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Utility of TEE for the evaluation of cerebral ischemia of uncertain origin.

We are writing in response to the article "Routine Transesophageal Echocardiography [TEE] for Cerebral Ischemia: Is It Really Necessary?" by Warner and Momah. 1 The authors' conclusions that (1) TEE is not cost-effective as a routine diagnostic procedure in patients presenting with cerebral ischemic events and (2) patients in sinus rhythm usually have findings for which there is no recommended therapy or for which only aspirin is indicated are inappropriately founded and are discordant with other published data. The primary question that is currently debated within the cardiology and neurology communities is whether or not TEE is indicated for patients with acute cerebral ischemia of uncertain origin (ie, cryptogenic stroke). Whereas the American Heart Association currently recommends TEE in patients with cryptogenic stroke or transient ischemic attack, 2 to our knowledge no governing body or practice guideline currently advocates the routine use of TEE in unselected patients with cerebral ischemia.