Therapeutic implications of transesophageal echocardiography after transthoracic echocardiography on acute stroke patients

Abstract

Background:The role of transesophageal echocardiography (TEE) in the evaluation of acute stroke patients is still ill-defi ned. We conducted a prospective observational study to fi nd the prevalence of TEE fi ndings that indicate anticoagulation as benefi cial, in acute ischemic stroke patients without indication for anticoagulation based on clinical, electrocardiographic and transthoracic echocardiography (TTE) fi ndings. Methods:We prospectively studied all patients referred to our laboratory for TTE and TEE. Patients were excluded if the diagnosis was not acute ischemic stroke or if they had an indication for anticoagulation based on clinical, electrocardiographic, or TTE data. Patients with TEE fi ndings that might indicate anticoagulation as benefi cial were identifi ed. Results: A total of 84 patients with acute ischemic stroke and without indication for anticoagulation based on clinical and electrocardiographic or TTE data were included in the study. Findings indicating anticoagulation as benefi cial were found in 32.1%: spontaneous echo contrast (1.2%), complex aortic atheroma (27.4%), thrombus (8.3%), and simultaneous patent foramen ovale and atrial septal aneurysm (2.4%). Conclusions:The results of our study show that TEE can have therapy implications in 32.1% of ischemic stroke patients in sinus rhythm and with TTE with no indication for anticoagulation.

The effect of TEE on treatment change in patients with acute ischemic stroke

“…Several studies have compared the efficacy of TEE with non-invasive transthoracic echocardiography [TTE] in AIS patients. While some researchers doubt the advantage of TEE over TTE [8,9], most studies confirm the superiority of TEE in the detection of cardiac thrombi, PFO, atrial septal defect (ASD) and aortic plaques [10][11][12][13][14]. The risk of ischemic stroke changes according to the cardiac abnormality (for example, patients with an artificial valve have a greater risk for stroke than patients with PFO); many patients have two or more coexistent cardiac pathologies [4,15].…”

“…As TEE is semi-invasive and relatively expensive [16], it is essential to determine the probability of treatment change due do TEE findings (yield), which ranges in the literature from 0% to 11% [8,12,13,[17][18][19][20]. Several studies further tried to find subpopulations with higher TEE yield.…”

Left Atrial Enlargement on Transthoracic Echocardiography Predicts Left Atrial Thrombus on Transesophageal Echocardiography in Ischemic Stroke Patients

“…In particular, cardiac morphology and rhythm changes have been documented as chief contributing factors for thrombus formation [3–6]. The left atrium is the most common chamber in which these thrombi originate, and thrombus formation is strongly associated with the pathophysiology of atrial fibrillation [4, 5].…”

“…Prior literature and clinical practice have recognized the cost-effectiveness and risk TEE or TTE in patients with suspected cardiac disease [3, 4]. TTE is noninvasive and less expensive than TEE; conversely, TEE is superior to TTE in detecting cardiac structural abnormalities and intracardiac thrombi [3, 4].…”

“…TTE is noninvasive and less expensive than TEE; conversely, TEE is superior to TTE in detecting cardiac structural abnormalities and intracardiac thrombi [3, 4]. Specifically, TEE is thought to be superior at quantifying the degree of LAE and visualizing the LAA.…”