Guidelines For The Use Of Echocardiography In The .
ASE GUIDELINES AND STANDARDSGuidelines for the Use of Echocardiography in theEvaluation of a Cardiac Source of EmbolismMuhamed Saric, MD, PhD, FASE, Chair, Alicia C. Armour, MA, BS, RDCS, FASE, M. Samir Arnaout, MD,Farooq A. Chaudhry, MD, FASE, Richard A. Grimm, DO, FASE, Itzhak Kronzon, MD, FASE,Bruce F. Landeck, II, MD, FASE, Kameswari Maganti, MD, FASE, Hector I. Michelena, MD, FASE,and Kirsten Tolstrup, MD, FASE, New York, New York; Durham, North Carolina; Beirut, Lebanon; Cleveland,Ohio; Aurora, Colorado; Chicago, Illinois; Rochester, Minnesota; and Albuquerque, New MexicoEmbolism from the heart or the thoracic aorta often leads to clinically significant morbidity and mortality due totransient ischemic attack, stroke or occlusion of peripheral arteries. Transthoracic and transesophageal echocardiography are the key diagnostic modalities for evaluation, diagnosis, and management of stroke, systemicand pulmonary embolism. This document provides comprehensive American Society of Echocardiographyguidelines on the use of echocardiography for evaluation of cardiac sources of embolism.It describes general mechanisms of stroke and systemic embolism; the specific role of cardiac and aortic sources in stroke, and systemic and pulmonary embolism; the role of echocardiography in evaluation, diagnosis,and management of cardiac and aortic sources of emboli including the incremental value of contrast and 3Dechocardiography; and a brief description of alternative imaging techniques and their role in the evaluation ofcardiac sources of emboli.Specific guidelines are provided for each category of embolic sources including the left atrium and left atrialappendage, left ventricle, heart valves, cardiac tumors, and thoracic aorta. In addition, there are recommendation regarding pulmonary embolism, and embolism related to cardiovascular surgery and percutaneousprocedures. The guidelines also include a dedicated section on cardiac sources of embolism in pediatric populations. (J Am Soc Echocardiogr 2016;29:1-42.)Keywords: Cardioembolism, Cryptogenic stroke, Cardiac mass, Cardiac tumor, Cardiac shunt, Vegetation,Prosthetic valve, Aortic atherosclerosis, Intracardiac thrombusTABLE OF CONTENTSIntroduction 3Methodology 3General Concepts of Stroke and Systemic EmbolismStroke Classification 33From New York University Langone Medical Center, New York, New York (M.S.);Duke University Health System, Durham, North Carolina (A.C.A.); AmericanUniversity of Beirut Medical Center, Beirut, Lebanon (M.S.A.); Icahn School ofMedicine at Mount Sinai Hospital, New York, New York (F.A.C.); Learner Collegeof Medicine, Cleveland Clinic, Cleveland, Ohio (R.A.G.); Lenox Hill Hospital, NewYork, New York (I.K.); the University of Colorado School of Medicine, Aurora,Colorado (B.F.L.); Northwestern University, Chicago, Illinois (K.M.); Mayo Clinic,Rochester, Minnesota (H.I.M.); and the University of New Mexico HealthSciences Center, Albuquerque, New Mexico (K.T.).The following authors reported no actual or potential conflicts of interest in relationto this document: Muhamed Saric, MD, PhD, FASE, Chair, Alicia Armour, MA, BS,RDCS, FASE, M. Samir Arnaout, MD, Richard A. Grimm, DO, FASE, Bruce F. Landeck, II, MD, FASE, Hector Michelena, MD, FASE, and Kirsten Tolstrup, MD, FASE.The following authors reported relationships with one or more commercialinterests: Farooq Chaudhry, MD, FASE serves as a consultant for Lantheus Medical Imaging and received grant support from GE Healthcare and Bracco. ItzhakType and Relative Embolic Potential of Cardiac Sources ofEmbolism 3Diagnostic Workup in Patients with Potential Cardiac Sources ofEmboli4Kronzon, MD, FASE, serves as a consultant for Philips Healthcare; KameswariMaganti, MD, FASE, received a research grant from GE Healthcare.Reprint requests: American Society of Echocardiography, 2100 GatewayCentre Boulevard, Suite 310, Morrisville, NC 27560 (E-mail: ase@asecho.org).Attention ASE Members:The ASE has gone green! Visit www.aseuniversity.org to earn free continuingmedical education credit through an online activity related to this article.Certificates are available for immediate access upon successful completionof the activity. Nonmembers will need to join the ASE to access this greatmember benefit!0894-7317/ 36.00Copyright 2016 by the American Society of 2015.09.0111
