Skip to main content
PMC home page
British Heart Journal logoLink to British Heart Journal
. 1992 Apr;67(4):297–303. doi: 10.1136/hrt.67.4.297

Limitations of transoesophageal echocardiography in patients with focal cerebral ischaemic events.

M A de Belder 1, L B Lovat 1, L Tourikis 1, G Leech 1, A J Camm 1
PMCID: PMC1024836  PMID: 1389703

Abstract

OBJECTIVE--To investigate the detection rate of cardiac sources of embolism by transoesophageal echocardiography in patients with focal cerebral ischaemic events and to relate the echocardiographic findings to other clinical findings. DESIGN--Prospective study with blinded analysis of the echocardiographic data and subsequent comparison with the other clinical findings. SETTING--Regional cardiothoracic unit based in a teaching hospital. PATIENTS--131 consecutive patients with focal ischaemic cerebral events (49 with a transient ischaemic attack, 77 with a cerebrovascular accident, and five with a retinal arterial embolus) referred for echocardiography. INTERVENTIONS--Full M mode, cross sectional, Doppler, and contrast echocardiography by both the precordial and transoesophageal techniques. RESULTS--Precordial echocardiography detected a cardiac abnormality in 72 patients. Transoesophageal echocardiography confirmed all the precordial findings (except left ventricular hypertrophy, which at present cannot be defined with this technique) and detected other abnormalities in a further 20 patients (18 with potential right-to-left shunts and two with valve vegetations). It also showed spontaneous contrast echoes in 27 of 28 patients with a large left atrium and showed atrial thrombus in three. Cardiac abnormalities were clinically detected in 53 patients, all of which were confirmed or documented by echocardiography. In the 78 patients with no clinically detectable cardiac abnormality six had mitral valve prolapse and one had a regional wall motion defect (identified by precordial echocardiography) and 17 had potential right-to-left shunts (11 of which were identified only by transoesophageal echocardiography). CONCLUSIONS--Transoesophageal echocardiography is more sensitive than precordial echocardiography in detecting potential sources of embolism in these patients. However, except for the detection of a potential right-to-left shunt, the yield in patients with no cardiac abnormality is low. Moreover, the abnormalities detected in those with previously detected cardiac disease merely confirm the clinical diagnosis. Patients with left atrial spontaneous contrast echoes may benefit from anticoagulation but this requires further study. Until more data are available on this feature and on the role of potential right-to-left shunts in this population, the contribution of echocardiography, precordial or transoesophageal, remains limited.

