Transesophageal Echocardiography Reports Research Articles

Abstract TMP39: Paucity of Evidence-Based Patent Foramen Ovale Severity Ratings in Transesophageal Echocardiogram Clinical Reports

Introduction: The presence of a large physiologic shunt, defined as >20 left atrial microbubbles within 3 cardiac cycles on transesophageal echocardiography (TEE), is a key, randomized controlled trial-validated, indication for patent foramen ovale (PFO) with a closure device in patients with otherwise cryptogenic ischemic stroke. The frequency with which this information is available to treating physicians from clinical TEE reports has not been well delineated. Methods: Among consecutive ischemic stroke patients admitted to an academic medical center undergoing TEE between January-June 2023, TEE reports were reviewed to determine frequency with which formal, clinical-trial definition-adherent characterization of PFO shunt size was provided, frequency of informal PFO shunt size descriptions, and correlations with transcranial Doppler (TCD) formal shunt grades (Spencer Grades 1-5). Results: Among the 50 patients, median age was 64 (IQR 58-74.5), and 20 (40%) were female. On TEE, shunt presence was assessed by bubble study in 38 (76%), direct Doppler alone in 6 (12%), and neither in 6 (12%). Among patients with bubble study, a right-to-left shunt (RLS) potentially due to PFO was present 15 (39%). RLS severity was quantified in 27% (4/15) of PFO patients, all with formally small (<20) shunts. For the remaining 11, reports informally characterized shunt severity with various descriptive terms, including “mild” (7 cases), “mild/trace” (1), “moderate” (2), and “large” (1). TCD bubble studies were performed in 67% (10/15) of the TEE RLS PFO patients. Shunt severity correlation between TEE and TCD was 100% (3/3) for the formally quantified TEE shunts, but poor for the 7 informally assessed TEE shunts, with 60% (3/5) of shunts deemed “mild” on TEE quantified as intermediate-large on TCD, 1/1 deemed “moderate” on TEE quantified as intermediate on TCD, and 1/1 deemed “large” on TEE quantified as miniscule on TCD. Conclusions: Quantified, evidence-based ratings of PFO shunt severity were present in less than 3 of every 10 TEE reports, and unquantified, informal size estimates correlated poorly with TCD quantification of shunt severity. Patient management would be aided by inclusion of formal PFO shunt size quantification in all clinical stroke patient TEE reports.

Abstract 18187: Scoring System to Predict Reduced Left Atrial Appendage Emptying Velocity

Introduction: Left atrial appendage emptying velocity (LAAev) as assessed on transesophageal echocardiography (TEE) is a surrogate for propensity for LAA thrombus and cardioembolic stroke. Identifying patients with decreased LAAev is important for risk stratification. CHA 2 DS 2 -VASc score is used to stratify stroke risk in atrial fibrillation (AF) but does not incorporate rhythm, type of atrial fibrillation or transthoracic echocardiography (TTE). Objective: To create a composite scoring system using clinical and TTE variables to predict reduced LAAev. Methods: We searched TEE reports of unique patients from 2016-2022 at the University of Kansas Medical Center. Additional information was extracted from review of TEE imaging, TTE reports and detailed medical chart review. Significant univariate predictors of reduced LAAev (<30 cm/s) were added to a stepwise selection multivariable logistic regression model with significance level for entry and stay 0.15. Based on their respective odds ratios, selected variables were assigned different point values to create a risk score. Results: We included 995 patients (women 38.1% men, age 71.3±12.7 yrs, white 89.3%, LAAev 41.6±21.0 cm/s). The derived score includes different points assigned for long-standing persistent/permanent AF, persistent AF, paroxysmal AF, current rhythm AF, coronary artery disease, congestive heart failure, female sex, age ≥70 yrs and negative points for >moderate mitral regurgitation; categorized into high, intermediate and low risk (see Figure). The rate of reduced LAAev <30 cm/s was respectively 55.7%, 35.2% and 9.0%. Conclusions: Our scoring system was able to stratify risk of reduced LAAev and needs to be validated in independent datasets.