2 Saric et alAbbreviations2D Two-dimensional3D Three-dimensionalASA Atrial septal aneurysmASD Atrial septal defectASE American Society ofEchocardiographyATS Aorticthromboembolism syndromeAVM ArteriovenousmalformationCES Cholesterol embolisyndromeCT Computed tomographyIE Infective endocarditisLA Left atriumLAA Left atrial appendageLV Left ventricleMAC Mitral annularcalcificationMRI Magnetic resonanceimagingMV Mitral valveNBTE Nonbacterialthrombotic endocarditisPE Pulmonary embolismPFE Papillary fibroelastomaPFO Patent foramen ovalePLAX Parasternal long-axisPSAX Parasternal shortaxisRA Right atriumRV Right ventricleSEC Spontaneousechocardiographic contrastTAVR Transcatheter aorticvalve replacementTCD Transcranial DopplerTEE TransesophagealechocardiographyTIA Transient ischemicattackTTE TransthoracicechocardiographyVSD ventricular septaldefectJournal of the American Society of EchocardiographyJanuary 2016Prevention andTreatment 4Role of Echocardiographyin Evaluation of Sourcesof Embolism 4Appropriate Use Criteria forEchocardiography in Evaluationof Cardiac Sources ofEmboli4Appropriate Use:TransthoracicEchocardiography(TTE) 4Appropriate Use: TEE4Uncertain Indication forUse: TEE 5Inappropriate Use:TTE5Inappropriate Use:TEE5A Practical Perspective:EchocardiographicTechniques for Evaluation ofCardiac Sources ofEmbolism 5Two-DimensionalHigh-Frequency andFundamentalImaging5Three-Dimensional andMultiplane Imaging5Saline and TranspulmonaryContrast 5Color Doppler, Off-Axisand Nonstandard Viewsand Sweeps 5TTE versus TEE5Recommendations forPerformance ofEchocardiography in Patientswith Potential Cardiac Sourceof phyPotentially Useful 8Echocardiography NotRecommended8TTE versus TEE8Alternatives to Echocardiographyin Imaging Cardiac Sources ofEmbolism 8Computed Tomographic orMagnetic ResonanceNeuroimaging8Transcranial Doppler(TCD) 8Nuclear Cardiology 9Chest CT 9Chest MRI9Recommendation forAlternative ImagingTechniques in Evaluation ofCardiac Sources ofEmbolism 10Alternative ImagingRecommended10Alternative Imaging Not Recommended10Thromboembolism from the Left Atrium and LAA10Pathogenesis of Atrial Thrombogenesis and Thromboembolism10Echocardiographic Evaluation of the Left Atrium and LAA 13Cardioversion 13Pulmonary Vein Isolation 14Guidance of LAA Percutaneous Procedures14Recommendations for Performance of Echocardiography in Patientswith Suspected LA and LAA Thrombus 14Echocardiography Recommended14Echocardiography Potentially Useful 14Echocardiography Not Recommended14Thromboembolism from the Left Ventricle 14Acute Coronary Syndromes 14Cardiomyopathy 15LV Thrombus Morphology 15Role of Echocardiography in the Detection of LV Thrombus 15Recommendations for Performance of Echocardiography in Patientswith Suspected LV raphyPotentially Useful 16Echocardiography NotRecommended16Valve Disease 16Infective Endocarditis 16Diagnosis 16Prognosis 18Recommendations for Performance of Echocardiography in Patientswith Suspected IE19Echocardiography Recommended19Echocardiography Not Recommended19Nonbacterial Thrombotic Endocarditis 19Verrucous Endocarditis or Libman-Sacks Endocarditis 19Marantic Endocarditis or NBTE20Recommendations for Performance of Echocardiography in Patientswith Suspected Noninfective Endocarditis 21Echocardiography Recommended21Echocardiography Not Recommended21Papillary Fibroelastomas21Valvular Strands and Lambl’s Excrescences 21Mitral Annular Calcification 21Recommendations for Performance of Echocardiography in Patientswith MACs21Echocardiography Potentially Useful 21Prosthetic Valve Thrombosis21Diagnosis 21TEE-Guided Prosthetic Thrombosis Management23Embolic Complications in Interventional Procedures25Recommendations for Performance of Echocardiography in Patientswith Prosthetic Valve Thrombosis25Echocardiography Recommended25Cardiac Tumors 25Echocardiographic Evaluation of Cardiac Tumors 26Myxoma 26Papillary Fibroelastoma 27Recommendations for Echocardiographic Evaluation of CardiacTumors 27Echocardiography Recommended27Echocardiography Potentially Useful 27Echocardiography Not Recommended27Embolism from the Thoracic Aorta 27Role of Echocardiography in the Visualization of Aortic Plaques 29Recommendations for Echocardiographic Evaluation of Aortic Sourcesof Embolism29Echocardiography Recommended29