Full text

PDF

Images in this article

299Image
on p.299
299Image
on p.299

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Aschenberg W., Schlüter M., Kremer P., Schröder E., Siglow V., Bleifeld W. Transesophageal two-dimensional echocardiography for the detection of left atrial appendage thrombus. J Am Coll Cardiol. 1986 Jan;7(1):163–166. doi: 10.1016/s0735-1097(86)80275-3. [DOI] [PubMed] [Google Scholar]
  2. Asinger R. W., Mikell F. L., Sharma B., Hodges M. Observations on detecting left ventricular thrombus with two dimensional echocardiography: emphasis on avoidance of false positive diagnoses. Am J Cardiol. 1981 Jan;47(1):145–156. doi: 10.1016/0002-9149(81)90303-9. [DOI] [PubMed] [Google Scholar]
  3. Bansal R. C., Heywood J. T., Applegate P. M., Jutzy K. R. Detection of left atrial thrombi by two-dimensional echocardiography and surgical correlation in 148 patients with mitral valve disease. Am J Cardiol. 1989 Jul 15;64(3):243–246. doi: 10.1016/0002-9149(89)90470-0. [DOI] [PubMed] [Google Scholar]
  4. Beppu S., Nimura Y., Sakakibara H., Nagata S., Park Y. D., Izumi S. Smoke-like echo in the left atrial cavity in mitral valve disease: its features and significance. J Am Coll Cardiol. 1985 Oct;6(4):744–749. doi: 10.1016/s0735-1097(85)80476-9. [DOI] [PubMed] [Google Scholar]
  5. Blackwood W., Hallpike J. F., Kocen R. S., Mair W. G. Atheromatous disease of the carotid arterial system and embolism from the heart in cerebral infarction: a morbid anatomical study. Brain. 1969;92(4):897–910. doi: 10.1093/brain/92.4.897. [DOI] [PubMed] [Google Scholar]
  6. Burnett P. J., Milne J. R., Greenwood R., Giles M. R., Camm J. The role of echocardiography in the investigation of focal cerebral ischaemia. Postgrad Med J. 1984 Feb;60(700):116–119. doi: 10.1136/pgmj.60.700.116. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. CARTER A. B. The immediate treatment of cerebral embolism. Q J Med. 1957 Jul;26(103):335–348. [PubMed] [Google Scholar]
  8. Daniel W. G., Nellessen U., Schröder E., Nonnast-Daniel B., Bednarski P., Nikutta P., Lichtlen P. R. Left atrial spontaneous echo contrast in mitral valve disease: an indicator for an increased thromboembolic risk. J Am Coll Cardiol. 1988 Jun;11(6):1204–1211. doi: 10.1016/0735-1097(88)90283-5. [DOI] [PubMed] [Google Scholar]
  9. Donaldson R. M., Emanuel R. W., Earl C. J. The role of two-dimensional echocardiography in the detection of potentially embolic intracardiac masses in patients with cerebral ischaemia. J Neurol Neurosurg Psychiatry. 1981 Sep;44(9):803–809. doi: 10.1136/jnnp.44.9.803. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Frazin L., Talano J. V., Stephanides L., Loeb H. S., Kopel L., Gunnar R. M. Esophageal echocardiography. Circulation. 1976 Jul;54(1):102–108. doi: 10.1161/01.cir.54.1.102. [DOI] [PubMed] [Google Scholar]
  11. GROCH S. N., McDEVITT E., WRIGHT I. S. A long-term study of cerebral vascular disease. Ann Intern Med. 1961 Sep;55:358–367. doi: 10.7326/0003-4819-55-3-358. [DOI] [PubMed] [Google Scholar]
  12. Harvey J. R., Teague S. M., Anderson J. L., Voyles W. F., Thadani U. Clinically silent atrial septal defects with evidence for cerebral embolization. Ann Intern Med. 1986 Nov;105(5):695–697. doi: 10.7326/0003-4819-105-5-695. [DOI] [PubMed] [Google Scholar]
  13. Humphrey R. D., Harrison M. J. How often can an embolic stroke be diagnosed clinically? A clinicopathological correlation. Postgrad Med J. 1985 Dec;61(722):1039–1042. doi: 10.1136/pgmj.61.722.1039. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Knopman D. S., Anderson D. C., Asinger R. W., Greenland P., Mikell F., Good D. C. Indications for echocardiography in patients with ischemic stroke. Neurology. 1982 Sep;32(9):1005–1011. doi: 10.1212/wnl.32.9.1005. [DOI] [PubMed] [Google Scholar]
  15. Kopecky S. L., Gersh B. J., McGoon M. D., Whisnant J. P., Holmes D. R., Jr, Ilstrup D. M., Frye R. L. The natural history of lone atrial fibrillation. A population-based study over three decades. N Engl J Med. 1987 Sep 10;317(11):669–674. doi: 10.1056/NEJM198709103171104. [DOI] [PubMed] [Google Scholar]
  16. Lechat P., Mas J. L., Lascault G., Loron P., Theard M., Klimczac M., Drobinski G., Thomas D., Grosgogeat Y. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med. 1988 May 5;318(18):1148–1152. doi: 10.1056/NEJM198805053181802. [DOI] [PubMed] [Google Scholar]
  17. Lovett J. L., Sandok B. A., Giuliani E. R., Nasser F. N. Two-dimensional echocardiography in patients with focal cerebral ischemia. Ann Intern Med. 1981 Jul;95(1):1–4. doi: 10.7326/0003-4819-95-1-1. [DOI] [PubMed] [Google Scholar]
