Transesophageal Echocardiography Risk Research Articles

A novel scoring system for stroke risk stratification in Japanese patients with low CHADS2 scores: Study using a transesophageal-echocardiogram endpoint.

BackgroundCatheter ablation is an effective treatment for atrial fibrillation (AF), but it carries risk of perioperative thromboembolism even in cases with low CHADS2 scores. Here, we examined whether a combination of clinical variables can predict stroke risk factors that are assessed by transesophageal echocardiography (TEE).MethodsThe study population consisted of 209 consecutive AF patients with a CHADS2 score of 0 or 1 (58.7 ± 10.6 years old; persistent AF, 33.0%). All patients underwent TEE, and TEE‐determined stroke risk (TEE risk) was defined as cardiac thrombus/sludge, dense spontaneous echo contrast (SEC), and/or peak left atrial appendage (LAA) flow velocity <0.25 m/s.ResultsTransesophageal echocardiography risk was observed in 10.5% of the patients. In multivariate logistic analysis, persistent AF [odds ratio (OR): 11.5, CI: 3.14‐42.1, P = .0002], left atrial diameter (LAD) (OR: 1.10, CI: 1.01‐1.20, P = .0293), contrast medium defect (CMD) in the LAA detected by computed tomography (OR: 20.2, CI: 6.3‐65.0, P < .0001), and serum brain natriuretic peptide (BNP) level (OR: 1.00, CI: 1.00‐1.01, P = .0056) were independent predictors of TEE risk. A new scoring system comprising LAD > 41 mm (1 point), BNP > 47 pg/mL (1 point), CMD (2 points), and persistent AF (2 points) was constructed and defined as TEE‐risk score. The area under the curve (AUC) for prediction of TEE risk was 0.631 in modified CHADS2 score and it was 0.852 in TEE‐risk score.ConclusionTransesophageal echocardiography risk is predictable by TEE‐risk score, and its combination with CHADS2 score may improve the stroke risk stratification in AF patients with a low CHADS2 score.

Characterization of Medical Professional Liability Risks Associated With Transesophageal Echocardiography

Medical claim data offer the possibility to improve patient care and mitigate liability. Although published analyses exist in cardiology, no information is available for transesophageal echocardiography (TEE). In this study, the authors reviewed medical claims involving TEE to identify potential risk management concerns so that these lessons could be used to improve the safety and quality of transesophageal echocardiographic practice. The authors reviewed anonymized clinical and claims data from all closed claims from 2008 to 2013 for a single national physician liability insurer. There were no claims involving transthoracic echocardiography and eight involving TEE. Three claims involved esophageal perforation, a known risk of TEE. Two claims involved quadriplegia allegedly due to neck manipulation in the setting of a cervical spinal abscess that should have been suspected. Three claims involved the cardiologist's failure to diagnose endocarditis, with allegations that the cardiologist did not perform TEE in an appropriate time frame to avoid major morbidity and mortality from endocarditis. Liability claims associated with TEE involve failure to order and perform TEE in an appropriate clinical scenario and in a timely manner; failure to properly document medical decision making; failure to inform patients regarding risks of TEE; failure to properly monitor the patient before, during, and after TEE; and technical difficulties in performing the procedure. Cardiologists should recognize guideline-based indications when TEE is needed and be mindful of the complication rates of this procedure. When screening a patient for TEE, consider expert input that may reduce the risks of TEE (e.g., a spine specialist for a neck injury, a gastroenterologist for esophageal comorbidity). Informed consent and medical record documentation should be practiced as a vehicle to inform patients of these risks and chronicle decision-making processes.

Real-Time Pathophysiologic Correlates of Left Atrial Appendage Thrombus in Patients Who Underwent Transesophageal-Guided Electrical Cardioversion for Atrial Fibrillation