Resuscitative transesophageal echocardiography during the acute resuscitation of trauma: A retrospective observational study

BackgroundResuscitative transesophageal echocardiography (TEE) is an emerging POCUS modality that can be used to guide trauma resuscitation. MethodsTrauma patients who underwent TEE within 24 h of admission from 2013 to 2022 were prospectively identified. We retrospectively analyzed resuscitative TEE reports and patient charts in duplicate. Results29 providers performed TEE for 54 acute trauma patients. 28 (52%) died in hospital; 33 (61%) required operative intervention (<24 h). Median injury severity score was 29 [IQR 22–43]. The most common indications for TEE were hemodynamic instability (34, 63%), inadequate windows for transthoracic echocardiography (14, 26%) and cardiac arrest (11, 20%). There were no identified complications. A new diagnosis was made in 31 (57%) cases: most commonly right ventricular dysfunction (10, 19%), pericardial effusion (9, 17%), and hypovolemia (6, 11%). TEE ruled out major cardiac injury in 83% of cases. TEE changed resuscitative strategy, in 17 (32%) patients, diagnostic imaging approach in 6 (11%) patients, procedural or operative approach in 5 (9%) patients and disposition from the trauma bay in 4 (7%) patients. ConclusionResuscitative TEE during acute trauma care has an additional diagnostic yield to existing diagnostic pathways and may impact definitive management for some patients in the trauma bay.

Yield of Echocardiography in Ischemic Stroke and Patients With Transient Ischemic Attack With Established Indications for Long-Term Direct Oral Anticoagulant Therapy: A Cross-Sectional Diagnostic Cohort Study.

BackgroundWe aimed to determine the diagnostic yield of transthoracic (TTE) and transesophageal echocardiography (TEE) in patients with ischemic stroke and transient ischemic attack with established indications for direct oral anticoagulants before the index event.Methods and ResultsThis was a retrospective cohort study of consecutive patients with preceding established indications for long‐term therapeutic direct oral anticoagulants presenting to a single comprehensive stroke center with ischemic stroke or transient ischemic attack. Choice of echocardiography modality was based on expert recommendations. The primary outcome was a composite of prespecified management‐relevant high‐risk findings adjudicated by an expert panel, based on TTE and TEE reports according to evidence‐based recommendations. Explorative analyses were performed to identify biomarkers associated with the primary outcome. Of 424 patients included (median [interquartile range] age, 78 [70–84] years; 175 [41%] women; National Institutes of Health Stroke Scale, 4 [1–12]; 67% atrial fibrillation), 292 (69%) underwent echocardiography, while 132 (31%) did not. Modality was TTE in 191 (45%) and TEE in 101 (24%). Median time from index event to echocardiography was 2 (1–3) days. TTE identified 26 of 191 (14%) patients with 35 management‐relevant pathologies. TEE identified 16 of 101(16%) patients with 20 management‐relevant pathologies. Most management‐relevant findings represented indicated coronary artery disease and valvular pathologies. In a further 3 of 191 (2%) patients with TTE and 4 of 101 (4%) patients with TEE, other relevant findings were identified. Variables associated with management‐relevant high‐risk pathologies included more severe stroke, diabetes, and laboratory biomarkers (NT‐proBNP [N‐terminal pro‐B‐type natriuretic peptide], C‐reactive protein, d‐dimer, and troponin levels).ConclusionsIn patients with established indications for long‐term direct oral anticoagulant therapy and stroke who received echocardiography, both TTE and TEE identified a relevant and similar proportion of management‐relevant high‐risk pathologies and predictive biomarkers could help to guide diagnostic workup in such patients.

The Effect of Transoesophageal Echocardiography on Treatment Change in a High-Volume Stroke Unit.

Background and purpose—current guidelines recommend the use of transesophageal echocardiography (TEE) in relation to cardio-embolic sources of stroke. Methods—by using an hospital-based cohort, we retrospectively analyzed consecutive patients with acute ischemic stroke (AIS), acute hemorrhagic stroke (AHS) and transient ischemic attack (TIA) who were admitted in Strasbourg Stroke Center, France between November 2017 to December 2018. TEE reports were screened for detection of potential cardiac sources of embolism and the subsequent change in medical management. We performed univariate and multivariate analyses to identify predictors of relevant TEE findings. Results-out of the 990 patients admitted with confirmed stroke, 432 patients (42.6%) underwent TEE. Patients with TEE were younger (62.8 ± 14.8 vs. 73.8, p < 0.001), presented less comorbidities and lower stroke severity assessed by lower NIHSS (2 IQR (0–4) vs. 3 IQR (0–10), p < 0.01) and Modified Rankin Scale (1 IQR (0–1) vs. 1 (0–3), p < 0.01). A total of 227 examinations (52.5%) demonstrated abnormal findings considered as potential cardiac sources of embolism and 31 examinations (7.1%) were followed by subsequent change in medical management. Age (HR: 0.948, 95% CI 0.923 to 0.974; p < 0.001), previous AIS (HR: 3.542, 95% CI 1.290 to 9.722; p = 0.01), previous TIA (HR: 7.830, CI 95% 2214 to 27,689; p = 0.001) and superficial middle cerebral artery territory infarction (HR: 2.774, CI 95% 1.168–6.589; p = 0.021) were strong independent predictors with change in medical management following TEE. Conclusions—additional TEE changed the medical course of stroke patients in 7.1% in a French high-volume stroke unit.

