Protruding atheromas in the thoracic aorta: a newly recognized source of cerebral and systemic embolization

Up to 40% of stroke patients do not have an obvious etiology for their illness. Because transthoracic echocardiography is often negative in these patients, there has been increasing enthusiasm for transesophageal echocardiography (TEE) as a newer tool for evaluating patients with embolic disease. In a study of patients referred because of unexplained stroke or transient ischemic attacks, the most common finding was protruding atheroma in the aortic arch. In a case control study, protruding aortic atheromas were found in 33 of the 122 patients with emboli (27%). Mobile components to the atheromas were found in 11 case patients, and there were no mobile components found in any control patients. It is also possible that protruding aortic atheromas may play a role in patients with other sources of emboli (e.g., carotid disease). Atheromas may also cause emboli during catheterization, balloon pump placement, and cardiopulmonary bypass. The pathological composition of the lesions seen on TEE has been atheroma with superimposed thrombus. The correct treatment for patients with embolization due to protruding aortic atheromas has not yet been determined, although anticoagulation may play a role, since the mobile components to these lesions appear to be thrombus. We have recommended surgery for several patients. However, the operation is a major one with major potential complications, including aortic dissection. TEE should be done in patients with unexplained emboli, and it may also play a role in patients with other sources of embolization. TEE should be considered in elderly patients or those with extensive vascular disease before cardiac catheterization or heart surgery. In addition, cannulation techniques during bypass can be modified to avoid atheromas. The ideal medical and/or surgical approaches to patients with protruding atheromas remain to be clarified.     

Importance of Performing Transesophageal Echocardiography in Acute Stroke Patients older than Fifty

Background: The purpose of this study was to determine the value of transesophageal echocardiography (TEE) in determining the presence of cardiac manifestations that required anticoagulation in patients presenting with acute stroke. Methods: Of 626 consecutive stroke patients who underwent TEE, 188 patients with no obvious etiology for stroke were subcategorized according to age. TEE results were analyzed for cardiac findings suggestive of a cause for embolic stroke, including complex atheromas in the arch/ascending aorta, patent foramen ovale (PFO), atrial septal aneurysm (ASA), and intracavitary thrombi. Data were analyzed using Fisher's exact test. Results: Of 188 patients, 66% (125/188) were older than 50 years and 34% (63/188) were younger than 50 years. The incidence of complex atheroma was 12.8% (16/125) in patients older than 50 years as compared to 0% (0/63) in patients who were younger than 50 years (P = 0.002). In patients older than 50 years, findings that indicated a need for anticoagulation based on TEE results were found in 22.4% (28/125) (atheroma = 16, PFO = 12, ASA = 5, thrombus = 3, PFO + ASA = 1) compared to 14.3% (9/63) (atheroma = 0, PFO = 5, ASA = 2, thrombus = 2, PFO + ASA = 1) in patients younger than 50 years. Conclusions: TEE plays an important role in suspected embolic stroke patients of all age groups. Due to the higher incidence of complex atheromas in patients older than 50 years of age, TEE might be of added importance in identifying the candidates who may benefit from anticoagulation. (Echocardiography 2010;27:1086‐1092)     

Atherosclerosis of the thoracic aorta and aortic debris as a marker of poor prognosis: benefit of oral anticoagulants

OBJECTIVES: Our aim was to confirm the poor prognosis related to thoracic aortic plaques, in particular aortic debris, diagnosed by transesophageal echocardiography (TEE) and to evaluate patients' prognosis as a function of the antithrombotic treatment. BACKGROUND: Aortic atheroma (AA) has been widely studied. However, it is still not known which antithrombotic treatment should be adopted in this disease. METHODS: Patients referred for TEE and diagnosed with AA were followed. All thromboembolic events and deaths were recorded during a follow-up of 22+/-10 months. The antithrombotic treatment to be adopted was left to the discretion of the practitioner in charge of the patient. RESULTS: Aortic atheroma was found in 12% of all TEE performed and in 27.5% of TEE performed for stroke. This prevalence was higher when no other etiology existed to explain the stroke (p < 0.001). During follow-up, an end point occurred in 22.5% of patients. The more severe the AA the greater the incidence of events (p = 0.007). A higher mortality rate is shown in patients with aortic debris (p = 0.049). Compared with those treated with oral anticoagulants, patients with aortic plaques >4 mm thick treated with antiplatelets had more embolic events and combined events (p = 0.01 and p = 0.007, relative risk [RR] = 5.9, 95% confidence interval [CI] = 1.4 to 15, respectively); patients with aortic debris had more combined events and a higher mortality rate (p = 0.001, RR = 7.1, 95% CI = 1.2 to 19 and p = 0.019, RR = 9.1, 95% CI = 1.2 to 25, respectively). CONCLUSIONS: We confirm the high incidence of vascular events and deaths in patients with AA. We have demonstrated, for the first time in this condition, a better outcome among patients treated with oral anticoagulants versus antiplatelets.     