Saric et al 3Journal of the American Society of EchocardiographyVolume 29 Number 1Echocardiography Potentially Useful 29Echocardiography Not Recommended 29Paradoxical Embolism 29Role of Echocardiography in Evaluation of Suspected ParadoxicalEmbolism31Recommendations for Echocardiographic Evaluation of SuspectedParadoxical Embolism 31Echocardiography Recommended31Echocardiography Potentially Useful 31Echocardiography Not Recommended 31Pulmonary Embolism 32Role of Echocardiography in Evaluation of PE32Recommendations for Echocardiography in Patients with SuspectedPE33Echocardiography Recommended33Echocardiography Not Recommended 33Cardiac and Aortic Embolism during Cardiac Surgery and PercutaneousInterventions 34Cardiac Catheterization34Cardiac Surgery 34Percutaneous Interventions 34Recommendations for Echocardiography in Patients Referred forCardiac Surgery or Percutaneous Intervention 34Echocardiography Recommended34Stroke in the Pediatric Population 35Role of Echocardiography in Evaluation of Systemic Embolism inPediatric Patients 35Recommendations for Echocardiography in Pediatric Patients withSuspected Systemic Embolism 35Echocardiography Recommended35Echocardiography Potentially Useful 36Notice and Disclaimer36Reviewers 36Supplementary data36References 36INTRODUCTIONEmbolism from the heart or the thoracic aorta often leads to clinicallysignificant morbidity and mortality due to transient ischemic attacks(TIAs), strokes, or occlusions of peripheral arteries.Stroke is the third leading cause of death in the United States andother industrialized countries. Echocardiography is essential for the evaluation, diagnosis, and management of stroke and systemic embolism.Cardiac embolism accounts for approximately one third of all casesof ischemic stroke. Paradoxical embolism and embolism from thethoracic aorta, especially of its atheroma contents, are responsiblefor additional cases of stroke and systemic embolism.This document provides the first set of guidelines of the AmericanSociety of Echocardiography (ASE) guidelines specific to this topic.METHODOLOGYThese guidelines are based on an extensive literature reviewincluding all other relevant guidelines from the ASE and other nationaland international medical societies. They provide primarily expertconsensus opinions, because randomized trial data are lacking formany topics discussed in these guidelines. Throughout these guidelines, recommendations are provided in the same format for all topics.There are three levels of recommendations: echocardiography recommended, echocardiography potentially useful, and echocardiographynot recommended. It is hoped that these guidelines will providestandardization in the echocardiographic evaluation of patients withcardiac sources of embolism and lead to improved patient care.GENERAL CONCEPTS OF STROKE AND SYSTEMICEMBOLISMStroke, probably embolic in origin, was first described by the Greekphysician Hippocrates (circa 460–370 BC). He also coined the termapoplexy (ἀpoplhxίa [apoplexia], ‘‘struck down with violence’’) whichwas used for centuries to describe what we now refer to as strokes orcerebrovascular accidents. In 1847, the German pathologist RudolfVirchow (1821–1902) provided initial evidence for the thromboembolic nature of some strokes.Each year, 795,000 people in the United States experience newor recurrent strokes; 610,000 are first attacks and 185,000 are recurrent strokes. It is