Related Experiment Videos
Multiplane transesophageal echocardiography and stroke
C Autore1, D Cartoni, M Piccininno
1Department of Cardiovascular and Respiratory Sciences, La Sapienza University of Rome, Italy.
Insights
Transesophageal echocardiography (TEE) aids stroke evaluation by visualizing cardiac sources of embolism. However, its role in guiding cardioversion and identifying specific high-risk cardiac abnormalities like atrial septal aneurysm requires further prospective study.
Area of Science:
- Cardiology
- Neurology
- Medical Imaging
Background:
- Up to 40% of ischemic strokes are presumed to have a cardiac origin.
- Transesophageal echocardiography (TEE) is a key diagnostic tool for evaluating stroke patients.
- TEE provides superior imaging of posterior cardiac structures and the aorta.
Purpose of the Study:
- To review the current role and limitations of TEE in identifying cardiac sources of ischemic stroke.
- To address unresolved questions regarding TEE's utility in specific clinical scenarios, such as cardioversion and risk stratification.
- To highlight methodological challenges in current research and advocate for prospective studies.
Main Methods:
- Review of existing literature on TEE in stroke evaluation.
- Analysis of evidence linking cardiovascular abnormalities to ischemic stroke.
- Discussion of unresolved clinical questions and methodological considerations.
Main Results:
- TEE has identified associations between cardiac abnormalities (e.g., left-sided thrombi, aortic plaques) and ischemic stroke.
- Unresolved issues include TEE's role in predicting embolism after cardioversion and identifying high-risk patent foramen ovale.
- Prospective studies are needed to clarify the pathogenetic role of abnormalities like atrial septal aneurysm and patent foramen ovale.
Conclusions:
- While TEE is valuable, its precise role in managing atrial fibrillation cardioversion and stratifying stroke risk requires further investigation.
- Methodological limitations in current studies, often retrospective, bias findings.
- Prospective research with appropriate control groups is essential to establish reliable markers of embolic risk and refine the diagnosis of cardiogenic embolism.
Abstract:
Transesophageal echocardiography (TEE) is considered a basic tool in the diagnostic and follow-up evaluation of stroke patients, since up to 40% of cerebral ischemic events are presumed to have a cardiac origin. TEE offers a superior resolution of the posterior cardiac structures, such as left atrium and appendage and atrial septum, as well as of the aorta. By means of TEE, evidence has accumulated that some cardiovascular abnormalities (left-sided thrombi, tumors and vegetative lesions, complicated plaques of the aortic arch) are associated with ischemic stroke. Nevertheless, some issues remain unresolved. Will exclusion of atrial thrombus by multiplane TEE preclude embolism after cardioversion of atrial fibrillation? If anticoagulation before and after cardioversion is needed to provide adequate protection against embolism, will TEE be indicated in all patients? Moreover, can the detection of spontaneous echo contrast or enlarged and hypokinetic left atrial appendage in atrial fibrillation modify the therapeutic strategy? Is atrial septal aneurysm (ASA) a real embolic source, particularly when a right-to-left shunt is not associated? Considering the high prevalence of patent foramen ovale (PFO) in normal subjects, how can we identify patients at higher risk of embolism? Furthermore, methodologic points have to be taken into account when we analyze data from the literature. First, most studies are retrospective; a sole prospective study demonstrated that atherosclerotic plaques >4 mm thick in the aortic arch are significant predictors of recurrent brain infarction and other cardiovascular events in patients > or =60 years of age. Second, the association between the aforementioned cardiac abnormalities (mainly ASA and PFO) and cardiogenic embolism is biased by the patient-enrollment criteria used in those studies so that their pathogenetic role has not yet been established. Prospective studies with the enrollment of appropriate control groups will be necessary to define what can be considered a marker of embolic risk; the diagnosis "cardiogenic embolism" will not be a definitive diagnosis in most cases.