Transesophageal echocardiography (TEE) is an accepted standard to exclude left atrial appendage (LAA) thrombus before direct current cardioversion (DCCV) for treatment of atrial fibrillation (AF). Although TEE-guided DCCV is considered an efficacious means to expedite restoration of sinus rhythm, TEE requires sedation and carries a small procedural risk of esophageal trauma, bleeding, or perforation.1 In addition, some individuals have esophageal pathology for which TEE is contraindicated, or they may have a nondiagnostic TEE evaluation for exclusion of LAA thrombus secondary to variations in esophageal–cardiac orientation or acoustic artifacts.