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[Cardiological diagnosis in arterial embolism]
1Abteilung Kardiologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover.
Insights
Echocardiography, particularly transesophageal echocardiography (TEE), is crucial for diagnosing cardiac sources of arterial embolism, such as thrombi and vegetations. TEE significantly improves detection rates for left atrial abnormalities and prosthetic valve issues compared to transthoracic methods.
Area of Science:
- Cardiology
- Medical Imaging
- Embolism Research
Context:
- Arterial embolism can originate from various cardiac abnormalities, including thrombi, tumors, and vegetations.
- Patent foramen ovale and atrial septal defects pose risks for paradoxical embolism.
- Spontaneous echo contrast indicates heightened thromboembolic risk.
Purpose:
- To evaluate the diagnostic utility of echocardiography, especially transesophageal echocardiography (TEE), in identifying cardiac sources of arterial embolism.
- To compare the effectiveness of transthoracic echocardiography (TTE) versus TEE in detecting specific cardiac abnormalities.
- To highlight the role of TEE in diagnosing challenging cases like left atrial thrombi and endocarditis.
Summary:
- Echocardiography is the primary diagnostic tool for cardiac sources of embolism.
- Transesophageal echocardiography (TEE) offers superior detection rates for left atrial thrombi, spontaneous echo contrast, endocarditis vegetations, and prosthetic valve complications compared to transthoracic echocardiography (TTE).
- While TTE is effective for left ventricular thrombi, TEE is essential for left atrial and prosthetic valve assessments.
Impact:
- Improved diagnostic accuracy for cardiac embolism through advanced echocardiographic techniques.
- Enhanced clinical decision-making by better identifying the embolic source.
- Potential for more targeted therapeutic strategies based on precise diagnosis.
Abstract:
Potential cardiac sources of arterial embolism are in particular thrombi within the left atrium or ventricle, or attached to a prosthetic valve, intracardiac tumors, and vegetations due to endocarditis. Patent foramen ovale and atrial septal defect may lead to paradoxical embolism, and spontaneous echo contrast within the heart has to be considered as a parameter of increased thromboembolic risk. In rare cases, atrial septal aneurysm, mitral valve prolapse or annulus calcification and calcified aortic stenosis has to be taken into consideration. Current method of choice for diagnosis of these abnormalities is echocardiography. When the transthoracic approach fails, transesophageal echocardiography (TEE) leads to a definite diagnosis in most cases. Precordial echocardiography allows the detection of left ventricular thrombi with a sensitivity ranging between 72 and 95%, and monoplane TEE does usually not increase these numbers. In contrast, thrombi within the left atrium and particularly in the left atrial appendage can be detected with a significantly higher detection rate when TEE is used. The same is true for spontaneous echo contrast in the left atrium, a phenomenon which is almost exclusively diagnosed by TEE, as well as for endocarditis associated vegetations that can be identified by TEE with a sensitivity higher than 90%. Patient foramen ovale is usually diagnosed by precordial contrast echocardiography combined with a Valsalva maneuver; color Doppler or contrast TEE allows to increase the detection rate. In the diagnosis of prosthetic valve attached thrombi and vegetations, TEE is clearly superior compared to the precordial examination, at least concerning prosthetic devices in mitral position. If echocardiography fails to identify a potential cardiac source of embolism, other techniques don't add significant information in most cases. Detection of a potential source of embolism, however, does not necessarily prove that the particular finding represents the true etiology of an embolic event; results of all clinical and technical examinations have to be evaluated in a critical synopsis. In addition, proper therapeutic consequences in quite a number of abnormalities considered as potential cardiac sources of embolism are not yet defined.