Atheromatous plaque in the distal aortic arch creating the potential for cerebral embolism during cardiopulmonary bypass

The present study evaluated the risk in cardiac patients of rupture of a plaque by a jet stream from the arch cannula. The entire thoracic aorta and cardiac function were routinely monitored by transesophageal echocardiography (TEE) in 88 adult patients who underwent coronary artery bypass surgery. The changes in the atheromatous plaque in the distal aortic arch were observed before and after cardiopulmonary bypass. Of the 88 patients, 13 were found to have preoperative atheromatous plaque at the distal aortic arch and 8 (61.5%) of them suffered plaque rupture caused by jet stream from the arch cannula. Only 1 patient experienced apparent embolic episodes manifesting as cerebral and left leg embolisms; the remaining 7 had no clinical embolic symptoms. In order to prevent atheroembolic events, attention should be paid not only to the ascending aorta, but also to the distal arch and in this regard TEE is useful for detecting atheromatous changes of the aorta.     

Rapid diagnosis and management of thoracic aortic dissection and intramural haematoma: a prospective study of advantages of multiplane vs. biplane transoesophageal echocardiography.

AIMS: The purposes of this study were to compare the accuracy of multiplane vs. biplane transoesophageal echocardiography (TEE) in the diagnosis of aortic dissection and aortic intramural haematoma, and to test whether these techniques provide all the diagnostic information required to make management decisions. METHODS AND RESULTS: Fifty-eight consecutive patients with clinically suspected aortic dissection were studied with multiplane TEE; all cases who required surgery underwent intraoperative monitoring with multiplane TEE. The following multiplane TEE data were analysed: the angle between current and 0 degrees plane at which each view was obtained; the success rate in the evaluation of true and false lumen, entry tear, coronary artery involvement, aortic regurgitation, pericardial effusion. Advantages of multiplane over biplane TEE have been evaluated by the demonstration of usefulness of views obtained in planes other than 0 degrees-20 degrees or 70 degrees-110 degrees, assuming that with manipulation of a biplane probe a 20 degrees arc could be added to the conventional horizontal and vertical planes. On the basis of TEE findings, aortic dissection was confirmed in 36 cases (18 type A, 12 type B, six intramural haematoma). The specificity and sensitivity of TEE in terms of the presence or absence of aortic dissection or intramural haematoma were 100%. An additional clinical value of multiplane over biplane TEE in the evaluation of ascending aorta, aortic arch, entry tears and coronary artery involvement was demonstrated. All cases with type A aortic dissection or intramural haematoma involving the ascending aorta had an operation that was performed immediately after the diagnosis (hospital mortality, 13%). Patients with type B aortic dissection were treated medically; 25% of these cases were operated later (hospital mortality, 0%). CONCLUSIONS: Multiplane and biplane TEE have excellent and similar accuracies in the evaluation of aortic dissection and intramural haematoma. Multiplane TEE improves the visualization of coronary arteries, aortic arch and entry tears; it appears to be an ideal method as the sole diagnostic approach before surgery in type A aortic dissection.     

Cardiovascular imaging in aortic disease. Multimodality approach in clinical practice

IntroductionIn the last decade, remarkable advances have been made in noninvasive imaging of aortic diseases. The aim of this article was to provide a comprehensive review of these imaging modalities. Echocardiography plays an important role in the diagnosis and follow-up of aortic diseases. Transthoracic echocardiography (TTE) permits adequate assessment of several aortic segments, particularly aortic root and proximal ascending aorta. Transoesophageal echocardiography (TEE) overcomes the limitations of TTE in thoracic aorta assessment. TTE and TEE should be used in a complementary manner. Although TEE is the technique of choice in the diagnosis of aortic dissection, TTE may be used as the initial modality in the emergency setting. Intimal flap in proximal ascending aorta, pericardial effusion/tamponade and left ventricular function can be easily visualised by TTE. TEE information (entry tear location, mechanisms and severity of aortic regurgitation and true lumen compression) is essential for selecting and monitoring surgical and endovascular treatment and detecting possible complications. Computed tomography has the advantage of providing optimum morphological information of the entire aorta and the accuracy of size measurements. Magnetic resonance imaging offers good morphological and dynamic information on the aorta without radiation, although in clinical practice its availability is lower.ConclusionsThe considerable advances in imaging techniques have greatly increased our understanding of aortic diseases. Not only clinical presentation and required information, but also local availability of imaging equipment and staff expertise in this field, should be considered to indicate echocardiography, computed tomography or magnetic resonance, in the assessment of different aortic diseases and their circumstances.     

