Transesophageal echocardiography in acute aortic transection

Confirming the diagnosis of acute transection of the descending aorta can be problematic. Unnecessary patient movement and time delay are often associated with conventional investigations. We describe a patient in whom such an injury was clearly and quickly defined at the bedside by transesophageal echocardiography.     

Transesophageal echocardiography and aortic valve surgery

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Transesophageal echocardiography after contrast-enhanced CT angiography in the diagnosis of type A aortic dissection

Contrast-enhanced CT angiography (CTA) currently is considered the diagnostic modality of choice in the diagnosis of acute type A aortic dissection. However, pitfalls associated with acquisition and interpretation of CTA images may result in misdiagnosis. We present examples of false-positive and false-negative interpretations of CTA in emergency situations that underline the importance of intraoperative preincision transesophageal echocardiography (TEE) in the diagnosis and management of this highly lethal entity.     

Transesophageal echocardiography for diagnosis of traumatic aortic injury: an appraisal of the evidence

BACKGROUNDS: An overview of the validity of transesophageal echocardiography (TEE) in patients suspected to have traumatic aortic injury (TAI). METHODS: Computerized bibliographic search of trials from 1994 to 2002 evaluating the use of TEE to confirm the diagnosis of TAI. Seven relevant studies out of 204 were identified, involving 758 patients. The accuracy of TEE was analyzed by constructing summary receiver-operating characteristic (sROC) curves and computing areas under the sROC curve. RESULTS: No prospective randomized trial was found. Although accuracy varied greatly, summary ROC curve found that TEE enjoyed a high diagnostic performance. Some study characteristics can affect accuracy. CONCLUSIONS: Our findings seems to indicate that TEE is a valuable tool for diagnosing TAI, and its use as first-line evaluation of such patients can be supported; however, given the lack of randomized trials, no standard of care can be drawn from the present overview: future studies should look at this problem more carefully, and should be methodologically rigorous.     

经食管超声心动图在胸主动脉瘤介入治疗中的应用

血管内修复术创伤性小，可应用于治疗多种主动脉疾病，如动脉瘤和主动脉夹层。经食管超声心动图(TEE)对主动脉疾病很敏感。术前可通过TEE找到撕裂的内膜片、发现内膜破口、区分类型、区分真假腔及了解心脏状况。术中TEE用于引导导管插至正确位置、观察支架放置过程、监测心功能和室壁运动状况、评价手术疗效。术后随诊通过TEE观察支架内血流情况、检出并发症如内漏等。     

Transesophageal echocardiography

Anesthesiologists are increasingly using transesophageal echocardiography in both cardiac and noncardiac cases. In cardiac anesthesia, considerable progress has been made in the evaluation of mitral valvular disease. Transesophageal echocardiography has also become more useful in the hemodynamic evaluation of patients undergoing coronary artery bypass grafting. It is particularly valuable in minimally invasive surgery and in heart surgery to correct congenital defects.     

Perioperative diagnosis of mesenteric ischemia in acute aortic dissection by transesophageal echocardiography

Objective: Although computed tomography, angiography, or magnetic resonance imaging is most commonly used for diagnosing mesenteric ischemia caused by acute aortic dissection, use of these modalities is often limited in the perioperative period. Thus, we have introduced transesophageal echocardiography to cover this deficit. Purpose of this study is to report the feasibility and accuracy of transesophageal echocardiographic diagnosis on mesenteric ischemia. Methods: The consecutive 24 cases with acute aortic dissection which involved abdominal aorta and underwent surgery were examined. The celiac artery and superior mesenteric artery was visualized with 5 MHz biplane transesophageal echocardiography and was assessed for presence of dissection and blood flow in each of true and false lumen. The transesophageal echocardiographic findings were then correlated to the clinical course, computed tomographic findings, and laboratory data. Results: The celiac artery and superior mesenteric artery was successfully visualized in 24 cases (100%) and 23 cases (95.8%), respectively. Perfusion patterns in superior mesenteric artery were categorized into four patterns: (1) intact artery with adequate perfusion (type A: 14 cases); (2) dissection in the artery but with adequate perfusion in true lumen (type B: 5 cases); (3) dissection in the artery with narrowed true lumen compressed by false lumen without detectable blood flow (type C: 1 case); and (4) obstruction of arterial orifice by the intimal flap with narrowed true lumen in the proximal aorta (type D: 2 cases). One case with immediate postoperative death and another case with unsuccessful visualization of superior mesenteric artery were excluded from the analysis. Clinically apparent intestinal ischemia was present in three cases: one case with type C and two cases with type D, but in none of the remaining 19 cases with type A or type B (both sensitivity and specificity were 100%). The superior mesenteric artery was opacified in all of these three cases with ischemia. Conclusions: The transesophageal echocardiographic assessment is feasible in nearly all patients and potentially provides correct diagnosis on intestinal ischemia in the perioperative period of acute aortic dissection. Types C and D indicate significant mesenteric malperfusion.     

