Value of Transesophageal Echocardiography in the Etiological Screening of Cardioembolic Stroke

doi:10.3969/j.issn.1673-5765.2026.05.009

Abstract

Abstract: Objective To evaluate the value of transesophageal echocardiography (TEE) combined with contrast-enhanced TEE in the etiological screening of cardioembolic stroke.
Methods This prospective study consecutively enrolled patients with clinically suspected cardioembolic stroke who were admitted to the Beijing Tiantan Hospital, Capital Medical University, between March 2023 and May 2025. All enrolled patients underwent routine transthoracic echocardiography (TTE) and TEE examinations. Among them, patients with atrial fibrillation underwent left heart contrast enhanced-TEE (LHCE-TEE), and patients with right-to-left shunt (RLS) indicated by TCD underwent agitated saline contrast enhanced-TEE (ASCE-TEE). The observed indicators included intracardiac and atrial appendage thrombi, the source and grade of RLS, prosthetic valve thrombus, and aortic arch plaque condition.
Results A total of 256 patients with suspected cardioembolic stroke were enrolled, including 80 patients with atrial fibrillation, 150 patients with RLS, and 26 patients with other etiologies. Among the 80 patients with atrial fibrillation, 16 patients were diagnosed with left atrial appendage thrombi. The initial examination results showed that the number of left atrial appendage thrombi detected by TTE, TEE, and LHCE-TEE was 1, 8, and 16, respectively. LHCE-TEE was superior to TEE in detecting hypoechoic thrombi (9 cases vs. 1 case, P<0.01) and non-active thrombi (9 cases vs. 1 case, P<0.01). Among the 150 patients with RLS, ASCE-TEE detected more cases of patent foramen ovale (PFO) (125 cases) than TTE (15 cases) and TEE (65 cases) and was able to identify smaller PFOs, with statistically significant differences (both P<0.01). ASCE-TEE detected 125 cases of PFO-RLS, 55 cases of pulmonary vein-related RLS (P-RLS), and 45 cases with both PFO-RLS and P-RLS. Semiquantitative analysis of RLS showed that the proportion of patients with grade 3 shunt volumes was higher than that with grade 1 and 2 shunt volumes in both PFO-RLS and P-RLS (both P<0.05). Additionally, TTE demonstrated a higher detection rate for left ventricular thrombi than TEE (12 cases vs. 8 cases), while TEE outperformed TTE in detecting prosthetic valve thrombi (6 cases vs. 1 case) and unstable aortic arch and/or descending aortic plaques (25 cases vs. 10 cases).
Conclusions LHCE-TEE can clearly delineate the borders of hypoechoic left atrial appendage thrombi and significantly improve the detection rate of hypoechoic and non-active thrombi. ASCE-TEE accurately identifies PFO and effectively differentiates the source and grade of RLS. TEE has important clinical value in detecting prosthetic valve thrombi, unstable aortic arch and/or descending aortic plaques.

Key words: Transesophageal echocardiography; Contrast agent; Cardioembolic stroke

