Routine Transesophageal Echocardiography for Cerebral Ischemia

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.