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Routine Transesophageal Echocardiography for Cerebral Ischemia: Is It Really Necessary?

Routine Transesophageal Echocardiography for Cerebral Ischemia: Is It Really Necessary? Abstract 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.Arch Intern Med. 1996;156:1719-1723 References 1. Pearson AC, Labovitz AJ, Tatineni S, Gomez CR. Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology . J Am Coll Cardiol. 1991;17:66-72.Crossref 2. Pop G, Sutherland GR, Kondstool PJ, Sit TW, de Jong G, Roelandt JR. Transesophageal echocardiography in the detection of intracardiac embolic sources in patients with transient ischemic attacks . Stroke. 1990;21:560-565.Crossref 3. Cujec B, Polasek P, Voll C, Shuaib A. Transesophageal echocardiography in the detection of potential cardiac source of embolism in stroke patients . Stroke. 1991;22:727-733.Crossref 4. Lee RJ, Bartzokis T, Yeoh TK, Grogin HR, Choi D, Schnittger I. Enhanced detection of intracardiac sources of cerebral emboli by transesophageal echocardiography . Stroke. 1991;22:734-739.Crossref 5. Aschenberg W, Schluter M, Kremer, P, Schroder E, Siglow V, Bleifeld W. Transesophageal two-dimensional echocardiography for the detection of left atrial appendage thrombus . J Am Coll Cardiol. 1986;7:163-166.Crossref 6. Castello R, Pearson AC, Labovitz AJ, Wallace P. Atrial spontaneous contrast in patients undergoing transesophageal echocardiography: prevalence and clinical implications . Am J Cardiol. 1990;65:1149-1153.Crossref 7. Cerebral Embolism Task Force. Cardiogenic brain embolism: the second report of the Cerebral Embolism Task Force . Arch Neurol. 1989;46:727-743.Crossref 8. Lechat P, Mas JL, Lascault G, et al. Prevalence of patent foramen ovale in patients with stroke . N Engl J Med. 1988;318:1148-1152.Crossref 9. DeRook FA, Comess KA, Albers GW, Popp RL. Transesophageal echocardiography in the evaluation of stroke . Ann Intern Med. 1992;117:922-932.Crossref 10. Hofmann T, Kasper W, Meinertz T, Geibel A, Just H. Echocardiographic evaluation of patients with clinically suspected atrial emboli . Lancet. 1990;336:1421-1424.Crossref 11. Karolis DG, Chandrasekaran K, Victor MF, Ross JJ, Mintz GS. Recognition and embolic potential of intraaortic atherosclerotic debris . J Am Coll Cardiol. 1991; 17:73-78.Crossref 12. Bougousslavsky J, Hachinski VC, Boughner DR, Fox AJ, Vinuela F, Barnett HJ. Cardiac and arterial lesions in carotid transient ischemic attacks . Arch Neurol. 1986;43:223-228.Crossref 13. Harvey JR, Teague SM, Anderson JL, Voyles WF, Thadani U. Clinically silent atrial septal defects with evidence for cerebral embolization . Ann Intern Med. 1986;105:695-697.Crossref 14. Belkin RN, Hurwitz BJ, Kisslo J. Atrial septal aneurysm: association with cerebrovascular and peripheral embolic events . Stroke. 1987;18:856-862.Crossref 15. Barnett HJM, Boughner DR, Taylor DW, Cooper PE, Kostuk WJ, Nichol PM. Further evidence relating mitral valve prolapse to cerebral ischemic events . N Engl J Med. 1980;302:139-144.Crossref 16. Tunick PA, Perez JL, Kronzon I. Protruding atheromas in the thoracic aorta and systemic embolization . Ann Intern Med. 1991;115:423-427.Crossref 17. Stratton JR, Lighty GW Jr, Pearman AS, Ritchie JL. Detection of left ventricular thrombus by two dimensional echocardiography: sensitivity, specificity, and causes of uncertainty . Circulation. 1982;66:156-166.Crossref 18. Daniel WG, Nellessen U, Schroder E, Daniel BN, Bednarski P, Nikutta P. Left atrial spontaneous echo contrast in mitral valve disease: an indicator for an increased thrombolic risk . J Am Coll Cardiol. 1988;11:1204-1211.Crossref 19. Tsai LM, Chen JH, Fang CJ, Lin LJ, Kwan CM. Clinical implications of left atrial spontaneous echo contrast in nonrheumatic atrial fibrillation . Am J Cardiol. 