Diagnosis of pulmonary embolism by transoesophageal echocardiography.

A 68-year-old woman was admitted for major dyspnoea. A transoesophageal echocardiogram was performed after the occurrence of acute circulatory shock. During the examination, the patient was under mechanical ventilation. We found a thrombus that had almost occluded the right pulmonary artery and which was later confirmed by selective angiography. Despite treatment, the patient died 2 days later; autopsy confirmed the thrombus in the right pulmonary artery.     

Diagnostic value of transoesophageal echocardiography in suspected haemodynamically significant pulmonary embolism

OBJECTIVE—To assess the value of transoesophageal echocardiography (TOE) for diagnosing suspected haemodynamically significant pulmonary embolism and signs of right ventricular overload at standard echocardiography.
METHODS—113 consecutive patients (58 male; 55 female), mean (SD) age 53.6 (13.3) years, in whom there was clinical suspicion of pulmonary embolism and right ventricular overload on transthoracic echocardiography, underwent TOE in addition to routine diagnostic procedures to identify pulmonary artery thrombi.
RESULTS—TOE revealed thrombi in 32 of 51 patients who had suspected acute pulmonary embolism and in 31 of 62 with suspected chronic pulmonary embolism. In one patient a pulmonary angiosarcoma rather than chronic pulmonary embolism was found at surgery. The diagnosis of pulmonary embolism was confirmed in 77 patients by scintigraphy, spiral computed tomography, angiography, or necropsy (reference methods). While TOE failed to provide a diagnosis of pulmonary embolism in 15 of these 77 patients, no false positive findings were reported (sensitivity 80.5%, specificity 97.2%). In 11 and 26 cases, respectively, the thrombi were confined to the left or right pulmonary artery. Bilateral thrombi were found in 25 patients. Mobile thrombi were observed only in acute pulmonary embolism (in 19 of 32 patients). No complications of TOE were noted.
CONCLUSIONS—TOE permits visualisation of pulmonary arterial thrombi, confirming the diagnosis in the majority of patients with pulmonary embolism and right ventricular overload. This may be useful for prompt decision making in patients with haemodynamic compromise considered for thrombolysis or embolectomy.


Keywords: pulmonary embolism; transoesophageal echocardiography     

Transesophageal echocardiographically detected atherosclerotic aortic debris in a patient with systemic embolism following coronary angiography

Summary Transesophageal echocardiography (TEE) has enabled detection of the cardiac source of systemic emboli. We report the case of a patient who manifested systemic, multiple embolization in the kidney, skin, and upper gastrointestinal tract following coronary angiography. TEE allowed visualization of the atherosclerotic debris in the thoracic aorta. The clinical picture of the patient was consistent with that of cholesterol embolism. We recommend that patients with extensive atherosclerotic disease should undergo TEE before cardiac catheterization or other invasive procedures involving the aorta are carried out.     

Transoesophageal echocardiography for definitive diagnosis of haemodynamically significant pulmonary embolism

Transoesophageal echocardiographic evaluation of right and leftpulmonary arteries, up to the origin of their lobar branches,was prospectively performed with a single plane probe in 32consecutive patients (18M, 14F, aged 55.5 ± 14.6, from32 to 80 years) with clinical or echocardiographic suspicionof pulmonary embolism, who met transthoracic echocardiographiccriteria of right ventricular overload Transoesophageal echocardiographyshowed unequivocal (20 patients) or suspected (three patients)intraluminar thrombi in 88.5% of 26 patients with haemodynamicallysignificant acute or chronic pulmonary embolism, confirmed withreference methods. The sensitivity of the unequivocal transoesophagealechocardiographic diagnosis was 80% for acute and 73% for chronichaemodynamically significant pulmonary embolism. No false-positiveresults were found (specificity 100%). Additionally, in three cases, transoesophageal echocardiographydisclosed the cause of the right ventricular overload revealinga previously undiagnosed atrial septal defect or Ebstein anomaly. Direct visualization of proximal pulmonary arterial thrombiby transoesophageal echocardiography emerges as a useful newmethod of prompt and definite diagnosis of haemodynamicallyimportant pulmonary embolism.     