Association between mitral annulus calcification and aortic atheroma: a prospective transesophageal echocardiographic study

BACKGROUND AND PURPOSE: Although mitral annulus calcification (MAC) has been reported to be a significant independent predictor of stroke, no causative relationship was proven. It is also known that aortic atheroma (AA), especially those >/=5 mm thick and/or protruding and/or mobile are associated with stroke. This study was designed to determine whether an association exists between MAC and AA. METHODS: We prospectively evaluated the records of 279 consecutive patients who underwent transesophageal echocardiography (TEE) for various indications to measure the presence and characteristics of AA. The 105 patients in whom a diagnosis of MAC was made on transthoracic echocardiography (TTE) immediately preceding the TEE, were compared with 174 age-matched patients without MAC. MAC was defined as a dense, localized, highly reflective area at the base of the posterior mitral leaflet. We measured MAC thickness with two-dimensional-TTE in four-chamber view and AA thickness, protrusion and mobility with TEE. AA was defined as localized intimal thickening of >/=3 mm. A lesion was considered complex if there was plaque extending >/=5 mm into the aortic lumen and/or if it was protruding, mobile or ulcerated. RESULTS: No differences were found between the groups in risk factors for atherosclerosis or in indications for referral for TEE. Significantly higher rates were found in the MAC group for prevalence of AA (91 vs. 44%, P<0.001), atheromas >/=5 mm thick (68 vs. 19%, P<0.001), protruding atheromas (44 vs. 15%, P<0.001), ulcerated atheromas (10 vs. 1%, P<0.001) and complex atheroma (74 vs. 22%, P<0.001). Sixty patients had MAC thickness >/=6 mm and 45<6 mm. AA thickness was significantly greater in the patients with a MAC thickness of >/=6 mm (6.1+/-2.8 vs. 5.0+/-2.6 mm, P=0.03). On multivariate analysis MAC, hypertension and age were the only independent predictors of AA (P=0.0001, 0.005 and 0.007, respectively). CONCLUSIONS: There is a significant association between the presence and severity of MAC and AA. MAC may be an important marker for atherosclerosis of the aorta. This association may explain in part the high prevalence of systemic emboli and stroke in patients with MAC.     

Use of echocardiography in detecting cardiac sources of embolus

Up to 20% of all ischemic strokes are felt to be the result of emboli from the heart. High resolution transthoracic (TTE) and transesophageal (TEE) echocardiography have been the principal diagnostic tools for detecting associated cardiac abnormalities and for guiding medical and surgical approaches to these patients. In addition to identifying the precise location and morphological characteristics of intracardiac masses, echocardiography has improved our ability to predict embolic potential of these masses. Specific cardiac lesions that are predisposed to stroke and are readily identifiable by echocardiography include: cardiac thrombi, valvular vegetations, cardiac tumors, aortic atheroma, atrial septal aneurysm, and regional left ventricular wall abnormalities. Careful interrogation of patients with cerebrovascular accidents has identified a potential cardiac source of embolus in approximately 30%. This is largely due to the advent of TEE, which has provided much better assessment of posterior cardiac chambers including left atrium and left atrial appendage. Use of TEE in identifying a cardiac source of embolus is indicated in patients with stroke who are young, have no apparent cerebrovascular disease, or have recurrent embolic events. Echocardiography is an essential diagnostic tool in evaluating patients with a suspected cardiac source of embolus. TTE and TEE provide invaluable information regarding the majority of cardiac sources of embolus.     

