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.
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References
Ansari A, Maron BJ (1997) Spontaneous echo contrast and thromboembolism. Hosp Pract 32:109–111
Balling G, Vogt M, Kaemmerer H et al (2000) Intracardiac thrombus formation after the Fontan operation. J Thorac Cardiovasc Surg 119(4 Pt 1):745–752
Bernhardt P, Schmidt H, Hammerstingl C, Luderitz B, Omran H (2005) Patients with atrial fibrillation and dense spontaneous echo contrast at high risk a prospective and serial follow-up over 12 months with transesophageal echocardiography and cerebral magnetic resonance imaging. JACC 45:1807–1812
Brembilla-Perrot B (2000) Risk of increasing incidence of atrial flutter, the most frequent arrhythmia, after repaired congenital heart disease. Int J Cardiol 75:138–139
Coon PD, Rychik J, Novello RT, Ro PS, Gaynor JW, Spray TL (2001) Thrombus formation after the Fontan operation. Ann Thorac Surg 71:1990–1994
de Bruijn SF, Agema WR, Lammers GJ, van der Wall EE, Wolterbeek R, Holman ER, Bollen EL, Bax JJ (2006) Transesophageal echocardiography is superior to transthoracic echocardiography in management of patients of any age with transient ischemic attack or stroke. Stroke 37:2531–2534 Epub Aug 2006
Driscoll DJ (2007) Long-term results of the Fontan operation. Pediatr Cardiol 28:438–442
Earing MG, Cetta F, Driscoll DJ, Mair DD, Hodge DO, Dearani JA, Puga FJ, Danielson GK, O’Leary PW (2005) Long-term results of the Fontan operation for double-inlet left ventricle. Am J Cardiol 96:291–298
Elhendy A, Gentile F, Khandheria BK, Gersh BJ, Bailey KR, Montgomery SC, Seward JB, Tajik AJ (2001) Thromboembolic complications after electrical cardioversion in patients with atrial flutter. Am J Med 111:433
Fatkin D, Herbert E, Feneley MP (1994) Hematologic correlates of spontaneous echo contrast in patients with atrial fibrillation and implications for thromboembolic risk. Am J Cardiol 73:672–676
Fatkin D, Kelly RP, Feneley MP (1994) Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast, and thromboembolic risk in vivo. JACC 23:961–969
Fishberger SB, Wernovsky G, Gentles TL, Gauvreau K, Burnett J, Mayer JE Jr, Walsh EP (1997) Factors that influence the development of atrial flutter after the Fontan operation. J Thorac Cardiovasc Surg 113:80–86
Garson A Jr, Bink-Boelkens M, Hesslein PS, Hordof AJ, Keane JF, Neches WH, Porter CJ (1985) Atrial flutter in the young: a collaborative study of 380 cases. J Am Coll Cardiol 6:871–878
Garson A Jr, Bink-Boelkens M, Hesslein PS, Hordof AJ, Keane JF, Neches WH, Porter C-BJ (1985) Atrial flutter in the young: a collaborative study of 380 cases. J Am Coll Cardiol 6:871–878. doi:10.1016/S0735-1097(85)80497-6
Garson AJR, Bink-Boelkens M, Hesslein PS, Hordof AJ, Keane JF, Neches WH, Porter CJ (1985) Atrial flutter in the young: a collaborative study of 380 cases. J Am Coll Cardiol 6:871–878
Ghali WA, Wasil BI, Brant R, Exner DV, Cornuz J (2005) Atrial flutter and the risk of thromboembolism: a systematic review and meta-analysis. Am J Med 118:101–107
Granada J, Uribe W, Chyou PH, Maassen K, Vierkant R, Smith PN, Hayes J, Eaker E, Vidaillet H (2000) Incidence and predictors of atrial flutter in the general population. J Am Coll Cardiol 36:2242
Horenstein MS, Karpawich PP, Epstein ML, Singh TP (2004) Transthoracic echocardiography for precardioversion screening during atrial flutter/fibrillation in young patients. Clin Cardiol 27:413–416