Although current guidelines advocate using the CHA2DS2-VASc score to assess the risk of stroke in patients with atrial fibrillation (AF), compared with transesophageal echocardiography (TEE), its ability to predict left atrial appendage thrombus (LAAT) is limited. We studied 3,324 consecutive patients with sustained AF from our prospective registry of patients who underwent first-time TEE-guided electrical cardioversion (ECV) from May 2000 through March 2012. The association of CHA2DS2-VASc score or TEE risk factors with the occurrence of LAAT was analyzed. The mean (SD) age was 69 (12.5) years and 67% were men. LAAT was identified in 49 (1.5%) during pre-ECV TEE. Compared with patients without LAAT, those with LAAT had lower peak left atrial appendage emptying velocity (LAAEV) (17.2 ± 8.5 vs 36.6 ± 20.8; p <0.001) and left ventricular ejection fraction (LVEF) (39.9 ± 17.6 vs 51.4 ± 13.7; p <0.001); their CHA2DS2-VASc score also was higher, but the difference was not statistically significant (3.6 ± 1.4 vs 3.2 ± 1.6; p = 0.06). Multivariate logistic regression analysis identified an LVEF ≤40% (adjusted odds ratio 2.48, 95% confidence interval 1.38 to 4.46), LAAEV 20.3 to 33.9 cm/s (odds ratio 12.19, 95% confidence interval 1.53 to 96.86), and LAAEV ≤20.2 cm/s as independent predictors of LAAT. An LAAEV cut-point of 20 cm/s and an LVEF ≤40% were optimal for detecting LAAT (sensitivity 75% and 62%; specificity 77% and 75%; area under the curve 0.822 and 0.776, respectively). On follow-up, LAAT was an independent risk factor of subsequent ischemic stroke but did not influence survival. In conclusion, reduced LVEF and reduced LAAEV are important pathophysiologic correlates of left atrial appendage thrombogenesis and subsequent ischemic stroke in patients who underwent TEE-guided ECV for AF.

Correlation of CHADS2 and CHA2DS2-VASc Scores with Transesophageal Echocardiography Risk Factors for Thromboembolism in a Multiethnic United States Population with Nonvalvular Atrial Fibrillation

The aims of this study were to evaluate the relationship of the CHA(2)DS(2)-VASc score and risk categories with transesophageal echocardiographic (TEE) risk factors for thromboembolism and to compare the CHA(2)DS(2)-VASc and CHADS(2) risk stratification schemes with respect to their ability to predict these risk factors in a multiethnic US population with nonvalvular atrial fibrillation. Transesophageal echocardiograms of 167 patients (mean age, 66.3±11.6 years; 146 men [87%]; 100 whites [60%]; 40 Hispanics [24%]; 27 blacks [16%]) with nonvalvular atrial fibrillation were retrospectively reviewed for smoke, sludge, thrombus, and left atrial appendage (LAA) emptying velocity ≤20 cm/sec. The patients' CHA(2)DS(2)-VASc and CHADS(2) risk scores and categories were also calculated. Any LAA abnormality, smoke, sludge, thrombus, and abnormal LAA emptying velocity were present in 45%, 38%, 13%, 3%, and 22% of patients, respectively. Heart failure (P<.001), age (P<.001 for age ≥75 vs ≤64 years, P=.013 for age 65-74 vs ≤64 years), and diabetes (P=.019) were independent predictors of LAA abnormalities, while ethnicity was not. The prevalence of TEE risk factors for thromboembolism increased with increasing CHA(2)DS(2)-VASc score and risk category. The CHADS(2) risk categories of 35 patients (21%) were upgraded by the CHA(2)DS(2)-VASc scheme. Using the latter scheme, fewer patients were classified as at intermediate risk compared with the CHADS(2) system (21 [13%] vs 46 [28%]). Patients classified as at low risk by either scheme had almost no TEE risk factors. Of 30 intermediate-risk patients by CHADS(2) score upgraded to high risk using CHA(2)DS(2)-VASc score, eight (27%) had at least one TEE risk factor for thromboembolism. C-statistics, sensitivity, and specificity for predicting any LAA abnormality were 0.607 (95% confidence interval, 0.549-0.665), 92.0%, and 28.9% for CHA(2)DS(2)-VASc score and 0.685 (95% confidence interval, 0.615-0.755), 81.3%, and 54.2% for CHADS(2) score. CHA(2)DS(2)-VASc score is associated with TEE risk factors for thromboembolism in a multiethnic US population. Compared with CHADS(2) score, it has increased sensitivity, decreased specificity, and lower ability for predicting TEE risk factors in this population.