Aortic atherosclerosis is a marker for significant coronary artery disease

Atherosclerosis is a generalized process that may involve the entire vasculature as well as the coronary arteries. Aortic atherosclerosis (AA) is associated with an increased risk for recurrent ischemic stroke and cardiovascular death and can be diagnosed by transesophageal echocardiography (TEE). We performed TEE in 60 patients (47 men and 13 women; age range 37-78, mean 53.5 +/- 9.9) who underwent coronary angiography, to assess whether atherosclerosis in the thoracic aorta correlates with coronary artery disease (CAD) or may be a marker for it. Significant CAD was defined as either > 50% reduction of internal diameter of the left main coronary artery or > 70% reduction of the internal diameter in the anterior descending, right coronary or circumflex artery. The number of diseased vessels was based on the Coronary Artery Surgery Study criteria. A grading system was used to detect AA. The thoracic aorta was considered to be normal and classified as grade I when the internal surface was smooth and without lumen irregularities or increased echo-intensity. Grade II changes consisted of increased echodensity of the intima without lumen irregularity or thickening. Grade III changes consisted of increased echodensity of intima with well defined atheroma extending < 3 mm in the aorta. Grade IV and V changes consisted of atheroma > 3 mm and protruding mobile plaques, respectively. Grades III-V were considered as AA. Twenty two of the 29 patients (75.9%) with CAD and 10 of the 31 patients (32.3%) without CAD had AA detected by TEE. There was a significant relationship between CAD and AA (r = 0.44, p < 0.001). The sensitivity and specificity of AA in detecting CAD were 75.9% and 67.7%, respectively. Our data suggest that AA is common in patients with significant CAD. Detection of AA by TEE may be a marker for CAD and early detection of aortic atherosclerosis may contribute to diagnostic and therapeutic interventions and thereby improve the prognosis.     

胸主动脉病变术中应用经食管超声心动图的初步探讨

目的：探讨胸主动脉疾病的术中应用经食管超声心动图（ＴＥＥ）的价值及适应证。方法：本文报道８例（１５～６３岁，平均年龄４４．５岁）不同类型胸主动脉疾病术中ＴＥＥ监测结果。病例包括先天性主动脉瓣上狭窄、升主动脉瘤、主动脉夹层及主动脉夹层伴假性动脉瘤、胸降主动脉假性动脉瘤、主动脉瓣脱垂等。结果：８例患者的术中检查与术前诊断全部吻合。术中ＴＥＥ发现１例主动脉夹层累及左锁骨下动脉，而术前磁共振成像未能提示。此外，术中ＴＥＥ还显示２例胸降主动脉内的粥样硬化斑块。结论：初步显示术中ＴＥＥ可即刻评价手术效果，对拟行主动脉瓣成形术的患者最有价值；为避免升主动脉粥样斑块的脱落导致术后体循环尤其是脑栓塞，对于高龄患者也积极提倡术中ＴＥＥ监测。     

Routine transesophageal echocardiography for the evaluation of cerebral emboli in elderly patients

BACKGROUND: Approximately 20% of cerebral infarctions are cardioembolic in nature. Transesophageal echocardiography (TEE) is widely regarded as the initial study of choice for evaluating cardiac source of embolism. Although the majority of cerebrovascular accidents occur in elderly patients, the value of TEE in this population is poorly defined. METHODS: We compared 491 patients older than 65 years with suspected embolic stroke or transient ischemic attack (TIA) who had undergone TEE evaluation between April 2000 and February 2004 to an age-, sex-, and time-matched control group that consisted of 252 patients. Studies were reviewed for abnormalities associated with thromboembolic disease. RESULTS: The overall incidence of stroke risk factors was significantly higher in the study than in the control group. However, the four patients with left atrial thrombi had a history of atrial fibrillation. Although ascending and aortic arch sessile atheromata were observed more frequently in the study than control group, there were no significant differences in the incidence of either complex or mobile aortic atheromata. The incidence of atrial septal aneurysm was higher in the stroke/TIA group, but not in association with patent foramen ovale. Finally, there were also no differences in the incidence of spontaneous echocontrast, and/or patent foramen ovale between study and control groups. CONCLUSIONS: We conclude: (1) There is a higher incidence of abnormalities implicated as sources of thromboembolic disease on TEE in elderly patients with cerebral infarctions, but (2) this incidence is driven by the presence of sessile aortic atheroma and atrial septal aneurysm. Until the benefits of specific therapies for these conditions are known, routine TEE in elderly patients with suspected embolic neurological events appears to be unwarranted.     

