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[How to search for a cardiac cause of an arterial embolism]
1Service de Cardiologie, Hôpital Cochin, Paris.
Insights
Transesophageal echocardiography (TEE) excels at detecting subtle heart lesions linked to embolic strokes, especially those missed by other methods. It provides superior imaging of atrial structures, aiding in diagnosing stroke causes.
Area of Science:
- Cardiology
- Neurology
- Medical Imaging
Background:
- Embolic strokes often originate from cardiac sources.
- Initial cardiac assessments may not identify all potential embolic causes.
- High-definition imaging is crucial for detecting subtle cardiac abnormalities.
Purpose of the Study:
- To highlight the diagnostic superiority of transesophageal echocardiography (TEE) in identifying cardiac causes of embolic strokes.
- To discuss the role of TEE in evaluating atrial structures and the interatrial septum.
- To explore the diagnostic challenges posed by minor cardiac abnormalities associated with embolism.
Main Methods:
- Utilizes high-definition transesophageal echocardiography (TEE) for detailed cardiac imaging.
- Integrates clinical history, physical examination, electrocardiogram, and chest X-rays.
- Considers transthoracic cardiac ultrasonography (TTE) and Holter monitoring in the diagnostic workup.
Main Results:
- TEE offers superior visualization of the mitral valve, atrial structure, and interatrial septum compared to other techniques.
- Identifies major embolic heart diseases like atrial fibrillation (AF), mitral stenosis, endocarditis, and valvular prostheses.
- Facilitates diagnosis of minor abnormalities such as patent foramen ovale and interatrial septum aneurysm, though their embolic mechanisms require further definition.
Conclusions:
- TEE is invaluable for screening cardiac lesions contributing to embolic strokes, particularly subtle ones.
- While major cardiac causes are readily identified, TEE aids in detecting and characterizing minor abnormalities.
- Further research is needed to clarify the embolic mechanisms and optimal management of patients with minor cardiac abnormalities detected by TEE.
Abstract:
Owing to a very high-definition image, transesophageal echocardiography (TEE) allows screening lesions that are not detected by other examination techniques. Its superiority is especially obvious in the analysis of the atrial structure of the mitral valve and of the interatrial septum, therefore for the analysis of structures that are most commonly involved in embolic strokes. After history taking, a clinical examination, and the analysis of the electrocardiogram and of the thoracic X-rays, two cases are possible: 1) There is an indisputable emboligenic heart disease: atrial fibrillation (AF), mitral stenosis, bacterial endocarditis, or a valvular prosthesis. Systematic transthoracic cardiac ultrasonography (TTE) completes this assessment. 2) When the initial findings are negative, ETT being included in the assessment, the identification of a potential cardiac cause of embolism depends on: the degree of investigation implemented: Holter to check for paroxysmal AF, TEE knowing that the diagnostic efficiency of this examination is low when the initial assessment is negative; what is selected as an emboligene cardiac cause. In fact, in addition to commonly recognized causes called major causes, there are so-called minor abnormalities that are still ill-defined but are known to be associated with arterial embolism. For example, a patent foramen ovale or an aneurysm of the interatrial septum are very easily diagnosed with TEE, but the exact mechanism of embolism and the appropriate therapeutic attitude still remain to be defined for this type of pathology.