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Accuracy of Transesophageal Echocardiography for Identifying Left Atrial Thrombi: A Prospective, Intraoperative Study

Warren J. Manning, MD; Ronald M. Weintraub, MD; Carol A. Waksmonski, MD; J. Michael Haering, MD; Paula S. Rooney, RN; Andrew D. Maslow, MD; Robert G. Johnson, MD; and Pamela S. Douglas, MD
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From Beth Israel Hospital (Charles A. Dana and Harvard-Thorndike Laboratory) and Harvard Medical School, Boston, Massachusetts. Acknowledgments: The authors thank Drs. Robert L. Thurer, Frank Sellke, William Cohen, Craig S. Keighley, James D. Chang, Daniel E. Forman, Peter Oettgen, Joseph P. Kannam, Laura Collins, John Mashikian, and Mark G. Hibberd for their assistance with surgical or transesophageal echocardiographic studies and Drs. James P. Morgan, Edward Lowenstein, and David J. Cohen for their helpful reviews of this manuscript. Grant Support: In part by the Edward Mallinckrodt Jr. Foundation, St. Louis, Missouri (Dr. Manning). Requests for Reprints: Warren J. Manning, MD, Cardiovascular Division, Beth Israel Hospital, 330 Brookline Avenue, Boston, MA 02215. Current Author Addresses: Drs. Manning, Weintraub, Waksmonski, Haering, Rooney, Maslow, Johnson, and Douglas: Beth Israel Hospital, 330 Brookline Avenue, Boston, MA 02215.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1995;123(11):817-822. doi:10.7326/0003-4819-123-11-199512010-00001
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Objective: To determine the ability of transesophageal echocardiography to accurately identify or exclude left atrial thrombi.

Design: Prospective cohort study.

Setting: University hospital.

Patients: 231 consecutive patients having transesophageal echocardiography before elective repair or replacement of the mitral valve or excision of a left atrial tumor. Fifty-six percent of patients had a history of atrial fibrillation, and 17% had a history of thromboembolism.

Measurement: Identification of left atrial thrombi during transesophageal echocardiographic examination and comparison with direct near-simultaneous visualization during cardiac surgery.

Results: Transesophageal echocardiography identified 14 left atrial thrombi in 14 patients (6%). Thrombus size ranged from 3 to 80 mm. Surgery confirmed 12 of 14 thrombi (86%), including 9 thrombi confined to the left appendage. No additional thrombi were found on direct inspection of the atria (sensitivity, 100% [95% CI, 74% to 100%]; specificity, 99% [CI, 97% to 99.9%]; positive predictive value, 86% [12/14]; negative predictive value, 100% [217/217]; for a population that had a 5.2% prevalence of thrombi). All 12 surgically confirmed thrombi were identified by two independent observers. Neither thrombus seen by only a single observer on transesophageal echocardiography was confirmed during direct inspection of the atria at surgery.

Conclusion: Transesophageal echocardiography is highly accurate for identifying left atrial thrombi and can be used clinically to exclude left atrial thrombi.


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Figure 1.
Transesophageal echocardiograms. Panel A.white arrowPanel B.white arrowPanel C.white arrowPanel D.white arrows

A 20-mm thrombus ( ) confined to the atrial appendage. A 14-mm thrombus ( ) along the lateral wall of the left atrium and extending into the atrial appendage in a patient with extensive spontaneous echo contrast. A 20-mm thrombus ( ) confined to the posterior left atrium. An 80-mm linear thrombus ( ) extending from the right atrium across the interatrial septum into the left atrium. LA = left atrium; LAA = left atrial appendage; RA = right atrium.

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Figure 2.
Transesophageal echocardiograms obtained during biplane examination. Panel A.Panel B.white arrow

No thrombus visualized in the horizontal (0-degree) imaging plane. In the same patient, an 8-mm left atrial appendage thrombus was identified ( ) in the vertical (90-degree) imaging plane and was confirmed during direct atrial inspection. AO equals ascending aorta; LAA equals left atrial appendage.

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