Transesophageal Echocardiographic Correlates of Clinical Risk of Thromboembolism in Nonvalvular Atrial Fibrillation

Objectives. This study explored the mechanisms linking clinical and precordial echocardiographic predictors to thromboembolism in atrial fibrillation (AF) by assessing transesophageal echocardiographic (TEE) correlations.

Background. Clinical predictors of thromboembolism in patients with nonvalvular AF have been identified, but their mechanistic links remain unclear. TEE provides imaging of the left atrium, its appendage and the proximal thoracic aorta, potentially clarifying stroke mechanisms in patients with AF.

Methods. Cross-sectional analysis of TEE features correlated with low, moderate and high thromboembolic risk during aspirin therapy among 786 participants undergoing TEE on entry into the Stroke Prevention in Atrial Fibrillation III trial.

Results. TEE features independently associated with increased thromboembolic risk were appendage thrombi (relative risk [RR] 2.5, p = 0.04), dense spontaneous echo contrast (RR 3.7, p < 0.001), left atrial appendage peak flow velocities ≤20 cm/s (RR 1.7, p = 0.008) and complex aortic plaque (RR 2.1, p < 0.001). Patients with AF with a history of hypertension (conferring moderate risk) more frequently had atrial appendage thrombi (RR 2.6, p < 0.001) and reduced flow velocity (RR 1.8, p = 0.003) than low risk patients. Among low risk patients, those with intermittent AF had similar TEE features to those with constant AF.

Conclusions. TEE findings indicative of atrial stasis or thrombosis and of aortic atheroma were independently associated with high thromboembolic risk in patients with AF. The increased stroke risk associated with a history of hypertension in AF appears to be mediated primarily through left atrial stasis and thrombi. The presence of complex aortic plaque distinguished patients with AF at high risk from those at moderate risk of thromboembolism.     

Nonobstructive aortic valve calcium as a window to atherosclerosis of the aorta

Aortic valve calcium without stenosis and mitral annulus calcium (MAC) are known to correlate with atherosclerotic risk factors. Recently, it has been reported that MAC is associated with atherosclerosis of the cardiovascular system, suggesting MAC as an atherosclerotic process by itself. Hence, the aim of the present study was to determine whether a similar association between aortic valve calcium and aortic atheroma exists. Ninety-six patients (54 men and 42 women, mean age 72 +/- 12 years) with aortic valve calcium who underwent transesophageal echocardiography (TEE) formed the study group. They were compared with 92 sex- and age-matched patients without aortic valve calcium who underwent TEE for the same indications during the same period. The presence and echocardiographic features of aortic atheromas were evaluated by TEE. No differences were found between the groups in risk factors for atherosclerosis or in indications for referral for TEE. Significantly higher rates were found in the aortic valve calcium group for prevalence of aortic atheroma (86% vs 30%, p = 0.001). This significant trend was also consistent with the dimension and complexity of the atheromas. On multivariate analysis aortic valve calcium, and MAC were the only independent predictors of aortic atheroma (p = 0.0001, 0.006 respectively). We conclude that there is a significant association between the presence of aortic valve calcium and the presence and severity of aortic atheroma. Thus, aortic valve calcium may serve as a window to atherosclerosis of the aorta.     

Assessment of elastic properties of the descending thoracic aorta by transesophageal echocardiography with acoustic quantification in patients with a stroke

