Response to Letter Regarding Article, “Transesophageal Echocardiography in Cryptogenic Stroke and Patent Foramen Ovale Analysis of Putative High-Risk Features From the Risk of Paradoxical Embolism Database”

I read with a great interest the Risk of Paradoxical Embolism (RoPE) Study of Wessler et al,1 who demonstrated that previously proposed high-risk transesophageal echocardiography (TEE) findings of septal hypermobility, shunt at rest, and a physiologically large shunt do not seem to be found more frequently in patients whose clinical and neuroimaging features (ie, superficially located lesions) are highly suggestive of a patent foramen ovale (PFO)-attributable index stroke. They concluded that, “Due to numerous technical limitations, TEE may be unreliable in risk stratifying PFO on the basis of physiological and anatomic features.” In my …