USEFULNESS OF TRANSESOPHAGEAL ECHOCARDIOGRAPHY IN PREDICTING MORTALITY AND MORBIDITY IN STROKE PATIENTS WITHOUT CLINICALLY KNOWN CARDIAC SOURCES OF EMBOLUS

This study tested the hypothesis that stroke patients without a cardia c source of embolism suspected by clinical examination can be risk str atified by transesophageal echocardiography. Forty ischemic stroke pat ients without atrial fibrillation, prosthetic valves, ejection fractio n <20%, or recent myocardial infarction underwent multiplane transesop hageal echocardiography: 24 (designated high risk) had greater than or equal to 1 of the following: left heart thrombus, vegetation, mass or spontaneous echo contrast, mobile ascending aortic or arch debris, pa tent foramen ovale, atrial septal defect or aneurysm, mitral annular c alcification, mitral valve thickening, prolapse or mitral valve strand s. End points were death, recurrent stroke, transient ischemic attack, myocardial infarction or peripheral embolism. Thirty-eight patients ( 95%) (23 high, 15 low risk) were followed for 14 +/- 8 months: 9 (24%) died of vascular causes including 4 who had a cardiac cause of death and 5 who had fatal strokes. Eight had recurrent strokes (4 nonfatal) and 1 nonfatal myocardial infarction occurred. Cardiovascular survival was predicted by transesophageal echocardiography: survival rates wer e 92% (low risk) and 63% (high risk) at 24 months (p = 0.036). Left at rial enlargement was independently associated with death from stroke ( fatal stroke occurred in 25% of those with atrial enlargement compared to 8% of those with normal atrial dimension, p less than or equal to 0.03), as was left atrial spontaneous echo contrast (50% died vs 9% wi thout contrast, p less than or equal to 0.03). Left ventricular hypert rophy and aortic atherosclerosis were both associated with the risk of recurrent stroke (30% of patients with ventricular hypertrophy had re current stroke compared to 10% with normal wall thickness (9 less than or equal to 0.05); 30% with aortic atherosclerosis had a recurrent st roke compared to none with a normal aorta (p less than or equal to 0.0 5). Thus, transesophageal echocardiography clearly identifies patients at a high risk for cardiovascular mortality and morbidity after strok e despite an unsuspected source of embolism by clinical examination. ( C) 1998 by Excerpta Medica, Inc.