Previous studies have described the use of transesophageal echocardiography (TEE) with acoustic quantification (AQ) in assessing aortic elastic properties. We hypothesized that patients with a prior history of stroke (ST) may have a higher risk of atherosclerotic change in great vessels compared to nonstroke subjects (NST) and thus have decreased elastic properties. We assessed the elastic properties of the descending thoracic aorta (DTA) by TEE in ST patients and compared them with data in NST patients. Subjects included 31 with ST without any evidence of emboli originating from the heart (age 51 +/- 10 years, M:F = 20:11) and 25 age-matched NST (M:F = 8:17). Patients with significant valvular heart disease including aortic and mitral regurgitation, left ventricular dysfunction (ejection fraction < 55%), and congenital heart disease were excluded. Compliance (C), distensibility (D), and stiffness index (SI) were measured using AQ and M-mode measurement at a level of the left atrium. We scored atherosclerotic risk factors (ARF) such as a history of diabetes, hypertension, smoking, hypercholesterolemia, and the presence of atheroma of DTA. There was no evidence of atheroma of DTA in NST. There were no significant differences in heart rate and systolic and diastolic blood pressure between ST and NST patients. Fractional area change (FAC) of DTA was significantly lower in ST than in NST patients (3.2 +/- 1.6 vs 5.4 +/- 2.5%, P = 0.000). ST patients had significantly lower C (1.2 +/- 0.4 vs 1.5 +/- 0.7 x 10(-3) cm2 mmHg(-1), P = 0.039), lower D (0.8 +/- 0.3 vs 1.5 +/- 0.8 x 10(-3) mmHg(-1), P = 0.000), and higher SI (10.3 +/- 8.8 vs 5.3 +/- 2.9, P = 0.006) than NST patients. ST patients without atheroma of DTA (n = 21) also had significantly lower C (1.1 +/- 0.4 vs 1.5 +/- 0.7 x 10(-3) cm2 mmHg(-1), P = 0.038) and lower D (3.5 +/- 1.4 vs 4.8 +/- 2.4 x 10(-3) mmHg(-1), P = 0.021) than NST patients. There was a significant positive correlation between SI and the score of ARF (r = 0.51, P = 0.000). The regional elastic properties of DTA measured by TEE with AQ and M-mode method were abnormal in ST. Therefore, TEE with AQ technique may have a possible clinical application for the detection of early atherosclerotic changes such as alteration of elastic properties in morphological normal DTA.     

Evaluating cardiac sources of embolic stroke with MRI

The evaluation of patients with stroke includes identifying its etiology in order to appropriately tailor therapy. Currently, the diagnostic work-up includes imaging of the brain, the arteries of the head and neck, the aorta, and the heart. Traditional methods of imaging include magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), duplex ultrasound, and transthoracic echocardiography (TTE) and/or transesophageal echocardiography (TEE). While echocardiography remains a cornerstone in the field of cardiac imaging, MRI is increasingly able to assess for the most common causes of cardioembolic stroke such as left atrial/left atrial appendage thrombus, left ventricular thrombus, aortic atheroma, cardiac masses and patent foramen ovale. This review will focus on the advantages and limitations of echocardiography and cardiac magnetic resonance (CMR) imaging in diagnosing patients suspected of having an embolic stroke and the role these modalities play in clinical practice today.     

Quantification of Atherosclerotic Burden in the Descending Aorta by Transesophageal Echocardiography: Inter- and Intraobserver Variability

Atherosclerotic plaques had been imaged but not quantitated in the thoracic aorta using transesophageal echocardiography. The aim of this study was to describe a method for measuring the atherosclerotic plaque area in the descending aorta by transesophageal echocardiography (TEE) and to evaluate its reproducibility. TEE examinations were performed by two independent sonographers, in 21 patients with angiographically proven coronary artery disease. Two hundred fifty-six transverse segments (mean 12 ± 3 patient) of the descending aorta were adequately recorded. In each segment the plaque and the lumen areas in the half of the aortic segment distant from the transesophageal probe were measured by one reader in the two studies (intersonographer reproducibility). Interreader reproducibility was also evaluated. The correlation coefficient between the first and second study (intersonographer reproducibility) was 0.81. The standard deviation of the difference between examinations equaled 0.137 cm² and the mean absolute difference between examinations was 0.003 cm² (95% CI: –0.015; 0.021; P = 0.75). The correlation coefficient between the two readers was 0.86, the standard deviation of the difference between readers was 0.175 cm² and the mean absolute difference was 0.006 cm² (95% CI: –0.029; 0.018; P = 0.63). A method for quantitative measurement of aortic atherosclerotic plaque area was evaluated and found to have high intersonographer and intereader reproducibilities. This method might be used in the future for noninvasive evaluation of regression or progression of aortic atherosclerosis.     

