SELECTION OF PATIENTS FOR TRANSESOPHAGEAL ECHOCARDIOGRAPHY AFTER STROKE AND SYSTEMIC EMBOLIC EVENTS - ROLE OF TRANSTHORACIC ECHOCARDIOGRAPHY

Background and Purpose This study examined whether patients suffering from stroke and other systemic embolic events may be selected for tran sesophageal echocardiography on the Oasis of clinical and transthoraci c echocardiographic findings. Methods We performed transthoracic and t ransesophageal echocardiography on 824 patients after stroke and other suspected embolic events. Patients were classified into group A if th e): were in sinus rhythm and had a normal transthoracic echocardiogram . Group B consisted of all other patients. Transesophageal echocardiog raphic findings of left atrial spontaneous contrast, left atrial throm bus, complex aortic atheroma, and interatrial septal anomalies were co rrelated with clinical and transthoracic echocardiographic results. Re sults Transesophageal echocardiography detected at least one potential source of embolism in 399 patients (49%): spontaneous contrast in 214 patients (26%), left atrial thrombus in 54 (7%), complex atheroma in 111 (13%), and interatrial septal anomalies in 126 (15%). Ln group A ( n=236). only 3 (1%) had spontaneous contrast, 11 (4.6%) had complex at heroma, and none had left atrial thrombus. Ln group B (n=588), 211 pat ients (36% P<.001) had spontaneous contrast. 54 (9.2%, P<.001) had atr ial thrombus, and 100 (17%, P<.001) had complex atheroma. Interatrial septal anomalies were detected in similar proportions of patients (18% in group A versus 14% in group B). Left atrial spontaneous echo contr ast, thrombus, and complex atheroma were significantly more prevalent in older patients, but interatrial septal anomalies were more prevalen t in younger patients irrespective of transthoracic echocardiographic findings. Multivariate analysis identified both an abnormal transthora cic echocardiogram and patient age to be independent predictors of tra nsesophageal echocardiographic findings of left atrial spontaneous ech o contrast, left atrial thrombus, or complex atheroma. Conclusions Tra nsesophageal echocardiography has a low yield for left atrial spontane ous contrast, left atrial thrombus, or complex aortic atheroma in pati ents with normal transthoracic echocardiogram and sinus rhythm and in younger patients. Interatrial septal anomalies are more prevalent in y ounger patients. Transthoracic echocardiogram should be performed in p atients after stroke or systemic embolic events as a noninvasive scree ning tool, We recommend transesophageal echocardiogram for patients wi th abnormal transthoracic echocardiogram and in younger patients when the finding of a patent foramen ovale may contribute to patient manage ment.