Echocardiography in detection of cardiac and aortic sources of systemic embolism
- Warren J Manning, MD
Warren J Manning, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine and Radiology
- Harvard Medical School
Intracardiac sources of embolism may account for 15 to 20 percent of the 500,000 strokes that occur annually in the United States (in addition to other embolic issues such as organ infarction [eg, renal infarct, splenic infarct, mesenteric infarct] or acute limb ischemia) . Although transthoracic echocardiography (TTE) remains the cornerstone of noninvasive cardiac imaging, transesophageal echocardiography (TEE) has been shown to be a superior method for the identification of most cardiac sources of emboli [2,3], although cardiac magnetic resonance imaging (CMR) is superior for left ventricular thrombus detection . (See "Transesophageal echocardiography: Indications, complications, and normal views".)
The potential cardiac and arterial sources of emboli, along with the role of TTE and TEE in their detection, will be reviewed here. The acute management of embolic disease and the secondary prevention of additional embolization are discussed in the appropriate clinically-oriented topics. (See "Antithrombotic treatment of acute ischemic stroke and transient ischemic attack" and "Overview of acute arterial occlusion of the extremities (acute limb ischemia)".)
OUR APPROACH TO IDENTIFYING THE SOURCE OF EMBOLISM
The choice between transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) as the initial imaging test to identify a source of embolism should be individualized on a case-by-case basis. For most patients, TEE yields higher quality images and has a greater sensitivity and specificity than TTE, but a few conditions (eg, left ventricular thrombus) are better seen on TTE with contrast or by cardiac magnetic resonance imaging (CMR). Because of widespread availability, ease of performance, and moderate to high yield in many patients, we typically begin with TTE, although for selected patients, directed TEE may be preferred.
TTE as the initial test — We choose TTE as the initial test for the majority of patients with a suspected cardiac or aortic source of emboli, including:
●Patients ≥45 years with a neurologic event and no identified cerebrovascular disease
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- OUR APPROACH TO IDENTIFYING THE SOURCE OF EMBOLISM
- TTE as the initial test
- TEE as the initial test
- POTENTIAL SOURCES OF EMBOLI
- Intracardiac sources of emboli
- - Thrombus
- - Non-thrombotic masses
- Arterial sources of emboli
- CHOOSING BETWEEN TTE AND TEE
- LA/LAA thrombi
- - Left atrial spontaneous echo contrast
- Left ventricular thrombi
- Valvular vegetations
- Prosthetic valve sources
- Cardiac tumors
- Abnormalities of the interatrial septum
- Aortic atherosclerosis
- SUMMARY AND RECOMMENDATIONS