Current Atherosclerosis Reports

, Volume 7, Issue 4, pp 255–262

Transesophageal echocardiography and stroke

  • Timothy D. Woods


Only coronary artery disease and cancer kill more people than stroke in the United States. Transesophageal echocardiography (TEE) is a semi-invasive ultrasound cardiac imaging technique that provides superior anatomic detail as well as functional information. Searching for a cause of cerebral ischemia is the most common indication for TEE in cardiac ultrasound laboratories. Although TEE is not superior to transthoracic imaging for identifying all sources of cardiac embolism, its ability to more sensitively detect atrial septal aneurysm, patent foramen ovale, and aortic atheroma has been well described in recent years. Care must be exercised in using TEE to identify suspected cardiac sources of embolism, as potential etiologies described in the literature are not equally established by rigorous clinical trials. Confidence level in cause and effect for any cardiac pathology identified must be factored into therapeutic decisions.


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References and Recommended Reading

  1. 1.
    American Heart Association: Heart Disease and Stroke Statistics—2005 Update. http://wwwamericanheartorg/presenterjhtml?identifier=1200026. Accessed February 1, 2005.Google Scholar
  2. 2.
    The Cerebral Embolism Task Force: Cardiogenic brain embolism. Arch Neurol 1986, 43:71–84.Google Scholar
  3. 3.
    Daniel WG, Erbel R, Kasper W, et al.: Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations. Circulation 1991, 83:817–821.PubMedGoogle Scholar
  4. 4.
    Birmingham GD, Rahko PS, Ballantyne FI: Improved detection of infective endocarditis with transesophageal echocardiography. Am Heart J 1992, 123:774–781.PubMedCrossRefGoogle Scholar
  5. 5.
    Daniel WG, Mugge A, Grote J, et al.: Comparison of transthoracic and transesophageal echocardiography for detection of abnormalities of prosthetic and bioprosthetic valves in the mitral and aortic positions. Am J Cardiol 1993, 71:210–215.PubMedCrossRefGoogle Scholar
  6. 6.
    Hart RG, Halperin JL: Atrial fibrillation and stroke: concepts and controversies. Stroke 2001, 32:803–808.PubMedGoogle Scholar
  7. 7.
    Wolf PA, Dawber TR, Thomas HE, Kannel WB: Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham study. Neurology 1978, 28:973–977.PubMedGoogle Scholar
  8. 8.
    Pollick C, Taylor D: Assessment of left atrial appendage function by transesophageal echocardiography. Implications for the development of thrombus. Circulation 1991, 84:223–231.PubMedGoogle Scholar
  9. 9.
    Kasliwal RR, Mittal S, Kanojia A, et al.: A study of spontaneous echo contrast in patients with rheumatic mitral stenosis and normal sinus rhythm: an Indian perspective. Br Heart J 1995, 74:296–299.PubMedGoogle Scholar
  10. 10.
    Klein AL, Grimm RA, Murray D, et al.: Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med 2001, 344:1411–1420.PubMedCrossRefGoogle Scholar
  11. 11.
    Manning WJ, Silverman DI, Keighley CS, et al.: Transesophageal echocardiographically facilitated early cardioversion from atrial fibrillation using short-term anticoagulation: final results of a prospective 4.5-Year Study. J Am Coll Cardiol 1995, 25:1354–1361.PubMedCrossRefGoogle Scholar
  12. 12.
    Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med 1994, 154:1449–1457.Google Scholar
  13. 13.
    Zabalgoitia M, Halperin JL, Pearce LA, et al.: Transesophageal echocardiographic correlates of clinical risk of thromboembolism in nonvalvular atrial fibrillation. J Am Coll Cardiol 1998, 31:1622–1626.PubMedCrossRefGoogle Scholar
  14. 14.