摘要： 目的探讨经食管超声心动图（transesophageal echocardiography，TEE）联合心脏声学造影在心源性卒中病因筛查中的应用价值。
方法本研究采用前瞻性设计，连续纳入2023年3月—2025年5月就诊于首都医科大学附属北京天坛医院的疑似心源性卒中患者。纳入患者均进行常规经胸超声心动图（transthoracic echocardiography，TTE）及TEE检查。其中，合并心房颤动患者行TEE联合左心声学造影（left heart contrast enhanced-TEE，LHCE-TEE）检查；TCD提示存在右向左分流（right-to-left shunt，RLS）的患者行TEE联合右心声学造影（agitated saline contrast enhanced-TEE，ASCE-TEE）检查。观察指标包括心腔内及心耳内血栓、RLS的来源及分流级别、人工瓣膜血栓及主动脉弓斑块情况。
结果共纳入256例疑似心源性卒中患者，其中合并心房颤动患者80例，RLS患者150例，其他病因患者26例。在80例合并心房颤动的患者中，确诊为左心耳血栓的有16例。初始检查结果显示，TTE、TEE和LHCE-TEE的左心耳血栓检出例数分别为1例、8例和16例；LHCE-TEE对低回声血栓（9例 vs. 1例，P<0.01）及非活动性血栓（9例 vs. 1例，P<0.01）的检出率均高于TEE。在150例疑似RLS患者中，ASCE-TEE对卵圆孔未闭（patent foramen ovale，PFO）的检出数量（125例）高于TTE（15例）与TEE（65例），且能识别较小的PFO，差异均具有统计学意义（均P<0.01）。ASCE-TEE共检出卵圆孔未闭相关的右向左分流（patent foramen ovale-related right-to-left shunt，PFO-RLS）125例，肺静脉相关的右向左分流（pulmonary vein-related right-to-left shunt，P-RLS）55例，同时存在PFO-RLS与P-RLS的45例。RLS半定量分析结果显示，PFO-RLS与P-RLS的3级分流患者比例均高于1级和2级分流（均P校正<0.05）。此外，TTE对左心室血栓的检出率高于TEE（12例 vs. 8例），而TEE对人工瓣膜血栓（6例 vs. 1例）、主动脉弓和（或）降主动脉不稳定斑块（25例 vs. 10例）的检出率高于TTE。
结论 LHCE-TEE能清晰显示左心耳低回声血栓边界，显著提高低回声及非活动性血栓的检出率；ASCE-TEE可精准识别PFO，并有效区分RLS的来源和分流级别。TEE在评估人工瓣膜血栓、主动脉弓和（或）降主动脉不稳定斑块方面具有重要的临床价值。

关键词: 经食管超声心动图; 造影剂; 心源性卒中

CLC Number:

ZHANG Huiqin, DU Lijuan, ZHANG Meng, LYU Yifei, HE Wen, ZHANG Wei. Value of Transesophageal Echocardiography in the Etiological Screening of Cardioembolic Stroke[J]. Chinese Journal of Stroke, 2026, 21(5): 585-592.

张惠琴, 杜丽娟, 张萌, 吕一飞, 何文, 张巍. 经食管超声心动图在心源性卒中病因筛查中的价值[J]. 中国卒中杂志, 2026, 21(5): 585-592.

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URL: https://www.chinastroke.org.cn/EN/10.3969/j.issn.1673-5765.2026.05.009