The Safety and Feasibility of Transesophageal Echocardiography in Patients With Esophageal Stricture

Expert guidelines consistently list esophageal stricture (ES) as a contraindication to the performance of transesophageal echocardiography (TEE), although anecdotally the authors are aware of patients with ES undergoing TEE without apparent complication. Therefore the authors sought to determine the outcomes of patients with ES who had undergone TEE at their institution. Single-center, retrospective review. Academic medical center (clinic and affiliated hospital). Patients with documented ES who also underwent TEE. None. In a 10-year period, 1,083 TEE reports were generated for 823 patients who had a diagnosis of ES. One case of esophageal perforation occurred (1/1,083 examination reports [0.09%]) in an 85-year-old male with gastroesophageal reflux disease-related ES who had undergone esophageal dilation the same day as the TEE. In 17.2% of the TEE reports reviewed, changes to the conduct of the examination occurred, such as use of a pediatric probe or avoidance of transgastric imaging. In 8% of reviewed examinations, procedural difficulty was recorded. Patients with nonmalignant ES commonly present for TEE (>100 per year, on average, at the authors' institution). Severe TEE-related esophageal injury rarely occurred in patients with ES. However, changes to the conduct of the TEE examination and procedural difficulty were not infrequent in this group. Clinicians contemplating TEE in patients with ES should prepare for the possibility of altered examination conduct and possible procedural difficulty.

Patent foramen ovale prevalence in atrial fibrillation patients and its clinical significance; A single center experience

BackgroundPatent foramen ovale (PFO) has been reported in 25–30% of the general population. The most commonly used test for detecting PFO is a contrast enhanced transesophageal echocardiography (TEE). PFO presence can be confirmed during pulmonary vein isolation (PVI) procedure by passing the transseptal catheter assembly through the foramen ovale, crossing the septum from the right to the left atrium without using a trans-septal needle for puncture. MethodsWe retrospectively reviewed data from a cohort of 178 patients with AF who underwent PVI at Saint Louis University. Pre-PVI procedure, scheduled TEE reports were reviewed to assess for the presence of PFO and the PVI procedure reports were reviewed for confirmation. ResultsRecords of 178 patients (55.6% male, mean population age 60.4 ± 11.8) were reviewed. 102 of 178 patients had a PFO detected during the PVI procedure. This translates into a 57.3% prevalence of PFO in AF patients. Out of the 178 patients, 75 patients had a pre-PVI procedure TEE for whom PFO presence was reported in 18.7%. The sensitivity and specificity of TEE in detection of PFO were 36.8% and 100%, respectively. There was no statistically significant association between stroke and PFO diagnosed during PVI (RR 1.07; 95% CI, 0.53–2.19; P = 0.805). ConclusionsOur study reports a PFO prevalence of 18.7% using a pre-procedure TEE and 56.6% during the PVI procedure in AF patients. Given that TEE is the gold standard for detection of PFO, our study suggests that the prevalence of PFO may be underestimated in our AF population.

Use of the Valve Visualization on Echocardiography Grade Tool Improves Sensitivity and Negative Predictive Value of Transthoracic Echocardiogram for Exclusion of Native Valvular Vegetation

Transesophageal echocardiography (TEE) remains the preferred test to rule out infective endocarditis (IE) but is resource intensive and carries risk. Multiple studies report low sensitivity of transthoracic echocardiography (TTE) for detection of IE; however, these studies did not account for TTE quality. We test the validity of a simple valve visualization grading tool to stratify TTEs by quality and determine whether a high-quality TTE may be used to exclude valvular vegetation and forgo the need for TEE. The Valve Visualization on Echocardiography Grade (VEG) tool scores the TTE from 0 to 10 based on leaflet visualization and valve leaflet clarity. The tool was retrospectively applied to 309 sequential patients who underwent both TTE and TEE at an academic teaching hospital between 2011 and 2015. The TEE report was the gold standard for presence or absence of vegetation. Patients with prosthetic valves and pacemaker wires were excluded. Sensitivity of TTE for detecting vegetation was calculated at each VEG score, and the optimal cutoff was identified. A total of 309 patients were included in the analysis. Among the 216 negative TTEs, 19 (9%) had a positive TEE. The median VEG score was 4. A VEG score cutoff >6 provided optimal sensitivity and was used as the cutoff. Overall, 75 (25%) patients had a VEG score >6, and 234 (75%) had a score ≤6. Sensitivity and negative predictive value for IE were higher in the VEG >6 versus VEG ≤6 group (sensitivity 96% vs 66%, negative predictive value 97.5% vs 90%; P<.05). The false-negative rate was lower (2.5% vs 10%; P=.04) in VEG>6 versus VEG≤6 groups, respectively. Leaflet visualization and valve leaflet clarity are important components in the TTE evaluation of patients with suspected IE. This study demonstrates that the better the valve leaflets are visualized on TTE (as represented in this population by a score >6), the higher the confidence one can have that the TTE will not be falsely negative for vegetation(s) when vegetation(s) are not noted on these TTEs. If validated in future prospective studies, this may reduce the need to perform an invasive TEE in selected patients undergoing evaluation for native valve IE.