Aorta and aortic valve morphologies predisposing to aortic dissection: An in vivo assessment with ransoesophageal echocardiography

Predisposing factors for aortic dissection are well known fromnecropsy series. To evaluate the frequency of aortic and aorticvalve disease in aortic dissection in vivo, 139 patients withacute aortic dissection (96 men, 43 women, mean age 60.5 ±15.7 years) were studied by transoesophageal echocardiography(TEE) using 3.5 and 5.0 MHz transducers. Left ventricular hypertrophyby TEE, defined as an end-diastolic wall thickness of the leftventricular septal wall over 1.5 cm, was found in 42 (67.7%)of 62 patients with type I, in 10 (58.8%) of 17 patients withtype II and in 46 (76.7%) of 60 patients with type III dissection.The mean value for the aortic root diameter was 3.2 ±1.3 cm. m^–2 in type I dissection and 2.8 ± 0.9cm. m^–2 (ns) in type II dissection. In the patient groupwith type III dissection this diameter was significantly smaller(1.8 ± 0.9 cm m^–2; P<0.001). Thickening of aorticvalve leaflets was demonstrated in six (9.7%) of 62 patientswith aortic dissection type I (two of them with mild aorticstenosis), in two (11.8%) of 17 patients with aortic dissectiontype II and in 15 (25.0%) of 60 patients with aortic dissectiontype III. A bicuspid aortic valve was diagnosed in five (6.3%)of 79 patients with aortic dissection types I and II and inone (1.7%) of 60 patients with type III dissection. By colourcoded Doppler echocardiography, aortic regurgitation was foundin 46 (74.2%) of 62 patients with type I, 13 (76.5%) of 17 patientswith type II and 23 (38.3%) of 60 patients with type III dissection.A coarctation of the aorta was present in two patients. TEE allows the diagnosis of aortic dissection, as well as ofaccompanying pathologies of the aorta and aortic valve. Factorspredisposing for aortic dissection can be detected in vivo.     

Paradoxical cerebrovascular embolism associated with pulmonary arteriovenous fistula: contrast transoesophageal echocardiographic diagnosis.

We report two cases of paradoxical cerebrovascular embolism associated with intrapulmonary arteriovenous fistulas. In both cases the diagnosis was made by the use of contrast transoesophageal echocardiography, which not only detected the fistulas but also localized the arteriovenous fistula to specific pulmonary vascular beds.     

Protruding atherosclerotic aortic plaques and dyslipidaemia: correlation to subtypes of ischaemic stroke.

AIMS: To evaluate whether thoracic aortic plaques together with dyslipidaemia are related to ischaemic stroke, and if so, to which of the subtypes of stroke. METHODS AND RESULTS: We performed transoesophageal echocardiography in 50 patients with acute ischaemic stroke and in 401 controls. The aorta was divided into two segments: (1) the proximal, proximal to the left subclavian artery, and (2) the distal aorta. Protruding plaques (Intima > or =4 mm in thickness) in the proximal aorta were detected in 14 of the 50 patients (28%) with stroke, and in 53 of the 401 controls (13%) (P<0.01). Plaque score in the proximal aorta (2.1 +/- 1.8 vs 0.9 +/- 0.7; P<0.05), low-density lipoprotein cholesterol level (3.60 +/- 0.85 vs 2.87 +/- 0.72 mmol/l; P<0.05), and apolipoprotein B/A-I ratio (0.98 +/-0.17 vs 0.73 +/- 0.16; P<0.005) were higher in patients with athero-thrombotic than in cardioembolic stroke. The score in the proximal aorta correlated with low-density lipoprotein cholesterol level (r=0.44, P<0.005) and apolipoprotein B/A-I ratio (r=0.40, P<0.01). CONCLUSION: Severe plaques in the proximal aorta together with dyslipidaemia are seen more frequently in patients with atherothrombotic stroke. Lipid analysis may contribute to the prediction and the treatment of the patients who are at high risk for atherothrombotic stroke.     

Relapsing polychondritis with aortic arch aneurysm and aortic arch syndrome

Summary A case of relapsing polychondritis with aortic arch aneurysm and aortic arch syndrome is described. The pattern of vascular involvement supports the inclusion of relapsing polychondritis within the spectrum of systemic vasculitides.     

