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Utility of transesophageal echocardiography in determining the source of arterial embolization
Myron C Mariano1, Charles J Gutierrez, Jason Q Alexander
1Department of Surgery, Huntington Hospital, Pasadena, California 91109, USA.
Insights
Transesophageal echocardiography is crucial for identifying the source of arterial emboli when other methods fail. This advanced ultrasound technique revealed the cause of embolization in all seven study patients, unlike conventional echocardiography or aortography.
Area of Science:
- Cardiology
- Vascular Surgery
- Diagnostic Imaging
Background:
- Arterial embolism often originates from cardiac sources, but arterial-arterial and paradoxical emboli also occur.
- Identifying the embolic source is critical for preventing recurrent, potentially preventable events.
- Conventional echocardiography and aortography have limitations in detecting embolic origins, including mobile aortic thrombus.
Purpose of the Study:
- To evaluate the diagnostic value of transesophageal echocardiography (TEE) in identifying the source or mechanism of arterial embolization.
- To compare the efficacy of TEE with conventional echocardiography and aortography in diagnosing arterial emboli.
Main Methods:
- Retrospective chart review of seven patients diagnosed with arterial emboli using TEE.
- Analysis of patient demographics, embolization type, and prior diagnostic imaging (transthoracic echocardiography, aortography).
Main Results:
- TEE identified the embolic source in all seven patients, whereas conventional methods did not.
- Primary sources included mobile aortic thrombus (3 patients), paradoxical embolization (2 patients), and atrial thrombus (1 patient).
- Peripheral embolization occurred in four patients, visceral in one, and cerebrovascular events in two.
Conclusions:
- Transesophageal echocardiography is uniquely valuable for diagnosing the source of arterial embolization when other imaging modalities are negative.
- TEE can identify diverse embolic sources, including mobile aortic thrombus and paradoxical emboli, guiding appropriate patient management.
- Despite its utility, the source of arterial emboli remains obscure in some cases.
Abstract:
Arterial embolism is frequently the product of a cardiac source. Arterial-arterial embolization and paradoxical embolization also occur. Failure to identify the point of origin may subject the patient to an important incidence of preventable events. Conventional echocardiography is insensitive in identifying a cardiac origin of emboli and is of little use in identifying sources of arterial-arterial emboli. Aortography is invasive and not as sensitive in detecting mobile aortic thrombus, which is a recently reported embolic source. Herein we describe seven cases in which transesophageal echocardiography was uniquely valuable in identifying the source or mechanism of arterial embolization. We performed chart reviews of patients with arterial emboli definitively diagnosed after utilizing transesophageal echocardiography. Four females and three males with a mean age of 68 years were included in the study. Peripheral embolization occurred in four patients, visceral embolization occurred in one patient, and two patients experienced cerebrovascular events. Six patients had transthoracic echocardiography and six patients had aortography. None of these studies identified the source of embolization. All patients were diagnosed with transesophageal echocardiography. Mobile aortic thrombus was the primary embolic source in three patients, paradoxical embolization occurred in two patients, and two patients had a combination of findings including one patient with atrial thrombus. Two patients received operative repair of the aorta and five underwent nonoperative management. There was one mortality in the operative group. The source of arterial emboli remains obscure in some patients. Transesophageal ultrasound can be valuable in identifying the source or mechanism of embolization even when angiography and conventional echocardiography are negative.