1992;70:327-331.Crossref 20. Stroke Prevention in Atrial Fibrillation Investigators. Stroke Prevention in Atrial Fibrillation Study: final results . Circulation. 1991;84:527-539.Crossref 21. Peterson P, Boysen G, Godtfredsen J, Andersen ED, Andersen B. Placebo-controlled, randomized trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation: the Copenhagen AFASAK Study . Lancet. 1989;1:175-179.Crossref 22. Connolly SJ, Laupacis A, Gent M, Roberts RS, Cairns JA, Joyner C. Canadian Atrial Fibrillation Anticoagulation (CAFA ) Study. J Am Coll Cardiol. 1991;18:349-355. 23. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation . N Engl J Med. 1990;323:1505-1511.Crossref 24. Ezekowitz MD, Bridgers SL, James KE, et al. Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation . N Engl J Med. 1992; 327:1406-1412.Crossref 25. Matchar DB, McCrory DC, Barnett HJM, Feussner JR. Medical treatment for stroke prevention . Ann Intern Med. 1994;121:41-53.Crossref 26. The Stroke Prevention in Atrial Fibrillation Investigators. Predictors of thromboembolism in atrial fibrillation , I: clinical features of patients at risk. Ann Intern Med. 1992;116:1-5. 27. The Stroke Prevention in Atrial Fibrillation Investigators. Predictors of thromboembolism in atrial fibrillation, II: echocardiographic features of patients at risk . Ann Intern Med. 1992;116:6-12.Crossref 28. Brand FN, Abbott RD, Kannel WB, Wolf PA. Characteristics and prognosis of lone atrial fibrillation: 30-year follow-up in the Framingham Study . JAMA. 1985; 254:3449-3453.Crossref 29. Bruns FJ, Segel DP, Adler S. Control of cholesterol embolization by discontinuation of anticoagulant therapy . Am J Med Sci. 1978;275:105-108.Crossref 30. Hyman BT, Landas SK, Ashman RF, Schelper RL, Robinson RA. Warfarinrelated purple toes syndrome and cholesterol microembolization . Am J Med. 1987;82:1233-1237.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Routine Transesophageal Echocardiography for Cerebral Ischemia: Is It Really Necessary?

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Publisher
American Medical Association
Copyright
Copyright © 1996 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1996.00440140155015
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Abstract

Abstract 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.Arch Intern Med. 1996;156:1719-1723 References 1. Pearson AC, Labovitz AJ, Tatineni S, Gomez CR. Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology . J Am Coll Cardiol. 1991;17:66-72.Crossref 2. Pop G, Sutherland GR, Kondstool PJ, Sit TW, de Jong G, Roelandt JR. Transesophageal echocardiography in the detection of intracardiac embolic sources in patients with transient ischemic attacks . Stroke. 1990;21:560-565.Crossref 3. Cujec B, Polasek P, Voll C, Shuaib A. Transesophageal echocardiography in the detection of potential cardiac source of embolism in stroke patients . Stroke. 1991;22:727-733.Crossref 4. Lee RJ, Bartzokis T, Yeoh TK, Grogin HR, Choi D, Schnittger I. Enhanced detection of intracardiac sources of cerebral emboli by transesophageal echocardiography . Stroke. 1991;22:734-739.Crossref 5. Aschenberg W, Schluter M, Kremer, P, Schroder E, Siglow V, Bleifeld W. Transesophageal two-dimensional echocardiography for the detection of left atrial appendage thrombus . J Am Coll Cardiol. 1986;7:163-166.Crossref 6. Castello R, Pearson AC, Labovitz AJ, Wallace P. Atrial spontaneous contrast in patients undergoing transesophageal echocardiography: prevalence and clinical implications . Am J Cardiol. 1990;65:1149-1153.Crossref 7. Cerebral Embolism Task Force. Cardiogenic brain embolism: the second report of the Cerebral Embolism Task Force . Arch Neurol. 