Transesophageal echocardiography in the emergency surgical management of patients with aortic dissection.

The diagnostic accuracy and benefit of transesophageal echocardiography were investigated in 32 patients with suspected aortic dissection. Results of transesophageal echocardiography were compared with surgical assessment. The Stanford classification was used for differentiation of dissection type. Examination time was 5 to 15 minutes. Twenty-eight patients were correctly identified to have aortic dissection; four patients had nondissecting aneurysms of the ascending aorta. Both sensitivity and specificity for detection of aortic dissection were 100%. Type of dissection was misdiagnosed in one patient. Classification of dissection type was correct in 96%. The primary entry site was correctly identified in 25 patients (89%). Aortic regurgitation was found in 57% of patients. Pericardial effusion was detected in 21%, with tamponade in one patient. Myocardial infarction was suggested by transesophageal echocardiography in 7%, and 14% had significantly reduced left ventricular function. Eight patients underwent operation based on transesophageal echocardiography alone. Intraoperative transesophageal echocardiography, performed in 20 patients, verified retrograde flow in the true lumen after femoral cannulation. Transesophageal echocardiography documented postrepair persistence of the intimal flap in aortic segments that were not operated on in all patients. Secondary tears and flow in the false lumen were detected in 35% of patients. We conclude that transesophageal echocardiography allows expedient and accurate diagnosis and classification of aortic dissection, and we recommend it as the primary bedside diagnostic modality. It can especially identify patients requiring surgical intervention without further delay caused by other diagnostic procedures.     

急性主动脉综合征诊治进展

主动脉夹层（aortic dissection,AD）、穿透性动脉硬化性溃疡（penetrating atherosclerotic ulcer,PAU）、壁内血肿（intramural hematomas,IMH）是一组有相似临床症状的主动脉病变,近几年来有人提议用急性主动脉综合征（acute aortic syndrome,AAS）描述主动脉的这组病理改变。这几个病变各自的病理生理不同,但有些患者表现为其中的2个或3个病变共存,证明他们相互之间存在某些联系。它们的临床表现相似,     

Transesophageal echocardiography. Preliminary results in patients with traumatic aortic rupture

Eleven patients with blunt chest trauma at risk for traumatic aortic rupture underwent transesophageal echocardiography to image the descending aorta. Diagnoses were compared with the results of radiographic studies. Ten of the 11 patients underwent arch aortography, with positive results in six cases. In one patient, the results of a computed tomographic scan were interpreted as consistent with aortic rupture. The results of transesophageal echocardiography were positive for ruptured descending aorta in three of six patients with positive aortographic findings, and negative in eight patients. All three patients with positive findings had the diagnosis of ruptured descending aorta confirmed at surgery. The remaining eight patients demonstrated no aortic morbidity. These preliminary findings suggest that transesophageal echocardiography is a useful technique for the diagnosis of ruptured descending aorta following blunt chest trauma.     

Transesophageal echocardiography and therapeutic management of patients sustaining blunt aortic injuries

BACKGROUND: No objective criteria have been described to help selecting patients with major blunt aortic injury (BAI) for postponed surgical repair. The efficacy of conservative management of minor BAI needs further evaluation. METHODS: We studied 31 patients (Injury Severity Score, 48 +/- 15) who sustained a BAI diagnosed using transesophageal echocardiography (TEE). In patients with major BAI, the timing of surgery was made on the basis of clinical findings (grade 2) or TEE results (grade 3). We retrospectively separated patients into group I (rapid surgery, < or = 12 hours; n = 13) and group II (late or no surgery; n = 11). All major BAIs were confirmed by alternative imaging modalities or surgery. Patients with minor BAI (grade 1; n = 7) prospectively underwent conservative management with serial TEE follow-up. RESULTS: All patients with grade 3 BAI (n = 4) were promptly operated on. No group II patient died as a result of aortic rupture, and all of them exhibited a small false aneurysm formation (ratio between the maximal diameter of the injured aortic isthmus and the diameter of the normal descending aorta < 1.4) and hemomediastinum (< 7.2 mm). TEE follow-up of group II patients (mean, 5 months) showed stable BAI, whereas follow-up of patients with minor BAI (mean, 15 months) disclosed total healing (n = 3) or stable lesions (n = 4). CONCLUSION: Conservative management of minor BAI with serial follow-up appears to be appropriate. In patients with a grade 2 BAI and small false aneurysm formation and hemomediastinum, postponed surgical repair appears to be safe. However, these TEE criteria remain to be tested prospectively.