estimated that 6.9 million American aged 20 yearshave had strokes, which represents 2.7% of all men and 2.6% of allwomen in the United States. The prevalence of silent cerebral infarction is higher, estimated to range from 6% to 28%. Stroke is the thirdleading cause of death in Western countries (after cancer and heartdisease); it accounts for one of every 19 deaths in the United States.In 2009, the direct and indirect cost of stroke in the United Stateswas 36.5 billion.1Fifteen percent of all strokes are heralded by TIAs, defined as localneurologic deficits that last 24 hours.Stroke ClassificationIt is estimated that 87% of all strokes are ischemic, and the remaining13% are hemorrhagic. Using the Trial of Org 10172 in Acute StrokeTreatment criteria,2 ischemic strokes may be further subdivided intofollowing types:1.2.3.4.5.Thrombosis or embolism associated with large vessel atherosclerosisEmbolism of cardiac origin (cardioembolic stroke)Small blood vessel occlusion (lacunar stroke)Other determined causeUndetermined (cryptogenic) cause (no cause identified, more than onecause, or incomplete investigation)The incidence of each cause is variable and depends on patient age,sex, race, geographic location, risk factors, clinical history, physicalfindings, and the results of various tests. This guidelines documentdeals primarily with cardioembolic strokes but also includes discussions of the role of echocardiography in evaluation of embolic strokesfrom the thoracic aorta (atheroembolism) and in cryptogenic strokes.Embolism of cardiac origin accounts for 15% to 40% of all ischemicstrokes,3 while undetermined (cryptogenic) causes are responsiblefor 30% to 40% of such strokes.4Type and Relative Embolic Potential of Cardiac Sources ofEmbolismIn patients who are at risk for or have already had potentially embolicstrokes, the primary role of echocardiography is to establish the existence of a source of embolism, determine the likelihood that such asource is a plausible cause of stroke or systemic embolism, and guidetherapy in an individual patient.Cardiac sources of embolism include blood clots, tumor fragments,infected and bland (noninfected) vegetations, calcified particles, andatherosclerotic debris. Conditions that are known to lead to systemicembolization are listed in Table 1 and subdivided into a high-risk and alow-risk risk group on the basis of their embolic potential. However, in
4 Saric et alJournal of the American Society of EchocardiographyJanuary 2016Table 1 Classification of cardiac sources of embolismHigh embolic potential1. Intracardiac thrombia. Atrial arrhythmiasi. Valvular atrial fibrillationii. Nonvalvular atrial fibrillationiii. Atrial flutterb. Ischemic heart diseasei. Recent myocardial infarctionii. Chronic myocardial infarction, especially with LVaneurysmc. Nonischemic cardiomyopathiesd. Prosthetic valves and devices2. Intracardiac vegetationsa. Native valve endocarditisb. Prosthetic valve endocarditisc. Nonvalvular endocarditis3. Intracardiac tumorsa. Myxomab. PFEc. Other tumors4. Aortic atheromaa. Thromboembolismb. Cholesterol crystal emboliLow embolic potential1. Potential precursors of intracardiac thrombia. SEC (in the absence of atrial fibrillation)b. LV aneurysm without a clotc. MV prolapse2. Intracardiac calcificationsa. MACb. Calcific aortic stenosis3. Valvular anomaliesa. Fibrin strandsb. Giant Lambl’s excrescences4. Septal defects and anomaliesa. PFOb. ASAc. ASDmany conditions more than one embolic source may be present(coexistence of embolic sources) or one cardioembolic conditionmay lead to another (interdependence of embolic sources). Forinstance, mitral stenosis is associated with spontaneous echocardiographic contrast (SEC), atrial fibrillation, left atrial (LA) clot, andeven endocarditis.Diagnostic Workup in Patients with Potential CardiacSources of EmboliEvaluation of suspected cardiac source of embolism requires rapiddiagnostic efforts, which should include detailed history, comprehensive physical examination, blood workup, and