1989;46:727-743.Crossref 8. Lechat P, Mas JL, Lascault G, et al. Prevalence of patent foramen ovale in patients with stroke . N Engl J Med. 1988;318:1148-1152.Crossref 9. DeRook FA, Comess KA, Albers GW, Popp RL. Transesophageal echocardiography in the evaluation of stroke . Ann Intern Med. 1992;117:922-932.Crossref 10. Hofmann T, Kasper W, Meinertz T, Geibel A, Just H. Echocardiographic evaluation of patients with clinically suspected atrial emboli . Lancet. 1990;336:1421-1424.Crossref 11. Karolis DG, Chandrasekaran K, Victor MF, Ross JJ, Mintz GS. Recognition and embolic potential of intraaortic atherosclerotic debris . J Am Coll Cardiol. 1991; 17:73-78.Crossref 12. Bougousslavsky J, Hachinski VC, Boughner DR, Fox AJ, Vinuela F, Barnett HJ. Cardiac and arterial lesions in carotid transient ischemic attacks . Arch Neurol. 1986;43:223-228.Crossref 13. Harvey JR, Teague SM, Anderson JL, Voyles WF, Thadani U. Clinically silent atrial septal defects with evidence for cerebral embolization . Ann Intern Med. 1986;105:695-697.Crossref 14. Belkin RN, Hurwitz BJ, Kisslo J. Atrial septal aneurysm: association with cerebrovascular and peripheral embolic events . Stroke. 1987;18:856-862.Crossref 15. Barnett HJM, Boughner DR, Taylor DW, Cooper PE, Kostuk WJ, Nichol PM. Further evidence relating mitral valve prolapse to cerebral ischemic events . N Engl J Med. 1980;302:139-144.Crossref 16. Tunick PA, Perez JL, Kronzon I. Protruding atheromas in the thoracic aorta and systemic embolization . Ann Intern Med. 1991;115:423-427.Crossref 17. Stratton JR, Lighty GW Jr, Pearman AS, Ritchie JL. Detection of left ventricular thrombus by two dimensional echocardiography: sensitivity, specificity, and causes of uncertainty . Circulation. 1982;66:156-166.Crossref 18. Daniel WG, Nellessen U, Schroder E, Daniel BN, Bednarski P, Nikutta P. Left atrial spontaneous echo contrast in mitral valve disease: an indicator for an increased thrombolic risk . J Am Coll Cardiol. 1988;11:1204-1211.Crossref 19. Tsai LM, Chen JH, Fang CJ, Lin LJ, Kwan CM. Clinical implications of left atrial spontaneous echo contrast in nonrheumatic atrial fibrillation . Am J Cardiol. 1992;70:327-331.Crossref 20. Stroke Prevention in Atrial Fibrillation Investigators. Stroke Prevention in Atrial Fibrillation Study: final results . Circulation. 1991;84:527-539.Crossref 21. Peterson P, Boysen G, Godtfredsen J, Andersen ED, Andersen B. Placebo-controlled, randomized trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation: the Copenhagen AFASAK Study . Lancet. 1989;1:175-179.Crossref 22. Connolly SJ, Laupacis A, Gent M, Roberts RS, Cairns JA, Joyner C. Canadian Atrial Fibrillation Anticoagulation (CAFA ) Study. J Am Coll Cardiol. 1991;18:349-355. 23. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation . N Engl J Med. 1990;323:1505-1511.Crossref 24. Ezekowitz MD, Bridgers SL, James KE, et al. Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation . N Engl J Med. 1992; 327:1406-1412.Crossref 25. Matchar DB, McCrory DC, Barnett HJM, Feussner JR. Medical treatment for stroke prevention . Ann Intern Med. 1994;121:41-53.Crossref 26. The Stroke Prevention in Atrial Fibrillation Investigators. Predictors of thromboembolism in atrial fibrillation , I: clinical features of patients at risk. Ann Intern Med. 1992;116:1-5. 27. The Stroke Prevention in Atrial Fibrillation Investigators. Predictors of thromboembolism in atrial fibrillation, II: echocardiographic features of patients at risk . Ann Intern Med. 1992;116:6-12.Crossref 28. Brand FN, Abbott RD, Kannel WB, Wolf PA. Characteristics and prognosis of lone atrial fibrillation: 30-year follow-up in the Framingham Study . JAMA. 1985; 254:3449-3453.Crossref 29. Bruns FJ, Segel DP, Adler S. Control of cholesterol embolization by discontinuation of anticoagulant therapy . Am J Med Sci. 1978;275:105-108.Crossref 30. Hyman BT, Landas SK, Ashman RF, Schelper RL, Robinson RA. Warfarinrelated purple toes syndrome and cholesterol microembolization . Am J Med. 1987;82:1233-1237.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Aug 12, 1996

References