Role of transesophageal echocardiography in the assessment and therapeutic management of patients with acute ischemic cerebral events before the age of 65]

Introduction: Ischemic stroke is the leading cause of mortality in Portugal, with around 30 to 50% of cases being of cardioembolic etiology. Transesophageal echocardiography (TEE) has assumed growing importance in the detection of cardiac sources of embolism. However, there is controversy regarding the implications of TEE findings for the therapeutic approach to patients with ischemic stroke. Objectives: To analyze TEE findings in the diagnostic work-up of patients with ischemic cerebral events and to determine their influence on therapeutic strategy. Methods: We retrospectively studied patients with stroke or transient ischemic attack (TA) before the age of 65, of no apparent cause after carotid ultrasound, electrocardiogram and transthoracic echocardiography, who underwent TEE between 1992 and 2009. The following diagnoses on TEE were considered as potential embolic sources: atrial septal defect; patent foramen ovate (PFO); atrial septal aneurysm (ASA); vegetations; tumors; intracavitary thrombi; and aortic plaques >2 mm (ascending aorta and arch). Results: We analyzed 294 patients, mean age 45 years, 56.8% men. TEE revealed a potential cardioembolic source in 36.7% of the patients, PFO and ASA being the most frequent. Throughout the period considered, there was an increase in the number of exams performed, as well as in diagnoses, mainly PFO and ASA. Comparison of patients with and without a diagnosis on TEE showed that the former were older and were more often prescribed oral anticoagulation. By multivariate analysis, the presence of a positive TEE finding was shown to be an independent predictor of treatment with oral anticoagulation (OR=2.48; CI 95%: 1.42-4.34; p=0.001). Conclusion: In the population under analysis, TEE was useful in identifying potential cardioembolic sources and influenced the therapeutic strategy. (C) 2010 Sociedade Portuguesa de Cardiologia. Published by Elsevier Espana, S.L. All rights reserved.