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Management of sources of embolism: the role of echocardiography

Non-Invasive Imaging

The session was organized in four lectures in order to highlight advantages and limitations of the echocardiographic assessment of sources of embolism.

From the neurologist’s point of view (JM Ferro, Lisbon, PT) echocardiography does not have an impact on the selection of patients suitable for thrombolyses and for prognostic stratification. However, TTE (2-37 %) and TOE (4-32 %) reveal conditions of uncertain management (e.g., PFO, echo-contrast). TTE is widely available, easy to perform and at low cost but TOE is much more sensitive in diagnosing several sources of embolism. In this view, the performance of TOE should be taken into account in all patients with new -onset stroke. Insufficient evidence cannot sustain a widespread use of TTE/TOE in all stroke patients.

In the lecture titled “Permanent foramen ovale: when to close?” Dr P Amarenco (Paris, FR) underscored the controversial data about the impact of patent foramen ovale (PFO), even when associated to atrial septal aneurysm (ASA) in sustaining the onset of ischemic stroke. Of consequence, also the need for the closure of PFO remains controversial. This is mainly due to the absence of randomized trials on this issue. In particular, one study showed a 4% annual risk in patients with PFO + ASA. In a recent meta-analysis, the RR of PFO for recurrent stroke is 0.52 to 1.74. The speaker concluded that the search for a PFO and/or ASA in patients with embolic stroke is imperative only when the standard diagnostic work-up is negative.

The lecture “Atherosclerosis of the aorta” (A Evangelista Map, Barcelona, Spain) pointed out the absolute role of TOE as the technique of choice in diagnosis of aortic atherosclerosis as a main source of embolism. A standard classification of aortic involvement was proposed: Grade I = normal aortic intima-media thickness (IMT), Grade II = IMT from 1 to 3.9 mm, Grade III = Atheroma, Grade IV = Thrombus with mobile structures. The prevalence of aortic involvement in patients with embolic stroke is, however, uncertain. The association of aortic atherosclerosis is very strong with aortic valve sclerosis (86%) while it is lower with abdominal aneurysm (52%) and with carotid involvement (only 38%).

In particular, the PICSS Study demonstrated the presence of an aortic arch plaque in 65% with embolic stroke. This reflects possible different strategies management. Again the PICSS Study showed 16.4% versus 15.8% (p=0.03) incidence of recurrent stroke in patients treated with aspirin or warfarin. The use of statins seems to be encouraged, in relation with both their lipid lowering action and pleiotropic effects.

The speaker of the lecture “Cardiac masses” (RP Martin, Atlanta, USA) showed a variety of cardiac masses possibly determining an embolic stroke. Suggestive echo images of cardiac masses, such as atrial and ventricular thrombi, endocarditis vegetations, primitive (mainly mixoma) and metastatic cardiac neoplasm were projected. All may be sources of embolism in clinical practice.

The speaker highlighted the mechanicistic role of atrial fibrillation, either in atrial cavity or in the appendage, in inducing the formation of thrombi. In this view, an accurate prevention of embolic stroke shall be done by 6-week anticoagulant therapy before the reversal of atrial fibrillation, with an additional role of TOE before restoring sinus rhythm. The echo scan is also important to differentiate false sources of embolism (e.g., Chiari network, pectinates muscles in the left appendage).




Management of sources of embolism: the role of echocardiography

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.