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November, 18 2018 — LAAT – Contrast Echocardiography

Background: The value of ultrasound enhancing agents (UEA) in patients undergoing transesophageal echocardiography (TEE) for the exclusion of left atrial appendage (LAA) thrombi prior to direct current cardioversion (DCCV) is evolving.

Methods: We retrospectively identified 88 consecutive TEEs, where a commercial UEA was used during LAA interrogation. De-identified non-enhanced (pre-UEA) and enhanced cine loop images (post-UEA) from the same subjects were randomly re- viewed by four expert readers in a blinded fashion.

Results: In 33% of the cases, UEA use was associated with a statistically insignificant improvement in physician confidence (scale, 0-3) in determining the presence or ab- sence of a LAA thrombus (P = 0.071). In instances where non-enhanced images yielded an uncertain interpretation or when the left atrium contained spontaneous echo contrast (SEC), UEA use was associated with an improvement in interpretive confidence in 49% (P < 0.001) and 41% of the cases (P = 0.001), respectively. Overall, the absolute rate of hypothetical decision to proceed with DCCV rose by 9% with the application of UEA (P = 0.004). In instances where non-enhanced images were inter- preted with limited confidence or when SEC was present, there were absolute in- creases of 16% (P < 0.001) and 21% (P < 0.001) in hypothetical procession to DCCV, respectively. In cases of a combination of limited interpretive confidence and SEC, UEA use was associated with a 29% absolute increase in the rate of procession to DCCV (P < 0.001).

Conclusions: In patients undergoing TEE interrogation of the LAA, the use of UEA is associated with an increase in the level of interpretive confidence and higher rates of theoretical procession to DCCV.

Authors: Rami Doukky MD, MSc1,2 | Merrick J. Donenberg MD2 | Jeremy Parker MD2 | Jonathan Kaplan MD2 | Chad Travers MD2 | Jeffrey S. Soble MD2 | Payman Sattar MD1,2 | Kousik Krishnan MD2 | Christopher Madias MD2 | Melissa Tracy MD2 | Steven B. Feinstein MD2

1Division of Cardiology, Cook County Health, Chicago, Illinois

2Division of Cardiology, Rush University Medical Center, Chicago, Illinois


Rami Doukky, MD, Division of Cardiology, Cook County Health, Chicago, IL.


DOI: 10.1111/echo.14228

Echocardiography. 2018;1–8. journal/ echo

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