Transesophageal Echocardiography of Intracardiac Thrombus in Congenital Heart Disease and Atrial Flutter: The Importance of Thorough Examination of the Fontan

Abstract

Transesophageal echocardiography (TEE) is used in atrial flutter or fibrillation (AFF) before electric cardioversion to detect intracardiac thrombi. Previous studies have described the use of TEE to diagnose intracardiac thrombi in the left atrium and left atrial appendage, which has an incidence of 8 % among patients without congenital heart disease (CHD). In their practice the authors have noted a significant incidence of intracardiac thrombi in other structures of patients with CHD and AFF. This study aimed to determine the incidence and location of intracardiac thrombi using TEE in patients with CHD requiring electric cardioversion of AFF and to compare the use of TEE and transthoracic echo (TTE) to detect intracardiac thrombus in this population. A retrospective chart review of TEE and TTE findings for all patients with CHD who had electric cardioversion of AFF at our institution from 2005 to 2013 was conducted. The diagnosis, presence, and location of intracardiac thrombus were determined. The TEE and TTE results were compared. The study identified 27 patients with CHD who met the study entry criteria at our institution between 2005 and 2013. Seven of these patients had a single ventricle with Fontan palliation. All the patients presented with AFF and had TEE before electric cardioversion. No patients were excluded from the study. The patients ranged in age from 2 to 72 years (median, 21 years) and weighed 17-100 kg (median, 65 kg). The duration of AFF before TEE and attempted cardioversion ranged from 1 day to 3 weeks (median, 3.5 days). Intracardiac thrombus was present in 18 % (5/27) of the patients and in 57 % (4/7) of the Fontan patients with AFF. No embolic events were reported acutely or during a 6-month follow-up period. Among patients with CHD who present with AFF, a particularly high incidence of intracardiac thrombi is present in the Fontan patients that may be difficult to detect by TTE. Thorough TEE examination of the Fontan and related structures is indicated before electric cardioversion of AFF. The incidence of intracardiac thrombus in CHD patients is more than double that reported in non-CHD patients.

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.…”

Difference in the prevalence of intracardiac thrombus on the first presentation of atrial fibrillation versus flutter in the pediatric and congenital heart disease population

“…[14][15][16][17][18] Further, with increasing complexity and age the proportion of tachycardia subtype skews toward more IART and less AF. Prevalence of IART has been seen in up to 60% of CHD adults under the age of 50 with AF being the most prevalent atrial tachycardia The current literature on atrial tachycardia in CHD focuses on the success of DCCV rather than the presence of thrombus at the time of examination, 20,21 and prior studies have not differentiated prevalence in AFL and AF. 22 Further, there has been limited research looking at the prevalence of intracardiac thrombus in AFL as compared to AF, and the research that does exist is not clear on how the two atrial arrhythmias compare with respect to their relative thromboembolic risks.…”

“…The current literature on atrial tachycardia in CHD focuses on the success of DCCV rather than the presence of thrombus at the time of examination, 20,21 and prior studies have not differentiated prevalence in AFL and AF 22 . Further, there has been limited research looking at the prevalence of intracardiac thrombus in AFL as compared to AF, and the research that does exist is not clear on how the two atrial arrhythmias compare with respect to their relative thromboembolic risks 23 .…”

Anaesthesia for the child with a univentricular heart: a practical approach

“…Intravascular volume status can be optimised using TOE as a dynamic monitor of fluid responsiveness, which is integral to the anaesthesia management of children with UHs undergoing surgery with expected significant blood loss or fluid shifts. In the perioperative setting in patients with univentricular cardiac anatomy, TOE is superior to transthoracic echocardiography in determining the presence of an intramural thrombus before cardioversion, 30 which is frequently present in these patients due to atrial flutter or fibrillation 31 (Videos 5, 6 and Figures 9, 10).…”