A patient with paroxsysmal atrial fibrillation is planed for rhythm controll therapy and cardioversion. The black and white videos show the non contrast enhanced pictures with an echogenic structure in the apex of the left atrial appendage. Is this a trabecula or an echogenic thrombus?
The video was demonstrated on the german echocardiography congress in cologne (EKK) 2011 as part of a contrast echo workshop and rated by the participants as follows :

1. normal left atrial appendage, echogenic trabecula, cardioversion possible: 12%
2. dilated left atrial appendage with little spontaneous echo contrast, cardioversion possible: 12%
3. diagnosis doubtful, thrombus possible, cardioversion deferred: 59%
4. thrombus in the left atrial appendage, cardioversion deferred: 17%

Three quarters of the participants had thus abstained from cardioversion.
After administration of contrast bubbles there is a homogenous filling of the left atrial appendage without a contrast filling defect in the area of the echogenic structure. The structure can easily be classified as a trabecular. Cardioversion was subsequently performed without complications.