imaging of the heartand the organs damaged by the embolus. Echocardiography shouldbe the primary form of cardiac imaging, supplemented by chest xray, computed tomography (CT), magnetic resonance imaging(MRI), and nuclear imaging when necessary. CT or MRI as well asangiography may be indispensable in the evaluation of organs and tissues affected by cardiac sources of embolism.Prevention and TreatmentEchocardiography plays an important role not only in the diagnosisbut also in the treatment and prevention of cardiac sources of embolism. This aspect of echocardiography is beyond the scope of thisguidelines document; references to appropriate treatment and prevention guidelines are given in individual sections of this document.ROLE OF ECHOCARDIOGRAPHY IN EVALUATION OFSOURCES OF EMBOLISMSince its earliest days, echocardiography has been considered animportant tool in the evaluation of possible cardiac source of embolism. Even the one-dimensional M-mode technique, which was firstintroduced in 1953 by Swedish cardiologist Inge Edler (1911–2001)and engineer Hellmuth Hertz (1920–1990), was capable of demonstrating conditions associated with embolic stroke and systemicemboli, such as mitral stenosis, LA dilatation, LA myxoma, and leftventricular (LV) systolic dysfunction.The introduction of two-dimensional (2D) echocardiography inthe early 1970’s further expanded the diagnostic capability and accuracy of ultrasound imaging in the evaluation of cardiac sources of embolism; wall motion abnormalities could be better defined, andvarious normal and abnormal cardiac structures could be better assessed.The introduction of Doppler techniques in the 1970’s and transesophageal echocardiography (TEE) in the 1980’s allowed more precise quantification of normal and abnormal intracardiac structuresand blood flows. Finally, the advent of real-time three-dimensional(3D) echocardiography at the turn of the 21st century has providedunprecedented anatomic and functional details of many cardiac structures implicated as cardiac sources of embolism and allowed guidanceof percutaneous treatments of sources of cardiac embolism (e.g.,percutaneous closure of LA appendage (LAA) in patients with atrialfibrillation).The overall use of echocardiography in the evaluation of cardiacsources of emboli should follow established appropriate use criteria.5Below is an excerpt from the appropriate use criteria guidelines, withentries relevant to cardiac sources of embolism.Appropriate Use Criteria for Echocardiography inEvaluation of Cardiac Sources of EmboliAppropriate Use: Transthoracic Echocardiography (TTE) Symptoms or conditions potentially related to suspected cardiac etiology,including but not limited to chest pain, shortness of breath, palpitations,TIA, stroke, or peripheral embolic event Suspected cardiac mass Suspected cardiovascular source of embolus Initial evaluation of suspected infective endocarditis (IE) with positive bloodculture results or new murmur Reevaluation of IE at high risk for progression or complication or with achange in clinical status or cardiac examination results Known acute pulmonary embolism (PE) to guide therapy (e.g., thrombectomy and thrombolytic therapy) Reevaluation of known PE after thrombolysis or thrombectomy for assessment of change in right ventricular (RV) function and/or pulmonary arterypressureAppropriate Use: TEE As initial or supplemental test for evaluation for cardiovascular source ofembolus with no identified noncardiac source
Journal of the American Society of EchocardiographyVolume 29 Number 1 As initial or supplemental test to diagnose IE with a moderate or high pretestprobability (e.g., staph bacteremi
cerebrovascular accidents. In 1847, the German pathologist Rudolf Virchow (1821–1902) provided initial evidence for the thromboem-bolic nature of some strokes. Each year, 795,000 people in the United States experience new or recurrent strokes; 610,000 are first attacks and 185,000 are recur-rent strokes.
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