  18. MacMahon S., Peto R., Cutler J., Collins R., Sorlie P., Neaton J., Abbott R., Godwin J., Dyer A., Stamler J. Blood pressure, stroke, and coronary heart disease. Part 1, Prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet. 1990 Mar 31;335(8692):765–774. doi: 10.1016/0140-6736(90)90878-9. [DOI] [PubMed] [Google Scholar]
  19. Mikell F. L., Asinger R. W., Elsperger K. J., Anderson W. R., Hodges M. Regional stasis of blood in the dysfunctional left ventricle: echocardiographic detection and differentiation from early thrombosis. Circulation. 1982 Oct;66(4):755–763. doi: 10.1161/01.cir.66.4.755. [DOI] [PubMed] [Google Scholar]
  20. Nishimura R. A., McGoon M. D., Shub C., Miller F. A., Jr, Ilstrup D. M., Tajik A. J. Echocardiographically documented mitral-valve prolapse. Long-term follow-up of 237 patients. N Engl J Med. 1985 Nov 21;313(21):1305–1309. doi: 10.1056/NEJM198511213132101. [DOI] [PubMed] [Google Scholar]
  21. Parker J. O., Vankoughnett K. A., Farrell B. Nitroglycerin lingual spray: clinical efficacy and dose-response relation. Am J Cardiol. 1986 Jan 1;57(1):1–5. doi: 10.1016/0002-9149(86)90940-9. [DOI] [PubMed] [Google Scholar]
  22. Petersen P., Boysen G., Godtfredsen J., Andersen E. D., Andersen B. Placebo-controlled, randomised trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation. The Copenhagen AFASAK study. Lancet. 1989 Jan 28;1(8631):175–179. doi: 10.1016/s0140-6736(89)91200-2. [DOI] [PubMed] [Google Scholar]
  23. Pop G., Sutherland G. R., Koudstaal P. J., Sit T. W., de Jong G., Roelandt J. R. Transesophageal echocardiography in the detection of intracardiac embolic sources in patients with transient ischemic attacks. Stroke. 1990 Apr;21(4):560–565. doi: 10.1161/01.str.21.4.560. [DOI] [PubMed] [Google Scholar]
  24. Ports T. A., Cogan J., Schiller N. B., Rapaport E. Echocardiography of left ventricular masses. Circulation. 1978 Sep;58(3 Pt 1):528–536. doi: 10.1161/01.cir.58.3.528. [DOI] [PubMed] [Google Scholar]
  25. Sandercock P. A., Warlow C. P., Jones L. N., Starkey I. R. Predisposing factors for cerebral infarction: the Oxfordshire community stroke project. BMJ. 1989 Jan 14;298(6666):75–80. doi: 10.1136/bmj.298.6666.75. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Schlüter M., Hinrichs A., Thier W., Kremer P., Schröder S., Cahalan M. K., Hanrath P. Transesophageal two-dimensional echocardiography: comparison of ultrasonic and anatomic sections. Am J Cardiol. 1984 Apr 1;53(8):1173–1178. doi: 10.1016/0002-9149(84)90657-x. [DOI] [PubMed] [Google Scholar]
  27. Seward J. B., Khandheria B. K., Oh J. K., Abel M. D., Hughes R. W., Jr, Edwards W. D., Nichols B. A., Freeman W. K., Tajik A. J. Transesophageal echocardiography: technique, anatomic correlations, implementation, and clinical applications. Mayo Clin Proc. 1988 Jul;63(7):649–680. doi: 10.1016/s0025-6196(12)65529-3. [DOI] [PubMed] [Google Scholar]
  28. Sherman D. G., Dyken M. L., Fisher M., Harrison M. J., Hart R. G. Cerebral embolism. Chest. 1986 Feb;89(2 Suppl):82S–98S. doi: 10.1378/chest.89.2_supplement.82s. [DOI] [PubMed] [Google Scholar]
  29. Shrestha N. K., Moreno F. L., Narciso F. V., Torres L., Calleja H. B. Two-dimensional echocardiographic diagnosis of left-atrial thrombus in rheumatic heart disease. A clinicopathologic study. Circulation. 1983 Feb;67(2):341–347. doi: 10.1161/01.cir.67.2.341. [DOI] [PubMed] [Google Scholar]
  30. TORVIK A., JOERGENSEN L. THROMBOTIC AND EMBOLIC OCCLUSIONS OF THE CAROTID ARTERIES IN AN AUTOPSY MATERIAL. I. PREVALENCE, LOCATION AND ASSOCIATED DISEASES. J Neurol Sci. 1964 Jan-Feb;1(1):24–39. doi: 10.1016/0022-510x(64)90052-8. [DOI] [PubMed] [Google Scholar]
  31. Webster M. W., Chancellor A. M., Smith H. J., Swift D. L., Sharpe D. N., Bass N. M., Glasgow G. L. Patent foramen ovale in young stroke patients. Lancet. 1988 Jul 2;2(8601):11–12. doi: 10.1016/s0140-6736(88)92944-3. [DOI] [PubMed] [Google Scholar]
  32. Zenker G., Erbel R., Krämer G., Mohr-Kahaly S., Drexler M., Harnoncourt K., Meyer J. Transesophageal two-dimensional echocardiography in young patients with cerebral ischemic events. Stroke. 1988 Mar;19(3):345–348. doi: 10.1161/01.str.19.3.345. [DOI] [PubMed] [Google Scholar]
  33. de Belder M. A., Leech G., Camm A. J. Transesophageal echocardiography in unsedated outpatients: technique and patient tolerance. J Am Soc Echocardiogr. 1989 Nov-Dec;2(6):375–379. doi: 10.1016/s0894-7317(89)80037-9. [DOI] [PubMed] [Google Scholar]
  34. de Bono D. P., Warlow C. P. Mitral-annulus calcification and cerebral or retinal ischaemia. Lancet. 1979 Aug 25;2(8139):383–385. doi: 10.1016/s0140-6736(79)90402-1. [DOI] [PubMed] [Google Scholar]

Articles from British Heart Journal are provided here courtesy of BMJ Publishing Group

RESOURCES