/sludge was found in patients with CHA2DS2VASc score ≤ 1.
Conclusions:
- Low LAA velocity, spontaneous echo contrast, longer arrhythmia duration, consecutive episodes, and dementia signs are key predictors of LAA thrombus.
- TEE indications may need expansion for most atrial arrhythmia patients due to unpredictable thrombus risk.
- Patients with CHA2DS2VASc score ≤ 1 represent a low-risk group where TEE might be forgone.
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.
Related Concept Videos
01:25ECG Interpretation of Arrhythmias II: Atrial, Junctional and Ventricular Arrhythmias
01:16ECG Interpretation of Arrhythmias I: Sinus Arrhythmias
Types of Arrhythmias
Sinus Node Arrhythmias
Sinus Bradycardia: Originating from the sinoatrial (SA) node, sinus bradycardia involves slower impulses, resulting in a heart rate of less than 60 beats per minute (bpm). Causes include sleep, vagal stimulation, beta-blockers, hypothyroidism,...
01:28Mechanism of Cardiac Arrhythmias
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...