Transthoracic echocardiography for precardioversion screening during atrial flutter/fibrillation in young patients

Abstract

SummaryBackground: 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 1997Michigan during -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

Transthoracic Doppler echocardiography for the assessment of left atrial appendage size and blood flow velocity. A multicentre study

“…TTE already showed low sensitivity [19] and low specificity [21] for the detection of LAA thrombi, but larger prospective studies are warranted for a final solution of this important issue.…”

Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease

“…526 Transesophageal echocardiography confirmed a right atrial thrombus in only 3 patients. None of those patients had a left atrial thrombus.…”

Guidelines for Performing a Comprehensive Transesophageal Echocardiographic

“…38,39,43,44 Outside of the procedural setting, TEE is used to provide diagnostic images when the patient has poor acoustic windows, if TTE is nondiagnostic, or in cases where TEE imaging has proven superior, such as evaluation for atrial thrombi prior to cardioversion, assessment for intra-cardiac shunting in patients with a cerebrovascular accident, visualization of the Fontan pathway, assessment of prosthetic valve function and associated pathology, and evaluation of endocarditis on both native and prosthetic valves. [33][34][35][45][46][47][48] Intraoperative TEE use is increasing for monitoring myocardial function and ventricular loading conditions in patients with CHD and other acquired pathologies undergoing high-risk non-cardiac procedures, as well as for the visualization of landmark structures during minimally invasive surgery. 36,[49][50][51][52][53][54] In the intensive care unit, TEE provides diagnostic information in the postoperative patient with suboptimal transthoracic windows or an open sternum, and in the management of patients undergoing mechanical circulatory support.…”