Patent Foramen Ovale: Comparison among Diagnostic Strategies in Cryptogenic Stroke and Migraine

Objective: The aim of this study was to compare transthoracic echocardiography (TTE) and transcranial Doppler ultrasonography (TCD) with transesophageal echocardiography (TEE) in order to define the best clinical approach to patent foramen ovale (PFO) detection. Methods: In total, 72 consecutive patients (33 men) with a mean age of 49 ± 13 years were prospectively enrolled. The TEE indication was cryptogenic stroke (36 patients) or migraine (36 patients, 22 with aura). All patients underwent standard TTE, TCD, and TEE examination. For any study, a contrast test was carried on using an agitated saline solution mixed with urea-linked gelatine (Haemaccel), injected as a rapid bolus via a right antecubital vein. A prolonged Valsalva maneuver was performed to improve test sensitivity. Results: TEE identified a PFO in 65% of the whole population: 56.5% in the migraine cohort and 43.5% in the cryptogenic stroke cohort. TTE was able to detect a PFO in 55% of patients positive at TEE (54% negative predictive value, 100% positive predictive value, 55% sensitivity, and 100% specificity). TCD was able to identify a PFO in 97% of patients positive at TEE (89% negative predictive value, 98% positive predictive value, 94% sensitivity, and 96% specificity). Conclusions: In patients with cryptogenic stroke and migraine, there is a fair concordance (k = 0.89) between TCD and TEE in PFO recognition. Accordingly, TCD should be recommended as a simple, noninvasive, and reliable technique, whereas TEE indication should be restricted to selected patients. TTE is a very specific technique, whose major advantage is the ability to detect a large right-to-left shunt, particularly if associated with an atrial septal aneurysm.     

食管超声心动图在重危心脏病人诊断治疗中的价值

目的　为评价食管超声心动图 (TEE)在重危心脏病人诊断治疗中的价值 ,对 3 7例收住监护病房的重症心血管病人进行了经胸超声心动图 (TTE)和TEE检查 ,其中男 2 5例 ,女 1 2例 ,平均年龄57( 1 9～ 85)岁。入选对象包括怀疑夹层动脉瘤 2 3例、心脏瓣膜功能异常 9例、感染性心内膜炎 3例 ,心内分流 2例。结果　所有病人均可耐受TEE检查 ,无并发症发生 ,TEE较TTE可提供更高的阳性诊断结果 ,阳性率分别为 65 0 %和 3 8 0 % ,在怀疑夹层动脉瘤者中 ,TEE检出夹层撕裂膜 1 4例 ;而TTE仅检出 7例 ,且图象欠清 ,检出部位有限。在 4例人工机械瓣膜功能异常者中 ,TEE发现瓣膜部位血栓形成 3例。结论　在对心脏大血管疾病的诊断中 ,TEE阳性诊断率高于TTE ,尤其在怀疑夹层动脉瘤及人工机械瓣膜病变时 ,应行TEE检查。即使在重危病人 ,TEE也是一种安全有效的诊断手段。     

Aortic atheromas: current concepts and controversies-a review of the literature.

The frequent use of transesophageal echocardiogram (TEE) has led to the increased recognition of aortic atheromas. Retrospective and prospective follow-up studies have reported an association between aortic atheromas and stroke in the high-risk patient population, with complex plaques being more likely to embolize than simple plaques. However, TEE-based studies in the low-risk cohorts have failed to show a similar association. There is growing body of evidence suggesting that aortic atheroma is a marker of generalized atherosclerosis. Although magnetic resonance (MR) imaging and computed tomography (CT) scan are emerging as a powerful noninvasive tool for characterization of aortic atheromas, TEE is the imaging modality of choice. Currently, treatment of aortic atheromas is not well defined, and mixed outcomes have been reported for anticoagulation therapy with warfarin. Statins appear promising based on their plaque stabilization properties. However, there are no randomized control trials to establish the role of both anticoagulation and statins in patients with aortic atheromas, and are warranted in the future.     

Routine preprocedural transesophageal echocardiography might not be necessary for stroke prevention evaluation in AF patients on anticoagulation therapy

Background

Preprocedural transesophageal echocardiography (TEE) is used to reduce the stroke during atrial fibrillation (AF) ablation. This study evaluated whether routine preprocedural TEE in addition to multidetector computed tomography (MDCT) is necessary to prevent periprocedural stroke in AF ablation.

Methods

Each patient underwent MDCT and TEE (group 1, n = 247) or MDCT alone (group 2, n = 103) for the initial evaluation before AF ablation. In group 2, TEE was performed only in patients who had left atrial (LA) thrombus or blood stasis in MDCT.