USE OF THE VALVE VISUALIZATION ON ECHOCARDIOGRAPHY GRADE (VVEG) TOOL IMPROVES NEGATIVE PREDICTIVE VALUE OF TRANSTHORACIC ECHOCARDIOGRAM FOR RULING OUT VALVULAR VEGETATION

Transesophageal echocardiography (TEE) remains the preferred diagnostic test to rule out infective endocarditis (IE), but is resource intensive and carries risk. Studies reporting low sensitivity of transthoracic echocardiography (TTE) for detection of IE did not use modern echo techniques, and do not take into account TTE quality. A good quality TTE may be sufficient to rule out IE in the absence of high risk clinical features. Reported technical adequacy of a TTE is variable amongst interpreters. No standardized method exists to assess TTE quality for ruling out valvular vegetation. Sequential patients who underwent TTE and TEE to rule out IE at an academic teaching hospital from 2011-2015 were identified. All studies were performed with modern echo machines. Patients with prosthetic valves and pacemaker wires were excluded. The Valve Visualization on Echocardiography Grade(VVEG) tool was developed by expert consensus after a thorough literature review. The score assigns each valve a score from 0-3 for mitral, tricuspid and aortic valves, and 0-1 for pulmonic, reflecting leaflet visibility and presence of orthogonal views, for a total score from 0-10. Each TTE was blindly graded using the tool. Reported technical difficulty and presence of vegetation was obtained from the TTE report. The TEE report was used as a gold standard for vegetation. 511 patients were identified, 316 TTE/TEE pairs were evaluated after exclusions. The average age was 65 and 67% had positive blood cultures. The average VVEG score was 4.5(SD+/-2.8). Overall, 20%(65) of TTEs were positive for vegetation, 69%(219) were negative, 10%(32) were indeterminate. Of the negative TTEs, 9%(19) went on to have positive TEEs. Overall, TTE had a sensitivity of 72%, a specificity of 93%, and a negative predictive value (NPV) of 91%. TTEs reported technically adequate had a sensitivity of 85% and NPV of 94% for detecting vegetation. Receiver operator characteristic analysis determined a cut off of >6 on the VVEG score was optimal for sensitivity. 24%(77) of patients had VVEG scores > 6; 38%(29) had positive TTEs for vegetation, 52%(40) had negative TTEs, and 10%(8) were indeterminate. A TTE with a VVEG score of > 6 had a sensitivity of 96% and an NPV of 98%. Applying the VVEG score increased the sensitivity of TTE from 72% to 96%. While this tool requires further validation, this demonstrates that when TTE quality is assessed by an objective measure, a high quality TTE can safely rule out vegetation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Diagnostic Impact of Transesophageal Echocardiography in Patients with Acute Cerebral Ischemia.

Transesophageal echocardiography (TEE) is the diagnostic gold standard for the detection of structural heart diseases as potential sources of cardiac emboli in patients with acute cerebral ischemia. We sought to determine the diagnostic yield of TEE in patients with acute ischemic stroke or transient ischemic attack (TIA). We retrospectively analyzed consecutive patients with acute cerebral ischemia who were admitted to our hospital between October 2008 and December 2011. TEE reports were screened for detection of cardiac source of embolism judged by the recommendation to change medical management. We performed univariate and multivariate analyses to identify predictors of clinically relevant TEE findings among baseline characteristics. Of 3314 patients with ischemic stroke or TIA, TEE was performed in 791 (24%) patients (mean age 64 ± 13 years, 589 [74%] ischemic stroke, 202 [26%] TIA). A potential cardioembolic source was found in 71 (9%) patients with patent foramen ovale with atrial septal aneurysm being the most common finding (24/71 patients, 34%). In multivariate analysis, peripheral vascular disease (OR 2.57; 95%CI 1.00-6.61), imaging evidence of infarction in multiple locations (OR 4.13; 95%CI 1.36-12.58), and infarction in the posterior circulation (OR 2.11; 95%CI 1.01-4.42) were associated with the identification of a potential cardioembolic source with TEE. TEE identified a potential structural cardioembolic source in nearly 10% of our selected patient population with acute ischemic stroke or TIA, thus underlining its diagnostic value. Our data suggest that patients with hitherto unknown stroke etiology should be considered for additional TEE.

