Efficacy of Low-Dose Isoproterenol Infusion for the Exclusion of a Left Atrial Appendage Thrombus in Patients With Dense Spontaneous Echo Contrast Caused by Atrial Fibrillation

Circ J. 2023 Nov 24;87(12):1800-1808. doi: 10.1253/circj.CJ-23-0271. Epub 2023 Jun 30.


Background: In patients with atrial fibrillation (AF) and severe blood stasis in the left atrial appendage (LAA), dense spontaneous echo contrast (SEC) disturbs the distinct visualization of the LAA interior, thus making thrombus diagnosis inconclusive. We aimed to prospectively assess the efficacy and safety of a protocol for a low-dose isoproterenol (ISP) infusion to reduce SEC to exclude an LAA thrombus.Methods and Results: We enrolled 17 patients with AF and dense SEC (Grade 4 or sludge). ISP was infused with gradually increasing doses of 0.01, 0.02, and 0.03 μg/kg/min at 3-min intervals. After increasing the dose to 0.03 μg/kg/min for 3 min, or when the LAA interior was visible, the infusion was terminated. We reassessed the SEC grade, presence of an LAA thrombus, LAA function, and left ventricular ejection fraction (LVEF) within 1 min of ISP termination. Compared with baseline, ISP significantly increased LAA flow velocity, the LAA emptying fraction, LAA wall velocities, and LVEF (all P<0.01). ISP administration significantly reduced the SEC grade (median) from 4 to 1 (P<0.001). The SEC grade decreased to ≤2 in 15 (88%) patients, and the LAA thrombus was excluded. There were no adverse events.

Conclusions: Low-dose ISP infusion may be effective and safe to reduce SEC and exclude an LAA thrombus by improving LAA function and LVEF.

Keywords: Atrial fibrillation; Isoproterenol; Left atrial appendage; Spontaneous echo contrast; Transesophageal echocardiography.

MeSH terms

  • Atrial Appendage* / diagnostic imaging
  • Atrial Fibrillation* / complications
  • Atrial Fibrillation* / drug therapy
  • Echocardiography, Transesophageal / methods
  • Heart Diseases* / etiology
  • Humans
  • Isoproterenol
  • Stroke Volume
  • Thrombosis* / diagnostic imaging
  • Thrombosis* / etiology
  • Ventricular Function, Left


  • Isoproterenol