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Chair, Dept. of Cardiovascular Sciences

Director, Non -Invasive Imaging

Professor of Medicine

ARTHUR J. LABOVITZ, MD, FASE

UNIVERSITY OF SOUTH FLORIDA

ECHO AND

CARDIAC SOURCE

OF EMBOLISM

- remains major cause of morbidity and mortality

-ki l ls almost 130,000 Americans each year —that ’s 1 in every 19 deaths

-On average, one American dies f rom stroke every 4 minutes

-Every year, more than 795,000 people in the United States have a s t roke. About 610,000 of these are f irs t/new strokes . 1 in 4 are recurrent s t rokes

- About 87% of all s t rokes are ischemic

-Stroke costs the U.S an est imated $38.6 bil l ion each year.

This total includes the cost of health care ser vices , medicat ions , and missed days of work.

STROKE

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Etiology

Vascular disease- 40%

Cardiac Embolic- 30%

Lacunar- 10%

Cryptogenic- 20%

STROKE

Associated clinical syndromes:

Atrial fibrillation

LV dysfunction

Valvular heart disease

Hypercoagulable states

CARDIAC EMBOLI

Intercardiac thrombus identification

Structural abnormalities

Associated clinical syndromes

THROMBOEMBOLIC DISEASE:

CARDIAC EVALUATION

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Implied

• Patent Foramen Oval

• Atrial Septal Aneurysm

• Mitral Valve Prolapse

• Mitral Annular Calcification

• Valve Strands

Culprit Lesion

•Thrombus

•Complex Plaque (AA)

•Cardiac Tumors (myxoma)

•Vegetations

Markers

•LV dysfunction

•LV enlargement

•LA enlargement

•LAA dysfunction

•Spontaneous Contrast

•Complex Plaque (DA)

CARDIAC STROKE ECHOCARDIOGRAPHIC

FINDINGS

ECHO AND CSE

Front End Anticoagulation

Thrombus

Dense “smoke”

Back End Anticoagulation

Stunning

Mechanical SR

ATRIAL FIBRILLATION

TEE

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AFib

LV dysfunction

Endocarditis

DISEASE STATE

Supplementary CHADS

Guiding Cardioversion

General Assessment

AFIB

LEFT ATRIAL APPENDAGE (LAA)

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231 pts. Undergoing mitral valve surgery

TEE identified 14 thrombi

Sensitivity 100%

Specificity 99%

TEE AND ATRIAL THROMBUS

LV Function EF

Thrombus

Atrial Abn SEC

Thrombus

LAA Velocity

Valve disease

Masses

Atrial Septum PFO

ASA

Aortic Atheroma TEE (60%) TTE (15%)

ECHO AND STROKE

SPAF III

Thromboembolic Events

Ann Int Med 1998

Group

Combo ADJ INR

SEC Faint 6% 2.8%

Dense 18% 4.5%

Thrombus Absent 7.2 2.3

Present 12.9 17.9

LAA vel <20 13.1 6.7

>20 6.3 1.4

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CHADS2 RISK STRATIFICATION

SCHEME

Risk Factors Score

C Recent congestive heart failure 1

H Hypertension 1

A Age >75 yrs 1

D Diabetes mellitus 1

S2 Hx of stroke or transient ischemic attack 2

Rockson et al JACC 2004;43

1.92.8

4

5.9

8.5

12.5

18.2

0

5

10

15

20

0 1 2 3 4 5 6

CHADS2 Score

Str

ok

e R

ate

(%

)

Rockson et al JACC 2004;43

Relationship Between CHADS2 Score and Risk of Stroke

Atrial Fibrillation

Risk Stratify

Cardioversion Suspected

Cardiac Emboli

TEE AND STROKE

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0

5

10

15

20

NML LV Function

Mild LV

Function

Mod-Severe LV

Function

Arch Int Med 1998;158

Str

ok

e r

ate

, pe

rce

nt p

er

pa

tie

nt ye

ar

SPAF

A-FIB RISK STRATIFICATION

TEE:

•LA Thrombus

•LA spontaneous contrast

•LAA velocity

•Aortic complex plaque

TEE AND STROKE

(SPAF III RESULTS)

Left Atrial Abnormality

7.8%/y

(4/50)

Both

20.5%/y

(7/36)

Complex Aortic Plaque

12.0%/y

(4/31)

Neither

1.3%/y

(1/61)

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SEC/Smoke

Atrial appendage velocity

Thrombus

ATRIAL STASIS

ATRIAL THROMBI AMONG PATIENTS WITH NEWLY

RECOGNIZED AF

TEE STUDIES

Study No. of

Patients

No. (%) With

Atrial Thrombi

Stoddard (1995) 206 37 (18%)

ACUTE Pilot (1997) 56 7 (13%)

Weigner (2001) 539 70 (13%)

ACUTE, Klein (2001) 619 76 (12%)

Corrado (1999) 123 11 (9%)

Corrado et al. Chest. 1999;115:140-143; Klein et al. Ann Intern Med. 1997:126:200-209; Klein et al. N Engl J Med. 2001;344:1411-1120;

Stoddard et al. Am Heart J. 1995;129:1204-1215; Weigner et al. Am J Med. 2001;110:694-702.

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Myxomas

Fibroelastoma

Metastatic

TUMORS

MYXOMA

TUMOR VS THROMBUS

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More prevalent in patients with cr yptogenic stroke

Risk Factors

Size

Shunting

Pressures

Associated ASA

Closure

PFO

RISK FACTORS

Early shunting

Marked shunting

Associated ASA

Hypercoagulable risk

Previous stroke

PFO & STROKE

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PFO AND STROKE

Most common consistent component of fetal circulation

Variable size (1-19 mm)

High prevalence in stroke

Shunting with normal PA pressures

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Post MI

CMP

WARCEF

Role of TTE

LV THROMBUS

Mitral Stenosis

Valve strands

Lambl’s

Endocardit is

Prosthetic Valves

VALVE DISEASE

FEVER/STROKE

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PFO /ASD

ASA

Lipomatous

ATRIAL SEPTUM

Complex plaque

Location

Treatment

Marker in AFib

High prevalence in stroke

Associated with carotid disease (marker)

Protruding (>4mm) and mobile components highest risk

Best identif ied with TEE

Optimal RX unknown

AORTIC ATHEROMA

AORTIC ATHEROMA

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STROKE AND AORTIC PLAQUE

0

2

4

6

8

10

12

>4mm 1-4mm 1mm

11.9

3.5 2.8

(n = 331)

P<.001

French Stroke Group NEJM 1996

Peripheral Emboli Stroke

0% 0% 0% 0% 0% 0% 0%

45%

PLAQUE MORPHOLOGY VS ANTICOAGULATION

Non-Mobile/No Warfarin

Non-Mobile/ Warfarin

Mobile/ No Warfarin

Mobile/ Warfarin

Follow-up Events (Dressler JACC 1994)

AORTIC ATHEROMAS AORTIC ATHEROMAS

High prevalence in stroke

Associated with carotid disease (marker)

Protruding (>4mm) and mobile components highest risk

Best identif ied with TEE

Optimal RX unknown

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Tunick et al AJC 2002:90:1320

AORTIC PLAQUE

(N=519)

O’Brien et al., AJC 1998

TEE AND STROKE: PROGNOSIS