Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation
Allan L. Klein, MD, FACCa,
R. Daniel Murray, PhDa and
Richard A. Grimm, DO, FACCa
a Cardiovascular Imaging Section, Department of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Figure 1 Transesophageal echocardiographic image of a mobile and protruding thrombus (arrow) located in the left atrial appendage of a patient with AF scheduled to undergo DC cardioversion. Cardioversion was postponed in this patient. AF = atrial fibrillation; DC = direct current.
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Figure 2 Precardioversion (left) and postcardioversion (right) images of the left atrial appendage (LAA) using TEE. After DC cardioversion, left atrial appendage function diminishes and spontaneous echocardiographic contrast intensifies. DC = direct current; LA = left atrium; LV = left ventricle; TEE = transesophageal echocardiography. (Reprinted with permission from the American College of Cardiology, 1994.)
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Figure 3 Protocol design of the ACUTE multicenter study. Enrolled patients are randomly assigned to either the TEE-guided group or the conventional group for an eight-week study period. (Reprinted with permission from Excerpta Medica, Inc., 1998.) ACUTE = Assessment of Cardioversion Using Transesophageal Echocardiography; DCC= direct current cardioversion; TEE = transesophageal echocardiography.
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Figure 4 Pitfalls in TEE screening for thrombi using the TEE-guided approach to cardioversion, including pectinate muscles (arrows) in the left atrial appendage (A), multilobed appendage (arrows) (B) and viscous spontaneous echocardiographic contrast, or "sludge" (C). Pectinate muscle tissue, multilobed appendage or sludge can be mistaken for thrombi, rendering a false positive TEE screening result. TEE = transesophageal echocardiography.
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