European Journal of Echocardiography (2010) 11, 461–476 RECOMMENDATIONS doi:10.1093/ejechocard/jeq045 Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism European Association of Echocardiography (EAE) (a registered branch of the ESC) Downloaded from Mauro Pepi 1*,ArturoEvangelista2, Petros Nihoyannopoulos 3, Frank A. Flachskampf 4, 5 6 7 8 George Athanassopoulos , Paolo Colonna , Gilbert Habib , E. Bernd Ringelstein , ejechocard.oxfordjournals.org Rosa Sicari 9, and Jose Luis Zamorano 10 on behalf of the European Association of Echocardiography Document Reviewers: Marta Sitges a and Pio Caso b 1Centro Cardiologico Monzino, IRCCS, Department Cardiovascular Sciences, University of Milan, Via Parea 4, 20138 Milan, Italy; 2Hospital Vall d’Hebron, Barcelona, Spain; 3Hammersmith Hospital, London, UK; 4University of Erlangen, Erlangen, Germany; 5Onassis Cardiac Surgery Center, Athens, Greece; 6Division of Cardiology, Policlinico Hospital, 7 8 9 Bari, Italy; University Hospital La Timone, Marseilles, France; Department of Neurology, University Hospital Mu¨nster, Germany; Institute of Clinical Physiology, Pisa, Italy; and at Landstinget i Uppsala län on August 24, 2010 10Hospital Clı´nico San Carlos, Madrid, Spain aIstitut de Torax, Hospital Clinic Universitat de Barcelona; and bOspedale Monaldi, Napoli Received 17 February 2010; accepted after revision 5 March 2010 Embolism of cardiac origin accounts for around 15–30% of ischaemic strokes. Strokes due to cardioembolism are generally severe and early and long-term recurrence and mortality are high. The diagnosis of a cardioembolic source of stroke is frequently uncertain and relies on the identification of a potential cardiac source of embolism in the absence of significant autochthone cerebrovascular occlusive disease. In this respect, echocardiography (both transthoracic and/or transoesophageal) serves as a cornerstone in the evaluation, diagnosis, and manage- ment of these patients. A clear understanding of the various types of cardiac conditions associated with cardioembolic stroke and their intrin- sic risk is therefore very important. This article reviews potential cardiac sources of embolism and discusses the role of echocardiography in clinical practice. Recommendations for the use of echocardiography in the diagnosis of cardiac sources of embolism are given including major and minor conditions associated with the risk of embolism. ----------------------------------------------------------------------------------------------------------------------------------------------------------- Keywords Cardioembolic stroke † Transthoracic echocardiography † Transoesophageal echocardiography Introduction peripheral embolism. Stroke is the third leading cause of death in several industrial countries and cardiogenic embolism accounts Why do we need recommendations for for 15–30% of ischaemic strokes.1 –3 The diagnosis of a cardioem- the echocardiographic diagnosis and bolic source of stroke is frequently uncertain and relies on the identification of a potential cardiac source of embolism in the management of cardiac sources of absence of significant autochthonous cerebrovascular occlusive embolism? disease. In this regard, echocardiography [both transthoracic Echocardiography is commonly used for the investigation of (TTE) and/or transoesophageal (TOE)] serves as a cornerstone patients with acute stroke, transient ischaemic attack (TIA) or in the evaluation and diagnosis of these patients. However, * Corresponding author. Tel: +39 2 580021; fax: +39 2 58002287, Email: [email protected] Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2010. For permissions please email: [email protected] 462 M. Pepi et al. cardioembolic stroke is a heterogeneous entity, since a variety of Method of article and definition of levels cardiac conditions can predispose to cerebral embolism. These of recommendations cardiac conditions may be classified as major, minor, or uncertain This consensus document is based on a literature review con- risk (Table 1). The indications for and role of ultrasound techniques ducted using Medline (PubMed) for peer-reviewed publications in these diseases are not well defined. Moreover, from a pathologi- and focuses on the studies published mainly in the last 10 years. cal point of view cardioembolic sources of embolism may be classi- Publications on appropriateness reflect an ongoing effort by the fied into three distinct categories: cardiac lesions that have a authors to critically and systematically create, review, and categor- propensity for thrombus formation [i.e. thrombus formation in ize clinical conditions and situations, where diagnostic tests are the left atrial appendage (LAA) in patients with atrial