Transesophageal echocardiography experience in thepediatric age group in a tertiary cardiac center.

The aim of this study was to evaluate the transesophageal echocardiography (TEE) findings of pediatric patients in a tertiary center where complex congenital heart surgery and interventional procedures have been performed. All TEE studies performed between December 2009 and December 2014 were reviewed retrospectively. Patients were divided into 3 groups: perioperative, during interventional procedures, and due to other reasons. Demographic features, transthoracic echocardiography (TTE) reports, TEE reports, change in decision after TEE evaluation, and related complications were recorded. A total of 703 patients who had TEE evaluation were included in the study; 51% were female and 49% were male. The median age was 90 months (2 months to 18 years). TEE was performed perioperatively in 430 patients (61%), during cardiac catheterization-angiography and electrophysiology studies in 181 patients (26%), and due to other reasons in 92 patients (13%). Mismatches between TTE and TEE or changes in decision after TEE evaluation were present in 45 patients (10.4%) who had perioperative TEE, in 10 patients (5.5%) who had TEE during interventional procedures, and 22 patients (24%) who had TEE evaluation due to other reasons. No major complications were detected. Information acquired by TEE increases the clarity of future plans for the patient and helps to decrease the mortality and morbidity caused by unnecessary procedures.

Abstract 17571: Use of Goal Directed Transesophageal Echocardiography in the Arresting Patient

Background: With outcomes from cardiac arrest remaining generally poor, there is an urgency to evaluate interventions that allow physicians to manage cardiac arrest more effectively. Transesophageal echocardiography (TEE) can be used at the point of care in a goal-directed manner and can rapidly provide a flurry of data on cardiac structure and function. TEE in the arrested patient is unobtrusive to resuscitation and can provide vital information regarding the potential etiology of arrest, guidance of certain procedures and prognosis. As such, some centers, including our own, have adopted increasingly routine use of TEE in this context. Given the paucity of data in this area, we sought to examine the influence of point-of-care TEE conducted by emergency physicians or intensivists at our institution for patients in or immediately after cardiac arrest. Methods: Goal-directed TEE in the emergency department (ED) or intensive care units (ICU) and their reports were archived in a dedicated point-of-care ultrasound imaging database. We conducted a search of all TEE examinations archived between December 2012 and April 2015 in the peri-arrest period (in or immediately after cardiac arrest). The details from reports were abstracted. TEE-directed management changes were noted when recommendation(s) regarding initiation/escalation of inotropes, fluid administration, termination of resuscitation or surgical procedure were featured in the TEE report. Results: A total of 57 peri-arrest TEE exams were identified (21 in ICUs and 36 in EDs). Goal-directed TEE changed management in 61.4% of cases. TEE facilitated the escalation/initiation of inotropes (35.3%), decision to terminate resuscitation (32.4%), guided fluid management (23.5%) and surgical procedures (8.8%). TEE studies altered management in 66.7% of cases in the Intensive Care Unit and in 58.3% of cases in the Emergency Department. Conclusions: Goal-directed TEE performed by emergency physicians or intensivists has an impact on management on patients in the peri-arrest setting the majority of the time. Given the lack of reliable diagnostic and therapeutic options in arresting patients, a larger study examining the influence of goal-directed TEE on patient outcomes in cardiac arrest should be carried out.

Diagnostic yield of echocardiography in cancer patients with ischemic stroke.

