Background Transesophageal echocardiography (TEE) has been used recently to detect atrial thrombi before cardioversion of atrial arrhythmias. It has been assumed that embolic events after cardioversion result from embolism of preexisting atrial thrombi that are accurately detected by TEE. This study examined the clinical and echocardiographic findings in patients with embolism after cardioversion of atrial fibrillation despite exclusion of atrial thrombi by TEE.Methods and Results Clinical and echocardiographic data in 17 patients with embolic events after TEE-guided electrical (n=16) or pharmacological (n=1) cardioversion were analyzed. All 17 patients had nonvalvular atrial fibrillation, including four patients with lone atrial fibrillation. TEE before cardioversion showed left atrial spontaneous echo contrast in five patients and did not show atrial thrombus in any patient. Cardioversion resulted in return to sinus rhythm without immediate complication in all patients. Thirteen patients had cerebral embolic events and four patients had peripheral embolism occurring 2 hours to 7 days after cardioversion.

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A 62-year-old man with intermittent claudication but normal foot pulses at rest had no atheroma shown on femoral arteriography. There was evidence of external compression of the artery at the level of a popliteal cyst which was demonstrated by arthrography on films taken after sufficient exercise to be in communication with the knee joint. At operation the cyst was continuous with changes of cystic adventitial disease of the popliteal artery. Both the main cyst and th cystic changes in the artery were removed. Postoperatively the patient's claudication disappeared. Evidence is presented that synovial cysts play a part in the production of arterial cystic adventitial disease.

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