Results

There was no difference in sex, CHADS₂ score, or LA dimension between the two groups. In group 1, a thrombus was detected in 12 (5%) and 6 (2%) patients by the MDCT and TEE, respectively. All (100%) patients, who were revealed to have thrombus in TEE, also had a thrombus in MDCT. In group 2, 3 (3%) patients exhibited LA thrombus in MDCT, among whom thrombus was observed in only one patient (1%) in TEE. AF ablation was not performed in patients with thrombus. While one patient had a periprocedural stroke in group 1, no patient had in group 2 (P = 0.52).

Conclusion

The overall periprocedural stroke rate was low (0.3%) in AF patients on anticoagulation therapy. The preprocedural MDCT detected all patients with the LA thrombus. In AF patients with low CHADS2 score, optimal anticoagulation and relatively preserved left ventricular ejection fraction, routine preprocedural TEE in addition to the MDCT might not be necessary to decrease the periprocedural stroke rate.     

Aortic Atheromas: Current Concepts and Controversies—A Review of the Literature

The frequent use of transesophageal echocardiogram (TEE) has led to the increased recognition of aortic atheromas. Retrospective and prospective follow-up studies have reported an association between aortic atheromas and stroke in the high-risk patient population, with complex plaques being more likely to embolize than simple plaques. However, TEE-based studies in the low-risk cohorts have failed to show a similar association. There is growing body of evidence suggesting that aortic atheroma is a marker of generalized atherosclerosis. Although magnetic resonance (MR) imaging and computed tomography (CT) scan are emerging as a powerful noninvasive tool for characterization of aortic atheromas, TEE is the imaging modality of choice. Currently, treatment of aortic atheromas is not well defined, and mixed outcomes have been reported for anticoagulation therapy with warfarin. Statins appear promising based on their plaque stabilization properties. However, there are no randomized control trials to establish the role of both anticoagulation and statins in patients with aortic atheromas, and are warranted in the future .     

Mobile atheromatous plaque of the aortic arch diagnosed by transthoracic echocardiography prior to coronary artery bypass surgery

A routine pre-operative chest X-ray of a patient admitted to our institution for an elective coronary artery bypass operation revealed a mildly dilated mediastinal silhouette, which led the cardiovascular surgery resident to schedule emergency transthoracic echocardiography (TTE), with a special note asking for detailed evaluation of the ascending aorta and aortic arch. TTE revealed a mobile atheroma at the aortic arch, which obliged the cardiac surgery team to modify their strategy to combined hemi-arcus aortae replacement and coronary artery bypass grafting (CABG). Although with transoesophageal echocardiography (TEE) a small portion of the ascending aorta may be obscured by the trachea, TEE provides higher resolution images than TTE. Therefore one can conclude that TEE is the imaging modality of choice for detecting aortic atheromatous plaques but in patients with low risk for stroke and aortic atheromas, a detailed TTE may be sufficient for the pre-operative assessment.     

The improved yield of transesophageal echocardiography over transthoracic echocardiography in patients with neurological events is largely due to the detection of aortic protruding atheromas

It is important to determine what, if any, the added contribution of transesophageal echocardiography is to the evaluation of patients with unexplained strokes and transient ischemic attacks. Transesophageal echocardiography was performed in 283 consecutive patients over an 8-month period. The reason for referral in 63 of these patients was unexplained stroke or transient ischemic attack. These 63 studies were evaluated for the presence of lesions that could be etiologic in these patients, including protruding aortic atheromas, spontaneous echo contrast, atrial septal aneurysms, and atrial clots. The transesophageal and transthoracic techniques were compared. The main finding was that there were 23 abnormal findings that might have been responsible for stroke or transient ischemic attacks seen on transesophageal echocardiography, which were not visualized on transthoracic echocardiography. Transthoracic echocardiography was false negative in 19 (30%) of 63 patients. None of the protruding aortic arch atheromas seen on transesophageal echocardiography were diagnosed with transthoracic echocardiography. Transesophageal echocardiography is indicated in the evaluation of patients with unexplained strokes and transient ischemic attacks, and the added yield of this technique is largely due to the finding of protruding aortic arch atheromas.