Impact of transesophageal echocardiography on clinical management of patients over age 50 with cryptogenic stroke and normal transthoracic echocardiogram.

Abstract

The utility of transesophageal echocardiography (TEE) subsequent to a normal transthoracic echocardiogram (TTE) in older patients with an unexplained stroke is uncertain. Two hundred sixty-three consecutive patients over the age of 50 years hospitalized with a clinical stroke confirmed with brain magnetic resonance imaging and a normal TTE were retrospectively analyzed. Patients with atrial fibrillation, atrial flutter, or any other causative reason for stroke were excluded. TEE was analyzed for findings that could explain the etiology of stroke as well as findings that would change therapy based on current guidelines. Baseline characteristics included a mean age of 66.7 years (range, 50-91 years); 42.5% of patients were female. A possible etiology of stroke was discovered by TEE in 111 (42.2%) patients and included 1 or more of the following: complex plaque of the ascending aorta or arch, patent foramen ovale, atrial septal aneurysm, both atrial septal aneurysm and patent foramen ovale, or spontaneous contrast. Only 1 patient (0.4%) had a finding that changed immediate management, which was a thrombus in the left atrial appendage for which anticoagulation was prescribed. Follow-up was available at 6 months on 85 patients, of whom 13 (15%) had been discovered to have developed atrial fibrillation. In our study population, when performed subsequent to a normal TTE in patients aged >50 years with cryptogenic stroke, TEE demonstrated a high diagnostic value, but had minimal incremental effect on patient management.