The yield of echocardiography in cancer patients with acute ischemic stroke is unknown. We identified adult patients with active systemic cancer diagnosed with acute ischemic stroke at a tertiary-care cancer center from 2005 through 2009 who underwent transthoracic (TTE) or transesophageal echocardiography (TEE). Two neurologists independently reviewed all clinical data, including TTE and TEE reports, and adjudicated whether echocardiographic studies revealed a definite or possible source of stroke according to pre-defined criteria. Patients were classified as having suspected cardioembolic strokes if imaging showed embolic-appearing infarcts in more than one vascular territory. Among 220 patients with cancer and ischemic stroke who underwent echocardiography, 216 (98%) had TTE and 37 (17%) had TEE. TTE revealed a definite source in 15 (7%, 95% CI 4-10%) patients and a possible source in 42 (19%, 95% CI 14-25%), while TEE revealed a definite source in 10 (27%, 95% CI 12-42%) patients and a possible source in 14 (38%, 95% CI 21-54%). In 92 patients with suspected cardioembolic strokes who underwent TTE, 6 (7%, 95% CI 1-12%) had a definite source, including 4 with marantic endocarditis, and 20 (22%, 95% CI 13-30%) had a possible source. Twenty-one of these patients also underwent TEE, which demonstrated a definite or possible source in 16 (76%, 95% CI 56-96%) patients, including marantic endocarditis in 4 (19%). The yield of TTE for detecting marantic endocarditis and other cardiac sources of stroke in cancer patients is low, but TEE may provide a higher yield in targeted patients.

Use of mobile tablet devices and reduction in time to perioperative transesophageal echocardiography reporting: a historical cohort study.

Timely communication of intraoperative transesophageal echocardiography (TEE) findings to the postoperative care team is critical to optimizing patient care. We compared the use of a personal computer (PC) system with the use of a mobile tablet device (MTD) system for point-of-care TEE data entry and hypothesized that the MTD-based system would reduce the time to preliminary TEE reporting and decrease the incidence of delinquent reporting by 50%. In this historical cohort study, we reviewed 508 perioperative TEE reports entered by cardiothoracic anesthesia fellows. Reports were grouped based on whether data were entered on a PC (PC group) or a MTD (MTD group). Time to TEE reporting was defined as the time from the patient leaving the operating room to the time the TEE report was generated. Delinquent reports were defined as those generated >24 hr after the initial exam. Time to TEE reporting and incidence of delinquent reports were compared between the two groups. Mean (SD) time to TEE reporting was significantly improved with MTD data entry vs PC data entry [233 (676) min vs 1,103 (3,830) min, respectively; mean difference 870 min; 95% confidence interval (CI) 293 to 1,448; P = 0.003], and median (IQR) time was also significantly improved [46 (163) min vs 126 (1,000) min, respectively; median difference 80 min; P = 0.0002]. The incidence of report delinquency with MTD data entry vs PC data entry was also significantly reduced [2.1% vs 6.8%, respectively; mean difference 2.2%; 95% CI 0.5 to 9.0; P = 0.02]. Implementation of a MTD system for data entry leads to improved TEE reporting time and reduces TEE reporting delinquency. Further studies are required to determine whether this strategy enhances quality of reporting, optimizes communication between care teams, and improves outcomes without increasing costs.

Impact of Transesophageal Echocardiography on Management in Patients With Suspected Cardioembolic Stroke

Transesophageal echocardiography (TEE) is frequently performed in patients with acute ischemic cerebrovascular events to exclude a cardioembolic source. We aimed to determine the clinical impact of TEE on management. This is a retrospective single-center study of 1,458 consecutive patients hospitalized with acute ischemic stroke or transient ischemic attack who underwent TEE for evaluation of a suspected cardioembolic cause. Significant TEE findings were determined for each patient as recorded on the TEE report. The medical record was reviewed for baseline, clinical, and demographic variables and to determine whether significant management changes occurred as a result of the TEE findings. Potential significant changes in management included initiation of anticoagulation, placement of a patent foramen ovale (PFO) closure device, initiation of antibiotic therapy for endocarditis, surgical PFO closure, other cardiac surgery, and coil embolization of a pulmonary arteriovenous malformation. A significant change in management occurred in 243 patients (16.7%); 173 (71%) underwent treatment for PFO with a percutaneous PFO closure device (n= 100), initiation of chronic systemic anticoagulation (n= 68), or surgical PFO closure (n= 5). Additional findings leading to achange in management included endocarditis (n= 20), aortic arch atheroma (n=14), intracardiac thrombus (n= 13), pulmonary arteriovenous malformation (n= 2), aortic valve fibroelastoma (n= 2), other valve masses (n= 4), and miscellaneous causes (n= 15). In conclusion, in patients with suspected cardioembolic stroke, TEE findings led to a change in management in 16.7% of patients. Of these, most (71%) were directed at prevention of subsequent paradoxical emboli in patients with PFO.

