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CALL FOR SUBMISSIONS: I N S I G H T S succinctly illuminates clinical problems or solu6ons of interest and importance to our readership. We welcome original material (see Instructions to Authors). William E Ba/istreri, Editor

Large right atrial thrombi undetected by transthoracic echocardiography A 19-year-old man with a histoi:y of complex congenital heart disease (pulmonary valve atresia with intact ventricular septum) who had undergone a Fontan palliation at 9 years of age was first seen after he had experienced several days of malaise, mild nausea, and chest discomfort. Physical examination at that time revealed an irregular heart rhythm, and an electrocardiogram revealed atrial fibrillation. A transthoracic echocardiogram was performed, and it revealed no evidence of atrial thrombi or indications of abnormal flow (Fig. 1). However, a transesophageal echoeardiogram, performed before cardioversion, revealed several large right atrial thrombi and spontaneous contrast in the right atrium caused by low-velocity blood flow (Fig. 2). The patient subsequently began receiving systemic anticoagulation therapy with eoumadin and did not undergo cardioversion. He continued to receive digoxin and captopril. Subsequent transesophageal echocardiograms revealed a decrease in the size of the atrial thrombi, and 6 months after his initial presentation, he underwent a revision of his Fontan connection with placement of a lateral tunnel, right atrioplasty, and pacemaker placement. He had an unremarkable operative and postoperative course and is currently doing well. Richard V Willian~, AID, Peter J. Morel/i, AID, Scott A. We/lnzan,AID, and 7~omas R. Kimball, AID The Noninvasive Cardiac Imaging and Hemodljnamic Research Laboratory, DiviJion of Cardiology, Children'sHospital AIedica/ Center Cincinnati, Ohio

F~. I. Transthoracic apical four-chamber view demonstrating a large right atri- F~g. 2. Transesophageal image demonstrating two large right atrial thrombi (arrows) and spontaneous contrast in right atrium caused by low-velocity blood um, which appears free of thrombi. LA, LeE atrium; LV, left ventricle; IRA, right atrium; RV, right ventricle; I, inferior; L, left; R, right; 5, superion

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flow.