Purpose: This study evaluated the value of transthoracic echocardiography (TTE), contrast TTE (cTTE), transesophageal echocardiography (TEE) and cardiovascular magnetic resonance imaging and angiography (CMR) for assessment of cardioembolic sources in a cohort of patients with recent systemic embolism and cardiac dysfunction.
Method: We prospectively enrolled 78 patients (58 men, mean age 63 ± 15 years) with recent systemic embolic event and evidence of left ventricular (LV) dysfunction (EF < 40% or regional wall motion abnormalities) on TTE. As part of the protocol, patients also underwent imaging using an ultrasound contrast agent (cTTE) and CMR within 1 week of TTE. TEE was also performed in a subset of patients if clinically indicated by the treating physician (n=26). Imaging studies were evaluated for potential sources of embolism. Information on resultant management of patients was obtained from review of the medical chart.
Result: Seventy-four patients (95%) had a cerebrovascular event, with the remaining 4 patients diagnosed with peripheral artery occlusion (2), retinal artery occlusion, and splenic infarct. Combining all modalities, a potential cardiovascular source of embolism was identified in 41 patients (53% of cohort), 5 with more than one potential source. The table below demonstrates different diagnostic testing strategies with diagnostic yield and effect on treatment.
Diagnostic Strategies | Potential Source of Embolism Identified (entire cohort; n=78) | Potential Source of Embolism Identified (subset with treatment data; n=57) | Strategy Resulted in Significant Change in Management |
| TTE only | 12/78 (15%) | 8/57 (14%) | 2/57 (4%) |
| cTTE only | 5/69 (7%) | 4/50 (8%) | 3/50 (6%) |
| TEE only | 15/26 (58%)* | 12/19 (63%)** | 4/19 (21%)** |
| CMR only | 31/78 (40%)*** | 17/57 (30%)* | 8/57 (14%)* |
| TTE+cTTE | 14/71 (20%) | 10/51 (20%)*** | 4/45 (9%) |
| TTE+TEE | 24/35 (69%)** | 16/24 (67%)** | 5/24 (21%)** |
| TTE+CMR | 33/78 (42%)*** | 20/57 (35%)** | 9/57 (16%)** |
| TEE+CMR | 38/46 (83%)*** | 24/30 (80%)*** | 9/30 (30%)*** |
| TTE+cTTE+TEE | 25/38 (66%)*** | 18/26 (69%)** | 7/26 (27%)** |
| TTE+cTTE+CMR | 34/78 (44%)*** | 21/57 (37%)** | 10/57 (18%)** |
| TTE+TEE+CMR | 41/49 (84%)*** | 25/32 (78%)*** | 9/32 (28%)*** |
| TTE+cTTE+TEE+CMR | 41/50 (82%)*** | 26/33 (79%)*** | 10/33 (30%)*** |
Conclusion: TEE and CMR both added significant diagnostic and treatment value to TTE. The use of TEE and CMR together, without TTE, provided the best streamlined diagnostic strategy for diagnosis and management of patients with systemic embolism.
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