Is transesophageal echocardiography necessary before D.C. cardioversion in patients with a normal transthoracic echocardiogram?
OBJECTIVE
Transesophageal echocardiography has emerged as an accepted approach before D.C. cardioversion for atrial fibrillation. The frequency of atrial thrombi detected on transesophageal echocardiography has varied from 7% to 23%. Many patients undergoing transesophageal echocardiography have had a previous transthoracic echocardiogram. Though transthoracic echocardiography has a low yield for the detection of intracardiac thrombi, it is highly accurate in diagnosing a structurally abnormal heart. The purpose of this study was to assess the frequency of thrombi detected by transesophageal echocardiography in patients with an entirely normal transthoracic echocardiogram and hence the advocacy of a selective approach in performing transesophageal echocardiography in patients undergoing D.C. cardioversion for atrial fibrillation.


METHODS
112 consecutive patients with atrial fibrillation who had undergone transesophageal echocardiography before D.C. cardioversion were evaluated. They all had a transthoracic echocardiogram within the 2 months preceding their transesophageal echocardiogram. Based on their transthoracic echocardiographic study, they were divided into two groups: Group 1 consisted of patients with a normal transthoracic echocardiogram and Group 2, those with an abnormal study.


RESULTS
Thrombi or spontaneous echo contrast were found in 14 of 112 patients (16%). All however were detected in Group 2 patients. There was no patient with a normal transthoracic echocardiogram who had thrombus on his/her transesophageal echocardiogram.


CONCLUSIONS
Our results suggest that a selective approach may be exercised in the use of transesophageal echocardiography prior to D.C. cardioversion for atrial fibrillation. Patients with an entirely "normal" transthoracic echocardiogram may proceed directly to cardioversion without a precardioversion transesophageal echocardiogram.
Sharifi
Mohsen
M
Section of Cardiology, Department of Medicine, Texas Tech University Health Sciences Center and Medical Center Hospital, 701 W. 5th Street, Odessa, Texas, USA. seyedmohsensharifi@yahoo.com
Parhizgar
Alireza
A
Gupta
Punam
P
Mehdipour
Mahshid
M
Emrani
Farnaz
F
Baldwin
David
D
D000368:Aged; D000369:Aged, 80 and over; D001281:Atrial Fibrillation / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000628:therapy*; D016275:Atrial Function; D016022:Case-Control Studies; D004452:Echocardiography; D017548:Echocardiography, Transesophageal; D004554:Electric Countershock; D005260:Female; D006801:Humans; D006980:Hyperthyroidism / Q000000981:diagnostic imaging; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D012107:Research Design; D012189:Retrospective Studies; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000503:physiopathology; D016896:Treatment Outcome