Comparison of conventional and transesophageal echocardiography with magnetic resonance imaging for anatomical mapping of thoracic aortic dissection

Thirty-five consecutive patients with clinically suspected aortic dissection were subjected to a dual noninvasive imaging protocol using comprehensive echocardiography and ECG-triggered MRI with multi-slice spin echo and cine sequences in random order. The purpose of this dual imaging study was to compare the diagnostic accuracy of two-dimensional and color-coded Doppler echocardiography using the conventional transthoracic (TTE) and the transesophageal approach (TEE) with magnetic resonance imaging (MRI) for the exact morphologic evaluation and anatomical mapping of the thoracic aorta. The results of each diagnostic method were validated independently against the gold standard of intraoperative findings (n=17), necropsy (n=4) or contrast angiography (n=22).Compared to conventional transthoracic echocardiography both TEE and MRI were more reliable in detecting aortic dissections (TTE vs TEE: p<0.02; TTE vs MRI: p<0.01) and associated epiphenomena. Moreover, the reliability of TTE decreased significantly from proximal to distal segments of the aorta, e.g. from the ascending segment to the arch (p<0.05) and to the descending aorta (p<0.005), whereas the sensitivities of both TEE and MRI were excellent irrespective of the site of dissection. With regard to epiphenomena such as thrombus formation and entry location, MRI emerged as the optimal method for detailed morphologic information in all segments of the aorta. No serious side effects were encountered with either method.Thus, in patients with suspected acute or subacute aortic dissections the echocardiographic assessment should include the transesophageal approach for significant improvement of the moderate sensitivity and specificity of TTE. Both TEE and MRI are non-traumatic, safe and diagnostically accurate to identify and classify acute and subacute dissections of the thoracic aorta irrespective of their location. MRI provides superb anatomical mapping of all type A and B dissections and more detailed information on the site of entry and thrombus formation than TEE. These features of TEE and MRI may render retrograde contrast angiography obsolete in the setting of thoracic aortic dissection and may encourage surgical interventions exclusively on the basis of noninvasive imaging.     

Diagnosis of Supravalvular Aortic Stenosis by Transesophageal Echocardiography

The role of transesophageal echocardiography (TEE) in diagnosis of disorders of the thoracic aorta is well established. In this report the TEE findings in an adult patient with supravalvular aortic stenosis are presented. This showed narrowing of the ascending aorta just above the sinuses, due to fibromuscular thickening, causing an hour-glass shaped deformity. The excellent image quality obtained by TEE is far superior to transthoracic echocardiography. Coronary artery ostial obstruction a known association of supravalvular aortic stenosis can be caused by different mechanisms including adherence of the aortic valve leaflet to the ridge of obstructive muscle or premature atherosclerosis. TEE can define the mechanism of coronary artery ostial obstruction associated with supravalvular aortic stenosis.     

Ascending aorta or arch surgery: is previous cardiac surgery a risk factor?

Surgery on the ascending aorta +/- arch is a challenge. The risks involved in such operations after previous cardiac surgery were assessed in elective and emergency settings in a single institution. Over a 10-year period, 29 patients underwent replacement of the ascending aorta +/- arch following previous cardiac surgery. In 12 patients (41.4%), the procedure was carried out on an emergency basis. Thirteen had previous replacement of the ascending aorta and 16 had previous valve replacement with or without coronary artery bypass; 4 patients were undergoing a 3rd cardiac operation. Concomitant procedures included coronary artery bypass in 2, arch replacement in 4, and descending aortic replacement in one. The overall in-hospital mortality was 13.8% (4/29) vs. 12.4% (33/267) in primary procedures. Mortality in elective repeat surgery was 5.9% (1/17) vs. 25% (3/12) in emergency re-operations. The incidences of permanent stroke (3.4%) and renal failure (3.4%) were similar to first-time operations. Elective re-operation for ascending aorta +/- arch repair can be accomplished with acceptable mortality and morbidity. Outcomes in emergency cases carry a higher early mortality but still conform to contemporary expectations and are similar to emergency first-time aortic surgery.     

Emergency surgical management of acute aortic dissection: role of transesophageal echocardiography.

