Transesophageal Echocardiography Is Superior to Transthoracic Echocardiography in Management of Patients of Any Age With Transient Ischemic Attack or Stroke

Abstract

Background and Purpose-The merits of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) in the management of transient ischemic attack (TIA) and stroke patients remains matter of debate. Methods-Two hundred and thirty-one consecutive patients with a recent TIA or stroke for which no definite cause and indication for anticoagulation was assessed after standardized work-up underwent TTE and TEE. Echocardiographic findings were categorized into minor and major risk factors. Results-A potential cardiac source of embolism was detected in 55% (127/ 231) of the patients by echocardiography, in 39% (90/231) only identified on TEE. Major risk factors, with an absolute indication for oral anticoagulation, were detected in 20% (46/231) of the patients, in 16% (38/231) of all patients identified on TEE only. A thrombus in the left atrial appendage was the most common major risk factor (38 patients, 16%). The presence of major risk factors was independent of age ( 2 ϭ1.48; Pϭ0.224). The difference in proportions of cardiac sources detected in favor of TEE was highly significant in both patients Յ45 years of age (10/39, Pϭ0.002) and in those Ͼ45 years of age (80/192; PϽ0.004). Conclusions-TEE proved superior to TTE for identification of a cardiac embolic source in patients with TIA or stroke without pre-existent indication or contraindication for anticoagulation. In patients with normal TTE, a cardiac source of embolism was detected by TEE in Ϸ40% of patients, independent of age. More than 1 of 8 patients of any age with normal TTE revealed a major cardiac risk factor on TEE, in whom anticoagulation is warranted. (Stroke. 2006;37:2531-2534.)

Risk Factors for Left Atrial Thrombus From Transesophageal Echocardiography Findings in Ischemic Stroke Patients

“…It is well known that TEE is one of the most useful tools and the gold standard for detecting potential sources of embolism from the heart and aorta 6) . In our TEE findings, LAA slow flow velocity was the most common one, SEC second and PFO third.…”

“…It is well known that atrial fibrillation (AF), which causes left atrial thrombus (LAT) that may produce an embolism, is a common cause of ischemic stroke, and that AF -related strokes are accompanied by severe neurological deficits, disability and high mortality 5) . 6) .…”

Practice Current: What is your diagnostic evaluation of cryptogenic stroke?

“…Some authors found that TEE is superior in detecting left atrial appendage and aortic atheroma pathology. 13 On the other hand, meta-analyses showed high interstudy variation in the definition and prevalence of common findings (including left atrial thrombus, aortic atheroma, and patent foramen ovale) between studies of similar populations. Moreover, even if the result of TEE prompted anticoagulation in up to 1/3 of patients, most of these decisions were not backed by data from randomized controlled trials.…”

A Case of Embolism due to a Floating Thrombus Migrating from the Left Atrial Appendage to the Ostium of the Celiac Artery

“…Her AF was NVAF, but no thrombus in the cardiac chamber was noted. We then performed transesophageal echocardiography to detect the origin of the embolism, 3) which revealed a ball-like floating thrombus in the LAA. Enhanced computed tomography (CT) scan also illustrated the presence of a thrombus in the LAA and left upper artery without the involvement of other sites ( Fig.…”