Clinical and transesophageal echocardiographic variables for prediction of thromboembolic events in patients with nonvalvular atrial fibrillation at low-intermediate risk

BackgroundThere is no clear consensus about antithrombotic treatment in atrial fibrillation (AF) patients at low-intermediate thromboembolic risk. Transesophageal echocardiography (TEE) is useful for prediction of thromboembolic events in AF. Methods and resultsOf 498 patients with nonvalvular AF, incidence of stroke, cardiac events, and mortality was investigated in 280 patients with CHADS2 score 0 or 1 (mean age 64 years, mean follow-up 6.4±3.1 years). Left atrial abnormality (low left atrial appendage flow, spontaneous echo contrast, or thrombi), complex aortic plaque (mobile, ulcerated, pedunculate, or thickness≥4mm), or both were defined as TEE risk. The incidences of ischemic stroke, cardiovascular events, and death were higher in patients with TEE risk than in those without the risk (2.0%/year vs. 0.5%/year, p<0.05; 4.7%/year vs. 1.9%/year, p<0.01; and 4.7%/year vs. 2.0%/year, p<0.01, respectively). This was also true for patients with CHADS2 score of 0 (1.7%/year vs. 0.3%/year, p<0.05; 4.1%/year vs. 1.6%/year, p<0.05; and 3.9%/year vs. 1.4%/year, p<0.01; respectively). On multivariate analysis, TEE risk predicted ischemic stroke, cardiovascular events, and mortality independently of clinical variables or CHADS2 score. ConclusionsTEE could be useful for further stratification of patients with nonvalvular AF stratified at low-intermediate risk (CHADS2 score 0 or 1) and could indicate who should receive anticoagulation treatment.

Transesophageal Echocardiographic Findings Are Independent and Relevant Predictors of Ischemic Stroke in Patients with Nonvalvular Atrial Fibrillation

Background and PurposeNot only clinical factors, including the CHADS2 score, but also echocardiographic findings have been reported to be useful for predicting the risk of ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF). However, it remains to be determined which of these factors might be more relevant for evaluation of the risk of stroke in each patient.MethodsIn 490 patients with NVAF who underwent transesophageal echocardiography (TEE), we examined the long-term incidence of ischemic stroke events (mean follow-up time, 5.7±3.3 years). For each patient, the predictive values of gender, the CHADS2 risk factors (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, history of cerebral ischemia), the CHADS2 score, and the findings on echocardiography, including TEE risk markers, were assessed.ResultsThe ischemic stroke rate was significantly correlated with the CHADS2 score (p<0.05). According to the results of univariate analyses, age ≥75 years, history of cerebral ischemia, CHADS2 score ≥2, and presence of TEE risk were significantly correlated with the incidence of ischemic stroke. Cox proportional hazards regression analyses identified age ≥75 years and presence of TEE risk as significant predictors of subsequent ischemic stroke events in patients with NVAF. As compared with that in persons below 75 years of age without TEE risk, the ischemic stroke rate was significantly higher in persons who were ≥75 years of age with TEE risk (4.3 vs. 0.56%/year, adjusted hazard ratio=8.94, p<0.001).ConclusionsTEE findings might be more relevant predictors of ischemic stroke than the CHADS2 score in patients with NVAF. The stroke risk was more than 8-fold higher in patients aged ≥75 years with TEE risk.

Relation of interleukin-6, C-reactive protein, and the prothrombotic state to transesophageal echocardiographic findings in atrial fibrillation

Atrial fibrillation (AF) is a major cause of morbidity and mortality from stroke due to thromboembolism from the fibrillating left atrium, including its appendage. We hypothesized that indexes of inflammation (as indicated by C-reactive protein and interleukin-6) and indexes of the prothrombotic state in AF that represent platelet activation (soluble P-selectin levels), endothelial damage or dysfunction (von Willebrand factor), coagulation (tissue factor and fibrinogen), and hemorrheology (plasma viscosity and hematocrit) would be related to the presence of thromboembolic predictors on transesophageal echocardiography in patients with long-term AF. To test this hypothesis, we recruited 37 patients with long-term AF who were receiving warfarin therapy with an international normalized ratio of ≥2.0 for ≥3 weeks before transesophageal echocardiography. Twenty-two patients had dense spontaneous echo contrast (SEC) visible in the left atrium or left atrial appendage, 10 had complex atheromatous plaque in the descending aorta, 11 had peak left atrial appendage velocities ≤0.2 m/s, and 3 had thrombus visible in the left atrial appendage. Twenty-eight patients had ≥1 transesophageal echocardiographic (TEE) risk factor for thromboembolism. Plasma levels of C-reactive protein (p = 0.03) and soluble P-selectin (p = 0.04) and hematocrit (p = 0.004) were higher among patients with AF with dense SEC than among those without. No significant associations were found for other TEE risk factors. Hematocrit was the only variable significantly associated with the presence of ≥1 TEE risk factor among patients with AF (p = 0.007) and the only independent associate of dense SEC after multivariate analysis (relative risk 1.4, 95% confidence interval 1.1 to 1.6) per 1% increase in hematocrit (p = 0.003, r 2 = 0.22). Although hematocrit was the only independent associate of dense SEC and ≥1 TEE risk factor, significant associations between dense SEC and the 2 indexes, C-reactive protein and soluble P-selectin, may indicate that mechanisms other than stasis are present with dense SEC. These observations support an “inflammatory hypothesis” in the pathogenesis of SEC that may have implications for thrombogenesis in AF.