Ito T, Suwa M, Nakamura T, Miyazaki S, Kpbashi A et al (2001) Quantification of left atrial appendage spontaneous echo contrast in patients with chronic nonalvular atrial fibrillation. J Cardiol 37:325–333
Jahangiri M, Shore D, Kakkar V, Lincoln C, Shinebourne E (1997) Coagulation factor abnormalities after the Fontan procedure and its modifications. J Thorac Cardiovasc Surg 113:989–992 discussion 992–993
Kanter RJ, Garson A Jr (1997) Atrial arrhythmias during chronic follow-up of surgery for complex congenital heart disease. Pacing Clin Electrophysiol 20(2 Pt 2):502–511
Li Wei, Somerville J (2000) Atrial flutter in grown-up congenital heart (GUCH) patients clinical characteristics of affected population. Int J Cardiol 75:129–137
Manning WJ (1997) Role of transesophageal echocardiography in the management of thromboembolic stroke. Am J Cardiol 80:19D–28D discussion 35D–39D
Mart CR (2012) Three-dimensional echocardiographic evaluation of the Fontan conduit for thrombus. Echocardiography 29:363–368. doi:10.1111/j.1540-8175.2011.01579.x
Monagle P, Cochrane A, Roberts R, Manlhiot C, Weintraub R, Szechtman B, Hughes M, Andrew M, McCrindle BW, Fontan Anticoagulation Study Group (2011) A multicenter, randomized trial comparing heparin/warfarin and acetylsalicylic acid as primary thromboprophylaxis for 2 years after the Fontan procedure in children. J Am Coll Cardiol 58:645–651. doi:10.1016/j.jacc.2011.01.061
Ohuchi H, Yasuda K, Miyazaki A, Kitano M, Sakaguchi H, Yazaki S, Tsuda E, Yamada O (2013) Haemodynamic characteristics before and after the onset of protein losing enteropathy in patients after the Fontan operation. Eur J Cardiothorac Surg 43:e49–e57. doi:10.1093/ejcts/ezs714
Patel SV, Flaker G (2008) Is early cardioversion for atrial fibrillation safe in patients with spontaneous echocardiographic contrast? Clin Cardiol 31:148–152
Potter BJ, Leong-Sit P, Fernandes SM, Feifer A, Mayer JE Jr, Triedman JK, Walsh EP, Landzberg MJ, Khairy P (2013) Effect of aspirin and warfarin therapy on thromboembolic events in patients with univentricular hearts andFontan palliation. Int J Cardiol 168:3940–3943. doi:10.1016/j.ijcard.2013.06.058
Shirai LK, Rosenthal DN, Reitz BA, Robbins RC, Dubin AM (1998) Arrhythmias and thromboembolic complications after the extracardiac Fontan operation. J Thorac Cardiovasc Surg 115:499–505
Tucker KJ, Wilson C (1993) A comparison of transoesophageal atrial pacing and direct current cardioversion for the termination of atrial flutter: a prospective, randomised clinical trial. Br Heart J 69:530–535
Turchetti V, Bellini MA, Ricci D, Lapi A, Donati G et al (2001) Spontaneous echo-contrast as an in vivo indicator of rheological imbalance in dilatative cardiomyopathy. Clin Hemorheol Microcirc 25:119–125
Zotz RJ, Muller M, Genth-Zotz S, Darius H (2001) Spontaneous echo contrast caused by platelet and leukocyte aggregates? Stroke 32:1127–1133
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Yousef, N., Philips, M., Shetty, I. et al. Transesophageal Echocardiography of Intracardiac Thrombus in Congenital Heart Disease and Atrial Flutter: The Importance of Thorough Examination of the Fontan. Pediatr Cardiol 35, 1099–1107 (2014). https://doi.org/10.1007/s00246-014-0902-x
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DOI: https://doi.org/10.1007/s00246-014-0902-x