BACKGROUND The utility of transesophageal echocardiography (TEE) subsequent to a normal transthoracic echocardiogram (TTE) in older patients with an unexplained stroke is uncertain. METHODS Two hundred sixty‐three consecutive patients over the age of 50 years hospitalized with a clinical stroke confirmed with brain magnetic resonance imaging and a normal TTE were retrospectively analyzed. Patients with atrial fibrillation, atrial flutter, or any other causative reason for stroke were excluded. TEE was analyzed for findings that could explain the etiology of stroke as well as findings that would change therapy based on current guidelines. RESULTS Baseline characteristics included a mean age of 66.7 years (range, 50–91 years); 42.5% of patients were female. A possible etiology of stroke was discovered by TEE in 111 (42.2%) patients and included 1 or more of the following: complex plaque of the ascending aorta or arch, patent foramen ovale, atrial septal aneurysm, both atrial septal aneurysm and patent foramen ovale, or spontaneous contrast. Only 1 patient (0.4%) had a finding that changed immediate management, which was a thrombus in the left atrial appendage for which anticoagulation was prescribed. Follow‐up was available at 6 months on 85 patients, of whom 13 (15%) had been discovered to have developed atrial fibrillation. CONCLUSION In our study population, when performed subsequent to a normal TTE in patients aged >50 years with cryptogenic stroke, TEE demonstrated a high diagnostic value, but had minimal incremental effect on patient management. Journal of Hospital Medicine 2016;11:95–98. © 2015 Society of Hospital Medicine

An 80-year-old woman with a history of paroxysmal atrial fibrillation and atrioventricular node disease status post-dual chamber pacemaker placement was noted to have abnormal pacing episodes during a percutaneous coronary intervention. Pacemaker interrogation revealed a high number of short duration mode switching episodes. Representative electrograms demonstrated high frequency nonphysiologic recordings predominantly in the atrial lead. Intrinsic pacemaker malfunction was excluded. A chest radiograph showed excess atrial and ventricular lead slack in the right ventricular inflow. It was suspected that lead-lead interaction resulted in artifacts and oversensing, causing frequent short episodes of inappropriate mode switching.