Stroke: After a stroke, what are the benefits of transesophageal echocardiography?

Cardiac embolism is the second leading cause of acute ischemic stroke (AIS) and transient ischemic attack (TIA), accounting for approximately 20% of all cases
.
Although atrial fibrillation (AF) is the most common cause of cardiogenic stroke, other major sources of heart embolism, such as heart thrombosis , foramen ovale (PFO) valve disease, ventricular wall movement disorders, endocarditis, or atrial fibroids , Can only be detected by cardiac imaging

Therefore, cardiac ultrasound is an important part of the diagnosis of stroke and TIA
.
However, the diagnostic effect of cardiac ultrasound on the treatment-related results of stroke patients is uncertain

The stroke guidelines suggest that echocardiography is reasonable as part of the routine diagnosis of acute stroke
.
However, these recommendations are based on very little evidence.

When looking for potential sources of myocardial embolism, there are still contradictions and controversies about whether TEE is needed
.
The European Stroke Organization's certification standards for stroke units require both TTE and TEE

There are research reports that in patients with AIS or TIA, the diagnosis results of TEE and TTE are contradictory
.
The results are mixed.

Most of the existing studies have a history of more than 10 years.
Therefore, they neither reflect the current evidence for secondary prevention of ischemic stroke nor represent modern ultrasound technology
.

In the CONTEST study (Comparative Effectiveness Study of Transthoracic and Transesophageal Echocardiography in Stroke), we aim to determine that the diagnostic rate of TEE is higher than that of TTE in patients with AIS or TIA, who have not yet determined the cause of stroke before cardiac imaging

For this reason, Götz Thomalla and others of the University of Hamburg, Germany, prospectively evaluated the frequency of treatment-related findings that were not detected by TTE in the TEEs of five stroke centers (academic and community hospitals)
.

Based on the currently speculated evidence on the treatment and secondary prevention of cardioembolic ischemic stroke, we can pragmatically judge the potential therapeutic relevance of TTE and TEE
.
It also aims to evaluate the impact of additional TEE on the classification of stroke causes according to the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) standard

In this multicenter cohort study, they conducted a TTE and TEE study on patients with acute ischemic stroke or transient ischemic attack of undetermined cause before echocardiography
.
The main outcome is the treatment-related discovery rate in TTE and TEE, as defined by the expert panel based on current evidence

Between July 1, 2017 and June 30, 2019, they recruited a total of 494 patients, of which 492 (99.
6%) received TTE and 454 (91.
9%) received TEE
.
The average age is 64.
7 years, and 204 (41.
3%) are women
.

TEE showed a higher treatment-related discovery rate than TTE (86[18.
9%] vs.
64[14.
1%], P<0.
001)
.
In addition to TTE, TEE also resulted in treatment-related findings in 29 patients (6.
4%)
.

Among 191 patients ≤60 years of age, 27 (14.
1%) patients were observed to have additional treatment-related findings through TEE
.
Among the 453 patients, 52 patients (11.
5%) changed the classification of the causes of stroke after TEE, resulting in a significant difference in the distribution of causes of stroke before and after TEE (P<0.
001)
.

The important significance of this study lies in the discovery: TEE has produced more treatment-related findings than TTE in stroke patients whose cause has not been determined
.
TEE is particularly useful for young stroke patients.
Among 7 patients ≤60 years of age, 1 had treatment-related findings
.

Original Source:
Thomalla G, Upneja M, Camen S, et al.
Treatment-Relevant Findings in Transesophageal Echocardiography After Stroke: A Prospective Multicenter Cohort Study .
Stroke.
Published online September 9, 2021.
doi:10.
1161/STROKEAHA.
121.
034868