Investigation of the thoracic aorta in cholesterol embolism by transoesophageal echocardiography

Objectives—To examine the thoracic aorta of patients with severe cholesterol embolism (CE) by transoesophageal echocardiography (TOE).
Methods—The thoracic aorta of 20 consecutive patients with CE was compared with that in a control population matched for age and risk factors by TOE. Patients were prescribed steroids after CE was diagnosed. Follow up is reported and compared with results in the literature.
Results—Aortic plaques and debris were more common in patients with CE than in the control population (p < 0.001 and p < 0.0001, respectively). The mean (SD) number of aortic plaques in the CE patients was 2.6 (0.7). This aortic atheroma was found predominantly in the descending aorta. One patient died during a mean (SD) follow up of 24 (10) months.
Conclusions—Aortic atheroma, as detected by TOE, should be considered as the main source of CE. In addition, the prognosis in our series, in which steroids were systematically prescribed, is much better than in others reported in the literature.

Keywords: aortic atheroma;  transoesophageal echocardiography;  cholesterol embolism     

Resolution of an aortic mobile mass with anticoagulation without evidence of arterial embolism

The prognostic significance of aortic mobile debris detected by transesophageal echocardiography (TEE) in patients without history of embolism has not been established. A mobile aortic arch mass was found by TEE in a 59-year-old man with coronary artery disease, and with rheumatic mitral valve disease, and with no embolic symptoms. The patient was anticoagulated for 6 weeks and the mass was no longer seen on repeated TEE. He had no embolic symptoms during 9 months of follow-up. Different therapeutic approaches to mobile aortic debris are discussed and anticoagulant treatment of asymptomatic cases is advocated.     

Complex atheromatosis of the aortic arch in cerebral infarction

In many stroke patients it is not possible to establish the etiology of stroke. However, in the last two decades, the use of transesophageal echocardiography in patients with stroke of uncertain etiology reveals atherosclerotic plaques in the aortic arch, which often protrude into the lumen and have mobile components in a high percentage of cases. Several autopsy series and retrospective studies of cases and controls have shown an association between aortic arch atheroma and arterial embolism, which was later confirmed by prospectively designed studies. The association with ischemic stroke was particularly strong when atheromas were located proximal to the ostium of the left subclavian artery, when the plaque was ≥ 4 mm thick and particularly when mobile components are present. In these cases, aspirin might not prevent adequately new arterial ischemic events especially stroke. Here we review the evidence of aortic arch atheroma as an independent risk factor for stroke and arterial embolism, including clinical and pathological data on atherosclerosis of the thoracic aorta as an embolic source. In addition, the impact of complex plaques (≥ 4 mm thick, or with mobile components) on increasing the risk of stroke is also reviewed. In non-randomized retrospective studies anticoagulation was superior to antiplatelet therapy in patients with stroke and aortic arch plaques with mobile components. In a retrospective case-control study, statins significantly reduced the relative risk of new vascular events. However, given the limited data available and its retrospective nature, randomized prospective studies are needed to establish the optimal secondary prevention therapeutic regimens in these high risk patients.     

CT detection of pulmonary embolism and aortic dissection

Triage of patients with acute, potentially life-threatening chest pain is one of the most daunting challenges currently facing emergency department physicians. Acute aortic syndrome and pulmonary embolism are two potentially underlying causes. For both, computed tomography has become the de facto clinical reference standard for diagnosis. This article discusses state-of-the-art computed tomography for the detection of these disorders, including recent advances and future perspectives.     

The utility of transoesophageal echocardiography to determine management in suspected embolic stroke

Background: Assessment for source of stroke is a common indication for transoesophageal echocardiography (TOE). Although an abnormality is frequently found, it remains uncertain how frequently the findings alter patient management. Also, the role of transthoracic echocardiography (TTE) prior to or instead of TOE is not well defined. We sought to determine the use of TTE prior to TOE, the outcome of the TOE and its impact on management. Methods: We retrospectively reviewed the records and echocardiography results of 100 consecutive patients who underwent TOE for any reason at a tertiary hospital. In 35 subjects (35%), the indication was evaluation for source of stroke. Among these, we determined clinical risk factors for stroke, if a TTE was performed prior to their TOE, the results of the TOE and its effect on management. Results: The mean age of the stroke patients was 64.6 years (17–90) and 49% were women. Eighty per cent had at least one risk factor for stroke and 17% had atrial fibrillation. A TTE, performed in 40% prior to the TOE, found an abnormality in 14% (2/14). The TOE showed an abnormality in 71% of patients; 54% had aortic atheroma; 17% PFO; 14% spontaneous echo contrast; 6% left atrial appendage thrombus, 3% left ventricular thrombus and 3% vegetation. In only one patient (3%) the management was altered based on the abnormal TOE findings. Conclusion: An abnormality on TOE, although common (71%) and more sensitive than TTE, altered management in only 3% of subjects referred for stroke assessment. Its role requires further consideration.     

