LETTER
Transesophageal Echocardiography: Useful Tool or Expensive Toy?
Claudia Stollberger, MD, and
Josef Finsterer, MD
1 November 1998 | Volume 129 Issue 9 | Page 749
TO THE EDITOR:
It is questionable to draw common conclusions from two studies on atrial fibrillation that have different aims and inclusion criteria [1]. The SPAF-III study aimed to correlate TEE characteristics with subsequent stroke in patients with high risk for thromboembolism [2]. The ELAT study, an observational study, aimed to correlate TEE characteristics with subsequent thromboembolism in outpatients [3].
The ELAT study assessed interobserver variabilities for atrial thrombi, spontaneous echocardiographic contrast, and left atrial appendage size; the SPAF-III study did not [4, 5]. Although criteria for thrombi differed between these studies, both studies showed that patients with atrial thrombi who received anticoagulation have a high stroke rate. Thus, with no treatment better than anticoagulation, identification of thrombi by TEE has no relevance.
The SPAF-III study found that patients who underwent TEE later than 2 weeks after enrollment had a lower rate of thrombi while receiving adjusted-dose warfarin than while receiving combination therapy, whereas the rate was the same in patients who underwent TEE before this date. The ELAT study showed that thrombi are associated with diabetes, heart failure, and low fractional shortening [4]. In the SPAF-III study, the authors did not state whether clinical characteristics and rate of anticoagulation before enrollment were equally distributed among the patients with thrombi who underwent TEE within 2 weeks and later than 2 weeks after randomization. Therefore, it cannot be concluded that the lower rate of thrombi in the adjusted-dose group is a consequence of anticoagulation [1].
The ELAT study showed that clinical characteristics such as hypertension, advanced age, and previous thromboembolism are more helpful than TEE characteristics for assessment of embolic risk. Because clinical characteristics were excluded from multivariate analysis in the SPAF-III study, conclusions about clinical characteristics are not justified.
The data provided by both studies do not suggest that an invasive investigation such as TEE is superior to simply taking the history for assessment of embolic risk in patients with atrial fibrillation.
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Author and Article Information
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For the ELAT Study Group; A-1030 Vienna, Austria
1. Manning WJ, Douglas PS. Transesophageal echocardiography and atrial fibrillation: added value or expensive toy? [Editorial] Ann Intern Med. 1998; 128:685-7.
2. Transesophageal echocardiographic correlates of thromboembolism in high-risk patients with nonvalvular atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators Committee on Echocardiography. Ann Intern Med. 1998; 128:639-47.
3. Stollberger C, Chnupa P, Kronik G, Brainin M, Finsterer J, Schneider B, et al. Transesophageal echocardiography to assess embolic risk in patients with atrial fibrillation. Ann Intern Med. 1998; 128:630-8.
4. ELAT study (Embolism in Left Atrial Thrombi): baseline clinical and echocardiographic data. Cardiology. 1995; 86:457-63.
5. Kronik G, Stollberger C, Schuh M, Abzieher F, Slany J, Schneider B. Interobserver variability in the detection of spontaneous echo contrast, left atrial thrombi, and left atrial appendage thrombi by transesophageal echocardiography. Br Heart J. 1995; 74:80-3.
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