fibrillation used by physicians caring for patients with a suspected of cardiac (AF)], cardiac masses (i.e. cardiac tumours, vegetations, thrombi, source of embolism. Although not intended to be entirely compre- aortic atherosclerotic plaques), and passageways within the heart hensive, the indications are meant to identify common scenarios serving as conduits for paradoxical embolization (i.e. PFO, patent encompassing the major part of contemporary practice in this foramen ovale). field. The ultimate aim of this document is to improve patient Recommendations are important in this field for several reasons. Downloaded from care and health outcomes in a cost-effective manner (whenever (1) The clinical diagnosis is now dominated by echocardiography possible) linked to clinical decision making. Availability or quality which has become the standard to evaluate these patients; of equipment or personnel may influence the choice of appropri- however, better transducers and new ultrasound modalities ate imaging procedures. These criteria are also associated with (i.e. second harmonic imaging, Doppler tissue imaging, contrast clinical judgement and practice experience. Because of the echocardiography, 3D, and others) have further improved and diverse nature of the topics and the absence of objective rating ejechocard.oxfordjournals.org expanded diagnostic capabilities. Consequently, the complemen- levels of evidence (mainly due to gaps in current knowledge in tary or alternative role of TTE and TOE may be further defined. several fields), it was not possible to provide a systematic (2) Treatment of these conditions and of ischaemic stroke has not uniform summary of recommendations in all chapters. On the only developed through the continuous advances in under- basis of all these considerations, the writing group decided to standing of the disease, but has also been reoriented by the avoid levels of recommendations and maintain only the term ‘Rec- development of new strategies and the advent of interven- ommendation’. This implies an appropriate method recommended tional techniques. for all patients with a suspected of cardiac source of embolism. (3) The today’s patient population has changed due to ageing, and increase of patients with heart failure with a significant decline at Landstinget i Uppsala län on August 24, 2010 in both rheumatic fever and rheumatic valve disease. General comments (4) The aim of these recommmendations is to provide a consensus document for the echocardiographic screening Patient evaluation and diagnosis of cardiac sources of embolism. Evidence for Ischaemic stroke or TIA may be caused by several factors such as indications to recommend echocardiography in patients with systemic hypoperfusion, in situ thrombosis or vascular or cardio- stroke, TIA, or peripheral embolism is reviewed in detail. genic embolism. Since embolism from a cardiac source accounts for 15–30% approximately of these cerebral events, a very detailed neurological and cardiac evaluation should first include Table 1 Potential cardioembolic sources the patient’s clinical presentation, even though there are several limitations in making this clinical diagnosis. Several neurological Major risk sources Minor or unclear risk and cardiac features (detailed information on the characteristics sources ................................................................................ of the clinical event, history of the patients, clinical evaluation) Atrial fibrillation Mitral valve prolapse may suggest a cardioembolic origin. Moreover, evidence of embo- Recent myocardial infarction Mitral annulus calcification lism to other organs suggests that a cardioembolic source is likely. Previous myocardial infarction (LV aneurysm) Neurological and cardiac evaluation Cardiomyopathies Calcified aortic stenosis A number of cardiac conditions have been proposed as potential Cardiac masses sources of embolism and an accurate clinical evaluation may Intracardiac thrombus Atrial septal aneurysm easily raise the suspicion of a cardioembolic even in the presence Intracardiac tumours of known structural heart disease or of clinical signs of cardiac dis- Fibroelastoma Patent foramen ovale eases (i.e. arrhythmias, heart murmurs). However, the presence of Marantic vegetations a potential cardioembolic source of embolism does not itself justify Rheumatic valve disease (mitral Giant Lambl’s excrescences the diagnosis of cardioembolic stroke or TIA, since atherosclerotic stenosis) cerebrovascular disease and cardiac disease often co-exist. The Aortic arch atheromatous plaques most frequent causes of cardiogenic stroke are AF, left ventricular Endocarditis (LV) dysfunction (congestive heart failure), valve disease and