Abstract
To evaluate the additional value of biplane transesophageal (TEE) compared to transthoracic (TTE) echo and the role of patent foramen ovale (PFO) and deep vein thrombosis (DVT) in the work-up of embolic events, patients (pts) with presumed cardiac embolic stroke or transient ischemic attack (TIA) (neurovascular etiology was excluded by dopplersonography) were prospectively studied by transthoracic and transesophageal contrast echo and phlebography if PFO was present. 220 pts, 136 men (60 ± 15 years) were studied. In 140 of 220 pts neuroimaging showed evidence of manifest stroke. TEE identified a potential cardiac source of embolism (left atrial thrombus [LAT], PFO, atrial septal aneurysm [ASA], spontaneous contrast [SC] endocarditic valve lesions, mitral valvular disease [MVD] and prosthetic head valves) in 43% of pts compared with only 18% by TTE (p < 0.01). TEE was especially superior compared to TTE for identifying LAT (10 versus 0 pts), SC (26 vs 6 pts), PFO associated with ASA (16 vs 6 pts) and PFO alone (34 vs 20 pts). Phlebography was performed in 50 pts with PFO. Of those pts 32 showed brain infarct ≥ 1 cm diameter on neuroimaging, 18 pts had TIA. Phlebography revealed clinically silent DVT only in pts with brain infarct (4 cases, 12.5%), no pt with TIA had positive phlebography. In this prospective study TEE detected significantly more potential sources of embolism than TTE; moreover, phlebography in the presence of PFO and a clear-cut ischemic brain lesion on neuroimaging revealed a 12.5% incidence of clinically unsuspected deep venous thrombosis. These findings strongly suggest paradoxical embolism as an important mechanism of stroke and support phlebography to define the relevance of PFO in the stepwise work-up of pts with suspected cardiogenic stroke.
Published Version
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