https://www.chinastroke.org.cn/EN/Y2026/V21/I5/585

References

[1] 中华医学会老年医学分会老年神经病学组，心源性卒中诊断中国专家共识撰写组. 心源性卒中诊断中国专家共识（2020）[J]. 中华老年医学杂志，2020，39（12）：1369-1378.
Geriatric Neuropathy，Geriatric Medicine Branch，Chinese Medical Association；Chinese Expert Consensus Writing Group on Diagnosis of Cardiogenic Stroke. Chinese experts’ consensus on the diagnosis of cardiogenic stroke（2020）[J]. Chin J Geriatr，2020，39（12）：1369-1378.
[2] LIN H J，WOLF P A，KELLY-HAYES M，et al. Stroke severity in atrial fibrillation. The Framingham study[J]. Stroke，1996，27（10）：1760-1764.
[3] YU M Y，CAPRIO F Z，BERNSTEIN R A. Cardioembolic stroke[J]. Neurol Clin，2024，42（3）：651-661.
[4] KIRCHHOF P，BENUSSI S，KOTECHA D，et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS[J]. Eur Heart J，2016，37（38）：2893-2962.
[5] BENITES-YSHPILCO L，CUPE-CHACALCAJE K，CACHICATARI-BELTRÁN A，et al. Complex aortic plaques：hidden danger in aortic stenosis. Role of transesophageal echocardiography[J/OL]. Arch Peru Cardiol Cir Cardiovasc，2024，5（2）：e377[2026-01-17]. https://doi.org/10.47487/apcyccv.v5i2.377.
[6] HUANG G S，SHEEHAN F H，GILL E A. Transesophageal echocardiography simulation：a review of current technology[J]. Echocardiography，2022，39（1）：89-100.
[7] PINHO J，DHAENENS L，HECKELMANN J，et al. Left atrial appendage thrombus in acute stroke：diagnostic accuracy of CT angiography compared to transesophageal echocardiography[J/OL]. J Stroke Cerebrovasc Dis，2023，32（2）：106936[2026-01-17]. https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106936.
[8] CAPDEVILLE S，GHOLSON B A，LINDNER J R. Contrast echocardiography for assessing myocardial perfusion[J]. Curr Cardiol Rep，2023，25（11）：1581-1587.
[9] GAO C Y，LIU Y J，XU D. The clinical diagnostic value of right-to-left shunt in cryptogenic stroke under right heart contrast echocardiography：a retrospective case-control study[J]. Cardiovasc Diagn Ther，2024，14（6）：1048-1057.
[10] TERAN F，PRATS M I，NELSON B P，et al. Focused transesophageal echocardiography during cardiac arrest resuscitation：JACC review topic of the week[J]. J Am Coll Cardiol，2020，76（6）：745-754.
[11] BERNIER M，ABDELMONEIM S S，STUART MOIR W，et al. CUTE-CV：a prospective study of enhanced left atrial appendage visualization with microbubble contrast agent use during transesophageal echocardiography guided cardioversion[J]. Echocardiography，2013，30（9）：1091-1097.
[12] LOZIER M R，SANCHEZ A M，MIHOS C G. A systematic review on the use of ultrasound enhancing agents with transesophageal echocardiography to assess the left atrial appendage prior to cardioversion[J]. Echocardiography，2021，38（8）：1414-1421.
[13] HE G J，LIU H X，HUANG X Y，et al. Intracardiac versus transesophageal echocardiography for diagnosis of left atrial appendage thrombosis in atrial fibrillation：a meta-analysis[J]. Clin Cardiol，2021，44（10）：1416-1421.
[14] SPOSATO L A，ALBIN C S W，ELKIND M S V，et al. Patent foramen ovale management for secondary stroke prevention：state-of-the-art appraisal of current evidence[J]. Stroke，2024，55（1）：236-247.
[15] VIZZARI G，PIZZINO F，ZWICKE D，et al. Patent foramen ovale：anatomical complexity and long-tunnel morphology related issues[J]. Am J Cardiovasc Dis，2021，11（3）：316-329.
[16] TRABATTONI D，GILI S，TERUZZI G，et al. A severe right-to-left intracardiac shunt after NobleStitch failure：when a device is needed[J]. Eur Heart J Case Rep，2020，4（5）：1-4.
[17] REIMANN L，MAYER L，SCHNEIDER S R，et al. Change in right-to-left shunt fraction in patients with chronic thromboembolic pulmonary hypertension after pulmonary endarterectomy[J/OL]. J Cardiovasc Dev Dis，2023，10（11）：442[2026-01-17]. https://doi.org/10.3390/jcdd10110442.
[18] YU Y H，LIU H，HE J H，et al. Risk factors for the development of cryptogenic stroke and the predictive value of right-to-left shunt in patent foramen ovale[J]. Eur Rev Med Pharmacol Sci，2024，28（3）：1027-1035.
[19] VORSELAARS V M M，VELTHUIS S，HUITEMA M P，et al. Reproducibility of right-to-left shunt quantification using transthoracic contrast echocardiography in hereditary haemorrhagic telangiectasia[J]. Neth Heart J，2018，26（4）：203-209.
[20] ZHANG H Q，HUANG W Y，LAN T Y，et al. The value of contrast-enhanced transesophageal echocardiography in the detection of cardiac right-to-left shunt related with cryptogenic stroke and migraine[J/OL]. Biomed Res Int，2020：8845652[2026-01-17]. https://doi.org/10.1155/2020/8845652.
[21] XIA H M，GAN L，JIANG Y，et al. Use of transesophageal echocardiography and contrast echocardiography in the evaluation of cardiac masses[J/OL]. Int J Cardiol，2017，236：466-472[2026-01-17]. https://doi.org/10.1016/j.ijcard.2017.01.073.
[22] MIYAKE Y，SUGIOKA K，BUSSEY C D，et al. Left ventricular mobile thrombus associated with ventricular assist device：diagnosis by transesophageal echocardiography[J]. Circ J，2004，68（4）：383-384.
[23] DE AGUSTIN J A，POZO OSINALDE E，OLMOS C，et al. Current usefulness of transesophageal echocardiography in patients undergoing transcatheter aortic valve replacement[J/OL]. J Clin Med，2023，12（24）：7748[2026-01-17]. https://doi.org/10.3390/jcm12247748.