    Agmon Y, Khandheria BK, Meissner I, et al.: Frequency of atrial septal aneurysms in patients with cerebral ischemic events. Circulation 1999, 99:1942–1944.PubMedGoogle Scholar
  15. 15.
    Mugge A, Daniel WG, Angermann C, et al.: Atrial septal aneurysm in adult patients: a multicenter study using transthoracic and transesophageal echocardiography. Circulation 1995, 91:2785–2792.PubMedGoogle Scholar
  16. 16.
    Schneider B, Hanrath P, Vogel P, Meinertz T: Improved morphologic characterization of atrial septal aneurysm by transesophageal echocardiography: relation to cerebrovascular events. J Am Coll Cardiol 1990, 16:1000–1009.PubMedCrossRefGoogle Scholar
  17. 17.
    Pearson AC, Nagelhout D, Castello R, et al.: Atrial septal aneurysm and stroke: a transesophageal echocardiographic study. J Am Coll Cardiol 1991, 18:1223–1229.PubMedCrossRefGoogle Scholar
  18. 18.
    Mas JL, Arquizan C, Lamy C, et al.: Recurrent cerebrovascular events associated with patent foramen oval, atrial septal aneurysms, or both. N Engl J Med 2001, 345:1740–1746.PubMedCrossRefGoogle Scholar
  19. 19.
    Schroeckenstein RF, Wasenda GJ, Edwards JE: Valvular competent patent foramen ovale in adults. Minnesota Med 1972, 55:11–13.PubMedGoogle Scholar
  20. 20.
    Hagen PT, Scholz DG, Edwards WD: Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984, 59:17–20.PubMedGoogle Scholar
  21. 21.
    Overell JR, Bone I, Lees KR: Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology 2000, 55:1172–1179.PubMedGoogle Scholar
  22. 22.
    Homma S, Sacco RL, Di Tullio MR, for the PFO in Cryptogenic Stroke Study (PICSS) Investigators: Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in cryptogenic stroke study. Circulation 2002, 105:2625–2631.PubMedCrossRefGoogle Scholar
  23. 23.
    Siostrzonek P, Zangeneh M, Gossinger H, et al.: Comparison of transesophageal and transthoracic contrast echocardiography for detection of a patent foramen ovale. Am J Cardiol 1991, 68:1247–1249.PubMedCrossRefGoogle Scholar
  24. 24.
    Tunick PA, Perez JL, Kronzon I: Protruding atheromas in the thoracic aorta and systemic embolization. Ann Inter Med 1991, 115:423–427.Google Scholar
  25. 25.
    SPAF III Investigators: Transesophageal echocardiographic correlates of thromboembolism in high-risk patients with nonvalvular atrial fibrillation. Ann Intern Med 1998, 128:639–647.Google Scholar
  26. 26.
    Amarenco P, Cohen A, Tzourio C, et al.: Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med 1994, 331:1474–1479.PubMedCrossRefGoogle Scholar
  27. 27.
    Karalis DG, Chandrasekaran K, Victor MF, et al.: Recognition and embolic potential of intraaortic atherosclerotic debris. J Am Coll Cardiol 1991, 17:73–78.PubMedCrossRefGoogle Scholar
  28. 28.
    Karalis DG, Quinn V, Victor MF, et al.: Risk of catheter-related emboli in patients with atherosclerotic debris in the thoracic aorta. Am Heart J 1996, 131:1149–1155.PubMedCrossRefGoogle Scholar
  29. 29.
    Katz ES, Tunick PA, Rusinek H, et al.: Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography. J Am Coll Cardiol 1992, 20:70–77.PubMedCrossRefGoogle Scholar
  30. 30.
    Vaduganathan P, Ewton A, Nagueh SF, et al.: Pathologic correlates of aortic plaques, thrombi and mobile “aortic debris” imaged in vivo with transesophageal echocardiography. J Am Coll Cardiol 1997, 30:357–363.PubMedCrossRefGoogle Scholar
  31. 31.
    Dressler FA, Craig WR, Castello R, et al.: Mobile aortic atheroma and systemic emboli: efficacy of anticoagulation and influence of plaque morphology on recurrent stroke. J Am Coll Cardiol 1998, 31:134–138.PubMedCrossRefGoogle Scholar
  32. 32.
