Efficacy of Optison Echo Contrast to Detect Thrombus in Left Atrial Appendage (DOLOP)

The investigators intend to determine if using Optison echocardiography contrast increases sensitivity and specificity of detecting left atrial appendage thrombus in transesophageal echocardiography studies as opposed to standard 2D and 3D TEE imaging without the use of echo contrast.

Accurate determination of the presence or absence of left atrial appendage (LAA) thrombus has a large impact on the clinical course of patients with atrial fibrillation or ischemic stroke and has large financial implications as well. Misdiagnosing the presence of LAA thrombus can lead to unnecessarily cancelled procedures (cardioversion and atrial fibrillation ablation) and potentially hazardous, unnecessary changes in clinical care (such as prolonged Coumadin anticoagulation). Missing LAA thrombus can result in continuation of cardioversion or atrial fibrillation ablation procedures at a time when there is higher risk of subsequent embolic stroke.

Several of the patients with atrial fibrillation require transesophageal echocardiography (TEE) performed prior to cardioversion or atrial fibrillation ablation procedures. There is opportunity to enroll most of these patients in our proposed study. There has been essentially no work published about the use of echo contrast materials in TEE (other than agitated saline), particularly the use of Optison. Thus, the investigators will be exploring a new field in echocardiography and echo contrast.

• Wei K, Mulvagh SL, Carson L, Davidoff R, Gabriel R, Grimm RA, Wilson S, Fane L, Herzog CA, Zoghbi WA, Taylor R, Farrar M, Chaudhry FA, Porter TR, Irani W, Lang RM. The safety of deFinity and Optison for ultrasound image enhancement: a retrospective analysis of 78,383 administered contrast doses. J Am Soc Echocardiogr. 2008 Nov;21(11):1202-6. Epub 2008 Oct 10.
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Inclusion Criteria:

1. > 18 years old
2. Cognitively sound and able to provide informed consent
3. Indicated for TEE as a standard clinical procedure for evaluation of cardiac health status.

Exclusion Criteria:

Patients will be excluded for meeting the contraindications for TEE or Optison administration.

1. Contraindications for TEE: Esophageal stricture, tracheoesophageal fistula, postesophageal surgery, esophageal trauma, esophagectomy/esophagogastrectomy, barrett esophagus, hiatal hernia, large descending aortic aneurysm, unilateral vocal cord paralysis, esophageal varices, postradiation therapy, previous bariatric surgery, zenker diverticulum, colonic interposition, dysphagia
2. Contraindications for administration of Optison, including but not limited to: Right-to-left cardiovascular shunt, bidirectional cardiovascular shunt, history of myocardial infarction, acute coronary syndrome, pulmonary embolism, pulmonary hypertension, tachycardia, Torsades de Pointes, prolonged Q-T Interval, acute heart failure, vasculitis, emphysema, respiratory compromise, congenital heart disease, hypoxia, allergy to albumin; Individuals objecting to receiving albumin, a blood product, for personal, religious, or cultural reasons.
3. Not able to provide informed consent
4. Women who are or who may become pregnant (since Optison may have effects on the fetus that are currently unknown). Women who show evidence for practicing approved contraceptive measure (abstinence, male or female condoms, on contraceptive pills, injection, ring or having mechanical devices such as Intra Uterine Devices) will be allowed to participate.