Abstract 18332: Diagnostic Yield of Transesophageal Echocardiography for Infective Endocarditis in Patients Referred for Suspected Endocarditis

Background: The expert panel that authored the 2011 Appropriate Use Criteria for Echocardiography considered the use of transesophageal echocardiography (TEE) to be appropriate when used to diagnose infective endocarditis (IE) with a moderate or high pretest probability. The panel appropriate use score was 9, the highest possible score achievable. Few published data are currently available to support this recommendation. We aimed to define the diagnostic yield of TEE in a population with moderate or high pretest probability for IE. Methods: Consecutive TEE reports (n=6,189) acquired between 1/1/2005 and 12/31/2012 at our institution were reviewed for the presence of possible or definite endocarditis. TEE were acquired from 5,347 individual patients. Endocarditis was considered to be present if a new vegetation was demonstrated or there was obvious abscess formation. The diagnostic yield for endocarditis was compared between exams performed for different indications. Results: The study group was 62 ± 15 years old and 55% male. Most TEE (78%) were performed on inpatients. TEE findings are reported in the Table. The yields for definite and possible IE were 9% and 8% respectively amongst subjects with bacteremia referred for suspected IE. Those referred for suspected IE had increased odds for finding definite IE (odds ratio (OR) 4.2, 95% CI: 2.7, 6.6, p&lt;0.001). Amongst those referred for suspected IE, prosthetic valve (OR 2.4, 95% CI: 1.5, 3.8, p&lt;0.001) and pacemaker/ICD (OR 16, 95% CI: 6, 44, p&lt;0.001) were independent predictors of definite IE. Conclusion: The diagnostic yield for finding IE on TEE in subjects with bacteremia referred for suspected IE is reasonably high. Our findings support the current recommendations for use of TEE in this population.

Comparison of Transesophageal Echocardiography Versus Computed Tomography for Detection of Left Atrial Appendage Filling Defect (Thrombus)

Patients with atrial fibrillation, who are referred for radiofrequency pulmonary vein antral isolation, frequently undergo transesophageal echocardiography (TEE) to detect and/or exclude left atrial or left atrial appendage (LAA) thrombus and cardiac computed tomographic angiography (CCTA) to define and/or evaluate left atrial and pulmonary venous anatomy. Previous studies have reported CCTA to have high sensitivity and negative predictive value (NPV) for detecting thrombus in the LAA. Previous studies determining an optimal LAA/ascending aorta (AA) Hounsfield unit (HU) density ratio for detection of LAA thrombus have been small, with limited numbers of thrombi. We thus sought to determine both the optimal cutoff for LAA HU density and LAA/AA HU density ratio in detecting LAA thrombus compared with TEE in a multicenter population. We included 84 patients who had undergone CCTA and TEE. LAA was evaluated by 64-row CCTA qualitatively (visual filling defect) and quantitatively (measurement of LAA HU density and LAA/AA HU density ratio), using a 1-cm area of interest in the same axial plane. Results were compared with TEE visualization of thrombus or spontaneous echo contrast. Qualitative identification of thrombus in LAA by CCTA compared with TEE detection of thrombus had a sensitivity of 100%, a specificity of 77.9%, a positive predictive value (PPV) of 51.6%, an NPV of 100%, and a total accuracy of 82.1%. The optimal LAA HU density cutoff for thrombus detection was 119 with a sensitivity of 88%, a specificity of 86%, PPV 56%, and an area under the curve of 0.923 (p = 0.0004). The optimal LAA/aorta HU ratio was 0.242 with a sensitivity of 87%, a specificity of 88%, a PPV of 64%, and an area under the curve of 0.921 (p = 0.0011). There is no significant difference (p = 0.72) between both areas under the curve, and both measurements improved the specificity and PPV compared with qualitative measures. Multidetector computed tomography is an imaging technique that can exclude LAA thrombus with very high NPV. Quantitative measurement of LAA HU density (cutoff 119) or LAA/aorta HU density ratio (cutoff 0.242) improves accuracy of positively detecting LAA thrombus. This technique is especially useful when delayed scanning is not performed and LAA is found incidentally after the patient scanning is complete.

Abstract WP230: The Yield of Echocardiography in Cancer Patients with Suspected Cardioembolic Stroke