    Ferrari E, Vidal R, Chevallier T, Baudouy M: Atherosclerosis of the thoracic aorta and aortic debris as a marker of poor prognosis: benefit of oral anticoagulants. J Am Coll Cardiol 1999, 33:1317–1322.PubMedCrossRefGoogle Scholar
  33. 33.
    Das A, Sivak M, Chak A: Cervical esophageal perforation during EUS: a national survey. Gastrointest Endosc 2001, 53:599–602.PubMedCrossRefGoogle Scholar
  34. 34.
    Mooe T, Eriksson P, Stegmayr B: Ischemic stroke after acute myocardial infarction: a population-based study. Stroke 1997, 28:762–767.PubMedGoogle Scholar
  35. 35.
    Mooe T, Olofsson BO, Stegmayr B, Eriksson P: Ischemic stroke: impact of a recent myocardial infarction. Stroke 1999, 30:997–1001.PubMedGoogle Scholar
  36. 36.
    Lichtman JH, Krumholz HM, Wang Y, et al.: Risk and predictors of stroke after myocardial infarction among the elderly: results from the Cooperative Cardiovascular Project. Circulation 2002, 105:1082–1087.PubMedCrossRefGoogle Scholar
  37. 37.
    SPAF III Investigators: Transesophageal echocardiographic correlates of thromboembolism in high-risk patients with nonvalvular atrial fibrillation. Ann Intern Med 1998, 128:639–647.Google Scholar
  38. 38.
    Black IW, Hopkins AP, Lee LC, Walsh WF: Left atrial spontaneous echo contrast: a clinical and echocardiographic analysis. J Am Coll Cardiol 1991, 18:398–404.PubMedCrossRefGoogle Scholar
  39. 39.
    Orsinelli DA, Pearson AC: Detection of prosthetic valve strands by transesophageal echocardiography: clinical significance in patients with suspected cardiac source of embolism. J Am Coll Cardiol 1995, 26:1713–1718.PubMedCrossRefGoogle Scholar
  40. 40.
    Homma S, Di Tullio MR, Sciacca RR, for the PICSS Investigators: Effect of aspirin and warfarin therapy in stroke patients with valvular strands. Stroke 2004, 35:1436–1442.PubMedCrossRefGoogle Scholar
  41. 41.
    Roberts JK, Omarali I, Di Tullio MR, et al.: Valvular strands and cerebral ischemia: effect of demographics and strand characteristics. Stroke 1997, 28:2185–2188.PubMedGoogle Scholar
  42. 42.
    Barbut D, Borer JS, Wallerson D, et al.: Anticardiolipin antibody and stroke: possible relation of valvular heart disease and embolic events. Cardiology 1991, 79:99–109.PubMedGoogle Scholar
  43. 43.
    Brenner B, Blumenfeld Z, Markiewicz W, Reisner SA: Cardiac involvement in patients with primary antiphospholipid syndrome. J Am Coll Cardiol 1991, 18:931–936.PubMedCrossRefGoogle Scholar
  44. 44.
    Asherson RA, Khamashta MA, Gil A, et al.: Cerebrovascular disease and antiphospholipid antibodies in systemic lupus erythematosus, lupus-like disease, and the primary antiphospholipid syndrome. Am J Med 1989, 86:391–399.PubMedCrossRefGoogle Scholar
  45. 45.
    Rogers LR, Cho ES, Kempin S, Posner JB: Cerebral infarction from non-bacterial thrombotic endocarditis. Clinical and pathological study including the effects of anticoagulation. Am J Med 1987, 83:746–756.PubMedCrossRefGoogle Scholar
  46. 46.
    Szekely P: Systemic embolism and anticoagulant prophylaxis in rheumatic heart disease. BMJ 1964, 5392:1209–1212.CrossRefGoogle Scholar
  47. 47.
    Boon A, Lodder J, Cheriex E, Kessels F: Mitral annulus calcification is not an independent risk factor for stroke: a cohort study of 657 patients. J Neurol 1997, 244:535–541.PubMedCrossRefGoogle Scholar
  48. 48.
    Gilon D, Buonanno FS, Joffe MM, et al.: Lack of evidence of an association between mitral-valve prolapse and stroke in young patients. N Engl J Med 1999, 341:8–13.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2005

Authors and Affiliations

  • Timothy D. Woods
    • 1
  1. 1.Cardiology Section, Department of Internal MedicineMedical College of WisconsinMilwaukeeUSA

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