Key result
TEE identifies additional cardiac abnormalities in ~38% of cryptogenic stroke patients with normal TTE.
Why the study?
The role of TEE in cryptogenic stroke and TIA with normal TTE remains controversial in the absence of definite guidelines.
Does transesophageal echocardiography improve diagnostic yield in patients with cryptogenic stroke or TIA and normal transthoracic echocardiography?
Meta-Analysis (n=2,054)
Does transesophageal echocardiography improve diagnostic yield in patients with cryptogenic stroke or TIA and normal transthoracic echocardiography?
TEE provides a substantial diagnostic yield for cardiac abnormalities in patients with cryptogenic stroke or TIA despite a normal TTE, which could lead to important changes in clinical management.
May support selective TEE after normal TTE in cryptogenic stroke/TIA; leaves open impact on recurrent events and need for RCTs.
INTRODUCTION: The role of transesophageal echocardiography (TEE) in cryptogenic stroke and transient ischemic attack (TIA) with normal transthoracic echocardiography (TTE) remains controversial in the absence of definite guidelines. We aimed to perform a systematic review and meta-analysis to estimate an additional diagnostic yield and clinical impact of TEE in patients with cryptogenic stroke and TIA with normal TTE. METHODS: We performed a systematic review of cohort studies on PubMed using the keywords 'cryptogenic stroke', cryptogenic TIA', 'TEE', and 'TTE' with matching MeSH terms. We included studies with patients who had cryptogenic stroke or TIA and had normal TTE findings, where the study intended to obtain TEE on all patients and reported all TEE abnormalities. The studies containing patients with atrial fibrillation were excluded. All studies were evaluated for internal and external validity. Inverse variance random effects models were used to calculate the effect size, the number needed to diagnose, and the 95% confidence interval. RESULTS: We included 15 studies with 2054 patients and found LA/LAA/aortic thrombus, valvular vegetation, PFO-ASA, valvular abnormalities, and complex aortic plaques on TEE. Of these, 37.5% (29.7%-45.1%) of patients had additional cardiac findings on TEE. Management of 13.6% (8.1%-19.1%) of patients had changed after TEE evaluation. Based on current guidelines, it should change management in 4.1% (2.1%-6.2%) of patients and could potentially change management in 30.4% (21.9%-38.9%) of patients. Sensitivity analysis was also performed with only class II studies to increase internal validity, which showed additional cardiac findings in 38.4% (28.5%-48.3%), changed management in 20.2% (8.7%-31.8%), should change management in 4.7% (1.5%-7.9%), and could potentially change management in 30.4% (17.8%-43.0%) of patients. CONCLUSIONS: The diagnostic yield of TEE to find any additional cardiac findings in patients with cryptogenic stroke or TIA is not only high, but it can also change management for certain cardiac abnormalities. TTE in cryptogenic stroke or TIA may mitigate future risks by tailoring the management of these patients.
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Shah et al. (2021) conducted a meta-analysis in Cryptogenic stroke or TIA with normal TTE (n=2,054). Transesophageal echocardiography (TEE) was evaluated on Additional diagnostic yield of TEE in evaluating cardiac abnormalities over TTE (37.5%, 95% CI 29.7%-45.1%). Transesophageal echocardiography identified additional cardiac abnormalities in 37.5% of patients with cryptogenic stroke or TIA who had normal transthoracic echocardiography.
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