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Background: Transesophageal echocardiography (TEE) is of proven value in the identification of intracardiac masses, TEE has been shown to be superior to transthoracic echocardiography (TTE) in the evaluation of left heart masses and right atrial (RA) tumors. To date no large series has addressed the role of TEE in the diagnosis and management of RA thrombi. Methods: Our echo database for all TTEs and TEEs done between 1988 and 1996 was retrospectively reviewed. Echoes showing RA thrombi were included in the present study. The location and extension of the thrombi were noted, as well as whether or not pt management was affected by the TEE results. Results: 20 cases of RA thrombi were identified by TEE, however TTE showed definite thrombi in only 6 of these (30%) and possible thrombi in an additional 2 pts. Therefore TTE was false negative in 60%. Demonstration of the size and site of attachment of the thrombus was better on TEE in 100% of pts. TEE only showed thrombi extending into the superior vena cava, the inferior vena cava, the right ventricle, and across a patent foramen ovale into the left atrium in 1 pt each. More than 1 thrombus was found on TEE in 11 of 20 pts (55%), whereas there was no pt in whom TTE showed more than one thrombus. Management: Anticoagulation was started or increased in 13 pts. In 8 (62%) of these, thrombus was seen only on TEE. Surgery was performed to remove thrombus in 6 pts, and in 3 (50%) the surgery was prompted by findings seen on TEE but missed by TTE. Therefore, management was changed in 11 of 20 pts (55%) because of findings seen only on TEE. Conclusions: 1. TEE is superior to TTE for the diagnosis and evaluation of RA thrombi. 2. TEE should be performed whenever RA thrombus is suspected, in spite of a negative TTE. 3. TEE has an important impact on clinical decision making in pts with RA thrombi