The utility of transesophageal echocardiography in determining the source of arterial embolization

Arterial embolism is frequently of a cardiac source. Arterial-arterial and paradoxical embolization also occurs. Failure to identify the origin may subject the patient to an important series of events. Herein we describe seven cases in which transesophageal echocardiography (TEE) was uniquely valuable in identifying the source or mechanism and in which conventional echocardiography and aortography were nondiagnostic. We conducted a chart review of patients with arterial emboli definitively diagnosed after undergoing TEE. Seven patients (mean age 68 years) were included in the study. Peripheral embolization occurred in four patients, visceral embolization occurred in one, and two experienced cerebrovascular events. Five patients had transthoracic echocardiography and six had aortography; none of these identified the source of embolization. All were diagnosed by TEE. Mobile aortic thrombus was the primary source in three patients, paradoxical embolization occurred in two, and two others had a combination of findings. Two patients received operative management with one mortality, and five received nonoperative management. The source of arterial emboli remains obscure in some patients. TEE can be valuable in identifying sources or mechanisms of embolization when angiography and conventional echocardiography are negative.