1131-141 Transesophageal echocardiographic risk markers of thromboembolism are present in patients with lone atrial fibrillation

1131-141 Transesophageal echocardiographic risk markers of thromboembolism are present in patients with lone atrial fibrillation

Age-Dependent Prevalence of Cardioembolic Sources Detected by TEE: Diagnostic and Therapeutic Implications.

To define the prevalence of cardioembolic sources found by transesophageal echocardiography (TEE) in different age groups of patients with and without cryptogenic systemic embolism, TEE risk factors for cardiogenic embolism were identified from 341 consecutive patients referred for TEE. One hundred and thirty-five had cryptogenic cerebral or systemic peripheral embolic events (CEE) and 206 other indications for TEE (CTR). Cardioembolic sources were found in 40% of CEE and in 29% of CTR (P < 0.02). Specifically, left atrial (LA) thrombi (P < 0.0001), atrial septal aneurysm with right-to-left shunt (P < 0.002), and atherosclerotic aortic plaques (P < 0.02) were more frequent. The prevalence of potential cardioembolic sources was significantly higher in patients >/= 70-years old than in younger patients (P < 0.03), specifically LA thrombi (P < 0.004) and atherosclerotic aortic plaques (P < 0.0001). In patients >/= 70-years old, potential cardioembolic sources were found in 63% and in 40% in CEE and CTR (P = 0.073), respectively. However, LA thrombi were more frequent in CEE (P < 0.003). Thus, potential cardioembolic sources observed by TEE are found more frequently in patients >/= 70-years old than in younger patients. LA thrombi were more frequent in CEE than in CTR patients >/= 70-years old. In patients >/= 70-years old with CEE who are eligible for an anticoagulant regimen, a search for potential cardioembolic sources by TEE should be considered.

1015-75 Detection of Aortic Plaques is not Predictive of Coronary Artery Disease In the Elderly: A Biplane Transesophageal Echocardiographic Study

Atherosclerotic aortic plaques detected by transesophageal echocardiography (TEE) have been reported to be a marker for coronary artery disease (CAD). Its significance may particularly be important in elderly population, though there are no data yet available. To elucidate the significance of aortic plaques in the elderly, we performed TEE on 84 patients (pts) (44 men, 40 women, age 61 ± 11 years) who had previously undergone coronary arteriography. (1) Significant CAD (≥ 75% stenosis) was detected in at least one major coronary artery in 26 of the 84 pts. Aortic plaques were detected by TEE in 24 of the 26 pts with CAD (92%) and in 32 of 58 pts without CAD (55%) (p &lt; 0.01). (2) In pts aged 70 years (n = 25), aortic plaques were present in 13 of 14 pts with CAD (93%) and 10 of 11 pts without CAD (91%) (p = ns). In pts aged &lt; 70 years (n = 59), aortic plaques were present in 10 of 12 pts with CAD (83%) and 22 of 47 pts without CAD (47%) (p = 0.02). (3) The independent association between CAD and age, the presence of aortic plaques on TEE and other coronary risk factors was examined by multiple regression analysis. In pts aged ≥ 70 years, the presence of aortic plaques on TEE failed to be a predictor of significant CAD, although it was indeed a strong predictor of CAD in pts aged ≥ 70 years (p &lt; 0.01). In elderly pts, atherosclerotic aortic plaque detected by transesophageal echocardiography is not useful in predicting significant coronary artery disease. It is useful only in a relatively younger population.