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Intraoperative transesophageal echocardiography (TEE) is a common adjunct to cardiac surgery. Postoperative atrial fibrillation (AF) requiring direct current cardioversion (DCCV) occurs frequently after cardiac surgery. TEE is often performed with DCCV to exclude left atrial (LA) or left atrial appendage (LAA) thrombus prior to DCCV. The need to repeat TEE before DCCV in postoperative patients with a recent intraoperative TEE that showed no LA/LAA thrombus is unclear. This study sought to determine the incidence of and risk factors for new thrombus in patients referred for DCCV with TEE after recent cardiac surgery.
This study was a retrospective review of 1175 patients referred for DCCV within 30 days of cardiac surgery from May, 2000 to December, 2009. Patients were included only if both intraoperative and pre-DCCV TEE were performed. Patients were excluded if a LA/LAA thrombus was noted on intraoperative TEE or if they had an LAA ligation. All pre-DCCV TEEs reporting thrombus were independently reviewed for confirmation. Univariate logistic regression was used to identify risk factors for new thrombus formation.
The study included 362 patients (median age 71 years; 71% male). Cardiac surgery involved the aortic valve in 44%, the mitral valve in 32%, and coronary bypass grafting in 39%. Median time from cardiac surgery to DCCV was 6 days. Duration of AF prior to DCCV was <48 hours in 20% and ≥2 days in 79%. LA/LAA thrombus was present in 13 patients (4%) on TEE prior to DCCV. Current or prior heart failure was associated with significant risk of new thrombus formation vs. those without current or prior heart failure (7% vs. 2%; odds ratio 3.26, 95% Cl 1.07 to 9.95). Duration of arrhythmia, time from operation to DCCV, and type of operation were not significantly associated with thrombus formation. The presence of thrombus was not significantly associated with an increased 30-day likelihood of stroke or mortality.
Development of new LA/LAA thrombus in patients with AF after cardiac surgery referred for TEE guided DCCV is not uncommon. Patients undergoing DCCV in the setting of heart failure carry a higher risk of thrombus and require careful evaluation with TEE.
Poster Sessions, Expo North
Sunday, March 10, 2013, 9:45 a.m.-10:30 a.m.
Session Title: Imaging: Echo: Atrial Imaging
Abstract Category: 18. Imaging: Echo
Presentation Number: 1226-338
- 2013 American College of Cardiology Foundation