title: Selection of patients for transesophageal echocardiography after stroke and systemic embolic events. Role of transthoracic echocardiography.
abstract: OBJECTIVE
  This study examined whether patients suffering from stroke and other systemic embolic events may be selected for transesophageal echocardiography on the basis of clinical and transthoracic echocardiographic findings.
  
  
  METHODS
  We performed transthoracic and transesophageal echocardiography on 824 patients after stroke and other suspected embolic events. Patients were classified into group A if they were in sinus rhythm and had a normal transthoracic echocardiogram. Group B consisted of all other patients. Transesophageal echocardiographic findings of left atrial spontaneous contrast, left atrial thrombus, complex aortic atheroma, and interatrial septal anomalies were correlated with clinical and transthoracic echocardiographic results.
  
  
  RESULTS
  Transesophageal echocardiography detected at least one potential source of embolism in 399 patients (49%): spontaneous contrast in 214 patients (26%), left atrial thrombus in 54 (7%), complex atheroma in 111 (13%), and interatrial septal anomalies in 126 (15%). In group A (n = 236), only 3 (1%) had spontaneous contrast, 11 (4.6%) had complex atheroma, and none had left atrial thrombus. In group B (n = 588), 211 patients (36%, P < .001) had spontaneous contrast, 54 (9.2%, P < .001) had atrial thrombus, and 100 (17%, P < .001) had complex atheroma. Interatrial septal anomalies were detected in similar proportions of patients (18% in group A versus 14% in group B). Left atrial spontaneous echo contrast, thrombus, and complex atheroma were significantly more prevalent in older patients, but interatrial septal anomalies were more prevalent in younger patients irrespective of transthoracic echocardiographic findings. Multivariate analysis identified both an abnormal transthoracic echocardiogram and patient age to be independent predictors of transesophageal echocardiographic findings of left atrial spontaneous echo contrast, left atrial thrombus, or complex atheroma.
  
  
  CONCLUSIONS
  Transesophageal echocardiography has a low yield for left atrial spontaneous contrast, left atrial thrombus, or complex aortic atheroma in patients with normal transthoracic echocardiogram and sinus rhythm and in younger patients. Interatrial septal anomalies are more prevalent in younger patients. Transthoracic echocardiogram should be performed in patients after stroke or systemic embolic events as a noninvasive screening tool. We recommend transesophageal echocardiogram for patients with abnormal transthoracic echocardiogram and in younger patients when the finding of a patent foramen ovale may contribute to patient management.
authors.affiliation: Department of Cardiology, Cleveland Clinic Foundation, OH 44195, USA.
authors.forename: D Y
authors.initials: DY
authors.lastname: Leung
authors.forename: I W
authors.initials: IW
authors.lastname: Black
authors.forename: G B
authors.initials: GB
authors.lastname: Cranney
authors.forename: W F
authors.initials: WF
authors.lastname: Walsh
authors.forename: R A
authors.initials: RA
authors.lastname: Grimm
authors.forename: W J
authors.initials: WJ
authors.lastname: Stewart
authors.forename: J D
authors.initials: JD
authors.lastname: Thomas
mesh_terms: D000367:Age Factors; D000368:Aged; D001018:Aortic Diseases / Q000000981:diagnostic imaging; D001161:Arteriosclerosis / Q000000981:diagnostic imaging; D016279:Atrial Function, Left; D002561:Cerebrovascular Disorders / Q000000981:diagnostic imaging*; D004452:Echocardiography; D017548:Echocardiography, Transesophageal; D005260:Female; D005544:Forecasting; D006325:Heart Atria / Q000000981:diagnostic imaging; D006331:Heart Diseases / Q000000981:diagnostic imaging; D006344:Heart Septal Defects, Atrial / Q000000981:diagnostic imaging; D006801:Humans; D002546:Ischemic Attack, Transient / Q000000981:diagnostic imaging; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018579:Patient Selection; D015995:Prevalence; D011446:Prospective Studies; D012189:Retrospective Studies; D013923:Thromboembolism / Q000000981:diagnostic imaging*; D013927:Thrombosis / Q000000981:diagnostic imaging