Background: Autopsy studies demonstrate that cardioembolism from nonbacterial thrombotic endocarditis (NBTE) is a common cause of stroke in patients with cancer. Echocardiography is often used to clinically diagnose NBTE, but it has unknown yield for NBTE lesions, which are typically small and difficult to detect. Methods: We identified all patients with active cancer admitted to Memorial Sloan-Kettering Hospital from 2008 to 2010 with acute ischemic stroke who underwent transthoracic (TTE) or transesophageal echocardiography (TEE). Two neurologists independently reviewed all clinical data and classified patients as having suspected cardioembolic (CE) strokes if brain MRI showed embolic-appearing infarcts in more than one vascular territory. They also reviewed TTE and TEE reports and adjudicated whether these studies revealed a definite or possible source of stroke. Definite sources included complex aortic arch atheroma, valve vegetation, left atrial or ventricular thrombus, patent foramen ovale (PFO) with documented venous thromboembolism (VTE), severe cardiomyopathy, or cardiac tumor. Possible sources consisted of PFO without VTE, atrial septal aneurysm, dyskinetic left ventricular segment, spontaneous echo contrast, and simple aortic arch atheroma. NBTE was diagnosed if valve vegetations were seen on echocardiography, blood cultures were negative, and clinical signs of infection were absent. Results: Among 119 patients with cancer and ischemic stroke (mean age 66 [SD 13], 51% men), 99 (83%) had TTE and 16 (13%) had TEE. TTE revealed a definite source in 3 (3%) patients and a possible source in 15 (15%). Conversely, TEE revealed a definite source in 6 (38%) patients and a possible source in 5 (31%). No vegetations were seen on TTE, but 4 were discovered on TEE, all from NBTE. In 42 of 52 patients with suspected CE stroke who underwent TTE, 3 (7%) had a definite source and 8 (19%) a possible source. Eleven of these patients also underwent TEE, which demonstrated a definite or possible source in 9 (81%). Conclusions: The yield of TTE for detecting NBTE and other cardiac sources of stroke in patients with cancer is poor, but TEE may be helpful in targeted patients.

Canadian guidelines for training in adult perioperative transesophageal echocardiographyRecommendations of the Cardiovascular Section of the Canadian Anesthesiologists’ Society and the Canadian Society of Echocardiography

To establish Canadian guidelines for training in adult perioperative transesophageal echocardiography (TEE). Guidelines were established by the Canadian Perioperative Echocardiography Group with the support of the cardiovascular section of the Canadian Anesthesiologists' Society (CAS) in conjunction with the Canadian Society of Echocardiography. Guidelines for training in echocardiography by the American Society of Echocardiography, the American College of Cardiology and the Society of Cardiovascular Anesthesiologists were reviewed, modified and expanded to produce the 2003 Quebec expert consensus for training in perioperative echocardiography. The Quebec expert consensus and the 2005 Guidelines for the provision of echocardiography in Canada formed the basis of the Canadian training guidelines in adult perioperative TEE. Basic, advanced and director levels of expertise were identified. The total number of echocardiographic examinations to achieve each level of expertise remains unchanged from the 2002 American Society of Echocardiography-Society of Cardiovascular Anesthesiologists guidelines. The increased proportion of examinations personally performed at basic and advanced levels, and the level of autonomy at the basic level suggested by the Quebec expert consensus are retained. These examinations can be performed in a perioperative setting and are not limited to intraoperative TEE. Training "on the job", the role of the perioperative transesophageal echocardiography examination, requirements for maintenance of competence, and duration of training are also discussed for each level of training. The components of a TEE report and comprehensive TEE examination are also outlined. The Canadian guidelines for training in adult perioperative TEE reflect the unique Canadian practice profile in perioperative TEE and address the training requirements to obtain expertise in this field.

Canadian guidelines for training in adult perioperative transesophageal echocardiography: Recommendations of the cardiovascular section of the Canadian Anesthesiologists’ Society and the Canadian Society of Echocardiography

To establish Canadian guidelines for training in adult perioperative transesophageal echocardiography (TEE). Guidelines were established by the Canadian Perioperative Echocardiography Group with the support of the cardiovascular section of the Canadian Anesthesiologists' Society in conjunction with the Canadian Society of Echocardiography. Guidelines for training in echocardiography by the American Society of Echocardiography, the American College of Cardiology and the Society of Cardiovascular Anesthesiologists were reviewed, modified and expanded to produce the 2003 Quebec expert consensus for training in perioperative echocardiography. The Quebec expert consensus and the 2005 guidelines for the provision of echocardiography in Canada formed the basis of the Canadian training guidelines in adult perioperative TEE. Basic, advanced and director levels of expertise were identified. The total number of echocardiographic examinations to achieve each level of expertise remains unchanged from the 2002 American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists guidelines. The increased proportion of examinations personally performed at basic and advanced levels, as well as the level of autonomy at the basic level suggested by the Quebec expert consensus are retained. These examinations may be performed in a perioperative setting and are not limited to intraoperative TEE. Training 'on-the-job', the role of the perioperative TEE examination, the requirements for maintenance of competence and the duration of training are also discussed for each level of training. The components of a TEE report and comprehensive TEE examination are also outlined. The Canadian guidelines for training in adult perioperative TEE reflect the unique Canadian practice profile in perioperative TEE and address the training requirements to obtain expertise in this field.