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Transesophageal echocardiography in patients with cryptogenic stroke: does it alter their management? A 3-year
J Walpot1, W H Pasteuning, M Hoevenaar
1Department of Cardiology, Ziekenhuis Walcheren, Vlissingen, The Netherlands. walpot@zwv.nl
Insights
Transesophageal echocardiography (TEE) findings significantly altered the management of stroke in over a third of patients under 65. This diagnostic tool is crucial for identifying cardiac embolism sources when other methods fail.
Area of Science:
- Cardiology
- Neurology
- Diagnostic Imaging
Background:
- Cardiac embolism accounts for 25% of ischemic cerebral-vascular insults (CVI).
- Transesophageal echocardiography (TEE) is a key diagnostic tool for stroke, superior to transthoracic echocardiography (TTE) for detecting cardiac embolism sources.
- TEE carries inherent risks and is time-consuming.
Purpose of the Study:
- To evaluate the impact of TEE findings on the management of CVI in patients younger than 65.
- To identify patients for whom TEE is essential when initial work-up (medical history, TTE, Carotid Ultrasonography) is inconclusive.
Main Methods:
- A 3-year retrospective study of patients admitted to a regional stroke unit.
- Analysis of the TEE database for eligible patients with unexplained CVI.
- Evaluation of TEE findings' influence on patient management.
Main Results:
- Of 54 patients (mean age 52), TEE revealed major cardiac embolism sources in 11.1% (e.g., infective endocarditis, valve dysfunction).
- Minor sources like patent foramen ovale (PFO) or atrial septal defect (ASD) with shunt were found in 27.8%.
- TEE findings altered management in 38.9% of cases, leading to surgery, percutaneous closure, or anticoagulation.
Conclusions:
- TEE findings significantly change CVI management in approximately 1 in 3 patients under 65 with cryptogenic stroke.
- TEE is vital for uncovering cardiac sources of embolism when initial investigations are negative.
Background:
Cardiac embolism is estimated to be the aetiology of ischemic cerebral-vascular insults (CVI) in 25% of cases. Transesophageal echocardiography (TEE) is a reliable and widely used examination in the diagnosticwork-up of stroke. TEE is superior to transthoracic echocardiography (TTE) in the search of minor sources of cardiac embolism but it is time consuming and has its inherent risks.
Aim:
The aim of this study was to determine whether in patients younger than 65 years of age with CVI our TEE-findings would alter their management. Only patients in whom nor the medical record, nor TTE, nor Carotid Ultrasonography could establish an aetiology, were included.
Methods:
A 3-year retrospective study was done in patients admitted to the stroke unit of a regional medical centre covering 110,000 inhabitants. The TEE-database was reviewed and all TEE's performed in eligible patients were selected. Minor and major sources of cardiac embolism were listed. The impact of TEE-findings on the management of CVI was evaluated.
Results:
Fifty-four patients fulfilled the criteria for this study. The mean age was 52 years (range 18 - 65). A major source of cardiac embolism was seen in 6 cases (11.1%). Four patients (7.4%) had infective endocarditis (IE) with vegetations. A small apical thrombosis in a patient with isolated left ventricular non-compaction was noted and in 1 patient dysfunction of a mechanical prosthetic valve was documented. The most frequently encountered minor source of cardiac embolism was a patent foramen ovale (PFO) or small atrial septal defect (ASD) with documented right-to-left shunt during Valsalva manoeuvre (15 patients, 27.8%). Of these 15 patients, an atrial septum aneurysm(ASA) was seen in 7 patients (13%). Our TEE-findings altered the management of CVI substantially in 21 cases (38.9%). The 4 patients with IE and the patient with mechanical valve dysfunction had cardiac surgery. Twelve patients (22.2%) were referred for percutaneous closure of the PFO/ASD. Three patients with PFO/ASD and the patient with IVNC were treated with maintenance therapy of oral anticoagulation.
Conclusion:
In 1 out of 3 patients, younger than 65 years, suffering from CVI in whom nor medical history, nor TTE, nor Carotid Ultrasound could reveal the cause of the CVI our TEE-findings altered their management.
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