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Routine transesophageal echocardiography for cerebral ischemia. Is it really necessary?
1Hoffman Heart Institute of Connecticut, St Francis Hospital and Medical Center, Hartford, USA.
Insights
Transesophageal echocardiography (TEE) detects cardiac embolic sources in 35% of patients with ischemic events. Routine TEE may not be cost-effective, as findings often lack specific treatment recommendations beyond aspirin or warfarin.
Area of Science:
- Cardiology
- Neurology
- Diagnostic Imaging
Background:
- Transesophageal echocardiography (TEE) is frequently used for stroke evaluation, often ordered by neurologists without prior transthoracic echocardiography.
- TEE is considered superior to transthoracic echocardiography for detecting cardiac sources of embolism.
Purpose of the Study:
- To evaluate the diagnostic yield and cost-effectiveness of routine TEE in patients presenting with cerebral ischemic events.
Main Methods:
- A retrospective review of 106 patients who underwent TEE for cerebral ischemic events over a 2-year period.
- TEE utilized biplane or omniplane transducers with Doppler color flow imaging and saline contrast.
- Studies and hospital charts were analyzed for cardiac/aortic embolic sources and clinical information.
Main Results:
- A potential cardiovascular embolic source was identified in 35% of patients.
- Abnormalities were more frequent in patients with atrial fibrillation (53%) compared to those in sinus rhythm (28%).
- Left atrial thrombus and spontaneous contrast were strongly associated with atrial fibrillation; aortic debris was common in sinus rhythm.
Conclusions:
- Routine TEE may not be cost-effective for all patients with ischemic events.
- Findings in atrial fibrillation patients often support warfarin therapy, while those in sinus rhythm may only warrant aspirin or have no clear therapeutic indication.
- The study suggests a more selective approach to TEE in this population.
Background:
Patients presenting with stroke or transient cerebral ischemic episodes often undergo transesophageal echocardiography (TEE) as part of their initial evaluation. Previous studies have demonstrated that TEE is superior to transthoracic echocardiography for the detection of potential cardiac sources of embolism. In our institution, this scenario now represents the most frequent reason for requesting TEE. For the most part, these TEE examinations are ordered by a neurologist, and transthoracic echocardiography is not performed beforehand.
Patients:
Over a 2-year period, TEE was requested for 137 patients at our institution for the evaluation of a cerebral ischemic event. The complete hospital chart was available for review in 106 of these patients, and they form the study group.
Methods:
All patients underwent TEE using either a biplane or omniplane transducer, with Doppler color flow imaging and saline contrast administration performed in every case. Studies were reviewed for the presence of possible cardiac or aortic sources of cerebral emboli, and hospital charts were reviewed to collect clinical information.
Results:
A potential cardiovascular embolic source was detected in 35% of patients. Abnormalities were discovered in 53% (16/30) of patients with atrial fibrillation vs 28% (21/76) of patients in sinus rhythm (P < .001). Both patients who had left atrial thrombus and 12 of 13 with left atrial spontaneous contrast had atrial fibrillation (P < .001). Protruding aortic atherosclerotic debris was the most frequent abnormality among patients in sinus rhythm.
Conclusions:
It may not be cost-effective to perform TEE as a routine diagnostic procedure in patients presenting with cerebral ischemic events. Most patients with atrial fibrillation are candidates for empiric warfarin sodium therapy, and patients in sinus rhythm usually have findings for which there is no recommended therapy or for which only aspirin is indicated.