Multiplane transoesophageal echocardiography detection of a papillary fibroelastoma of the aortic valve causing myocardial infarction

Primary aortic valve tumours are rare. A patient is reportedwith a papillary fibroelastoma attached to the edge of the rightcoronary aortic cusp. This tumour was diagnosed by multiplanetransoesopliageal echocardiography after the patient experiencedan acute inferolateral myocardial infarction. Multiplane transoesopliagealechocardiography was useful to visualize and identify the precisepoint of attachment of the tumour, enabling cardiac surgeonsto plan aortic valve repair rather than replacement.     

Recurrent systemic embolism caused by thrombosis in a stenotic bicuspid aortic valve

Thrombosis in a native aortic valve is a rare complication whichmay lead to systemic embolization. A few cases of aortic thrombosisin previously abnormal valves have been described. In this report,we describe a 42-year-old male who suffered two acute ischaemicattacks, one in the upper right limb and another in the cerebralterritory supplied by the left sylvian artery, from a thrombusthat developed in a bicuspid and stenotic aortic valve. Thediagnosis was made with transthoracic and transoesophageal echocardiography,and the patient subsequently underwent surgery. In cases ofbicuspid aortic valves, we should think of thrombosis as a possiblecomplication with its resulting risk of embolism, and assesssuch patients with transthoracic and transoesophageal echocardiography,thus enabling their early detection and treatment.     

Pulmonary embolism and impending paradoxical embolism: A role for transesophageal echocardiography?

Thrombolysis is advocated as the treatment of choice for hemodynamically important pulmonary embolism. This paper reports the case of a patient with subacute massive pulmonary embolism in which thrombolysis was not considered appropriate because transesophageal echocardiography demonstrated a patent foramen ovale and impending paradoxical embolism.     

Hybrid repair of aortic arch aneurysm

Aneurysms of the transverse aortic arch requiring surgery most often affects elderly patients with multiple co-morbidities and represents a significant challenge to both patient and surgeon. The hybrid approach developed in recent years (debranching followed by endovascular repair) may improve the morbidity and mortality of the population risk. We present the case report of a 72-year-old man with aortic arch aneurysm arising at the origin of the left subclavian artery involving whole caudal segment of an aortic arch with concomitant single vessel coronary disease. The hybrid procedure was carried out in two stages, first (open surgical approach) performing an extra-anatomic bypass – debranching combining with concomitant coronary artery bypass procedure without heart–lung machine and following day deploying the aortic endograft. Postoperative period was uneventful. On the 15th day after hybrid procedure, the patient was discharged in a stabilized condition for ambulatory care. This approach may be an alternative to standard open procedures in high-risk patients with promising midterm results.     

主动脉弓去分支化术在主动脉病变中的应用

主动脉弓去分支化术(Aortic arch debranching,AAD)作为全弓置换的替代方案,正逐渐被运用于高危患者中.在主动脉弓部瘤的患者中,联合去分支化及胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)的杂交技术可降低75岁以上患者的住院死亡率.在B型主...     

A bovine aortic arch in humans

We describe a curious congenital variation of human aortic arch (AA) branching pattern termed the “bovine aortic arch”. Rather than arising directly from the AA as a separate branch as occurs in the most common AA branching pattern, the left common carotid artery moves to the right and merges from the brachiocephalic trunk. It is the normal AA branching pattern presented in a number of animals (canines, felines or Macaque monkeys) but it has nothing to do with anatomy of AA in ruminant animals, including cattle and buffalo. That is why it is one of the most widely misnomers used in medical literature whose origin is nowadays unknown.     

Transoesophageal echocardiographic visualization of renal cyst mimicking aortic aneurysm.

We report a tricky case of a 63-year-old man with previous coronary artery bypass graft surgery in whom transoesophageal echocardiography revealed a voluminous echolucent cavity simulating aortic ectasia but that proved to be of nephrogenic origin.