The accuracy of transesophageal echocardiography in the diagnosis and surgical management of acute aortic dissection was determined in 54 patients who underwent surgery for acute aortic dissection. Results of the investigations were compared to the surgical assessment. From April 1993 to November 1997, we operated 54 patients (44 male and 10 female) for acute aortic dissection. Mean age was 60 +/- 9 years. At surgery, a De Bakey type I aortic dissection was diagnosed in 30 patients, type II in 23 and type III retrograde in 1. Operating procedures were: replacement of ascending aorta (24 cases), replacement of ascending aorta and aortic arch (17 cases), replacement of ascending aorta and aortic valve replacement (2 cases), Bentall procedure (6 cases) and end-to-end anastomosis of the ascending aorta (4 cases). Initial diagnosis, performed in emergency wards, was done on a clinical basis in 6 patients, on CT scan in 19, on transthoracic echocardiography in 14, and on TEE basis in 12. Three patients underwent angiography before our evaluation. As per our protocol, all patients underwent confirmation of the diagnosis by TEE. Seven patients needed additional instrumental investigations, 2 with CT scan and 5 with angiography. TEE confirmed the diagnosis of aortic dissection in all cases but one. Moreover, it described the site of the intimal tear, the extension of the dissecting process and accessory findings, such as pericardial effusion, aortic incompetence and left ventricular function. The interval between patient presentation and skin incision was a maximum of 70 minutes. At surgery, diagnosis of De Bakey classification was confirmed in 98% of cases; in 90.7% of cases exact location of the entry site was confirmed. In one case, an entry site in the arch diagnosed by TEE but not recognized at surgery, was observed at necropsy. Intraoperatively, we routinely used TEE to monitor retrograde systemic perfusion and correct implant of the vascular prosthesis. One case of malperfusion of the thoracic aorta through the false lumen was observed and managed. In one case we diagnosed acute obstruction of the prosthesis by bleeding in the wrapped aorta, which required reoperation. Assessment of ventricular function was obtained in all patients: in two cases, observation of low right ventricular function led us to perform aortocoronary by-pass to the right coronary artery. In conclusion, the high level of correspondence between TEE diagnosis and surgical anatomy prompted us to perform transesophageal echocardiography as the primary and often sole diagnostic procedure in acute aortic dissection. TEE, in experienced hands, has proven to be a highly reliable, safe and low-cost diagnostic tool. It can be performed at the patient's bedside within just a few minutes of the suspected diagnosis, thereby lowering the mortality rate of the natural history. Again, it can also be used in the operating theatre as an "on-line examination" as well as for assessment of correct surgical repair. Other diagnostic procedures do not yield more information and can cause dangerous delays in intervention.     

Rapid progression of discrete type A intramural hematoma: prevention of a "procedure-related" complication by intraoperative transesophageal echocardiography.

PURPOSE: To report a case illustrating the utility of transesophageal echocardiography (TEE) before planned stent-graft placement for chronic type B aortic dissection. CASE REPORT: A 64-year-old man with acute aortic syndrome and an 8-year-old interposition graft in the distal aortic arch for acute type B dissection was referred for dissection of the descending thoracic aorta down to the aortic bifurcation; the false lumen was dilated to 65 mm and was partially thrombosed. The ascending aorta showed discrete, eccentric, 4-mm wall thickening that was not considered clinically significant. Stent-graft closure of the entry tear in the proximal descending thoracic aorta was elected. However, as the endovascular procedure was about to commence, TEE showed striking eccentric thickening of the aortic wall of up to 18 mm. The endovascular procedure was stopped, as it was decided to urgently replace the ascending aorta. The next day, the patient underwent successful ascending aortic replacement and simultaneous antegrade stent-graft implantation over the descending thoracic aortic entry tear via the open aortic arch. The postoperative course was uncomplicated, and the patient was discharged 19 days after surgery. He remains well at 6 months after the procedure. CONCLUSIONS: Our case demonstrates that dissection of the ascending aorta may occur not only due to endograft-induced intimal injury, but may also occur due to underlying but undiagnosed or underestimated disease of the ascending aorta or arch. Besides procedural guidance, intraoperative TEE is a useful tool to detect such disease to avoid subsequent "procedure-related" complications.     

Prediction of Homograft Aortic Valve Size by Transthoracic and Transesophageal Two-Dimensional Echocardiography

To avoid the problem of patient valve mismatch we assessed the reliability of echocardiographic measurements in selecting an appropriate-sized homograft aortic valve. Preoperative transthoracic echocardiography (TTE) was performed in 26 consecutive patients undergoing aortic valve replacement with a cryopreserved human homograft; 19 of the patients also had intraoperative transesophageal echocardiography (TTE). The diameters of left ventricular outflow tract (LVOT), aortic annulus, sinuses of Valsalva, and ascending aorta were measured by the same technique in all patients. There was a strong correlation between LVOT diameter measured by intraoperative TEE and homograft aortic valve size selected by the surgeon (r = 0.91, P < 0.001). A good correlation was also found between LVOT measured by preoperative TTE and the homograft valve size (r = 0.82, P = 0.001). The correlation between the homograft aortic valve size and the diameter of aortic annulus was less optimal; the correlation was poor for the diameter of aorta measured at the level of the sinuses of Valsalva and ascending aorta. Measurement of the LVOT diameter by intraoperative TEE and preoperative TTE is reliable and clinically useful for the preparation of homograft aortic valves and selection of proper size, particularly in those patients undergoing repeat aortic valve replacement, with heavily calcified aortic valve or with ascending aortic aneurysm.     

Value of multislice CT scan in redo cardiac surgery with previous Lita graft

Redo cardiac surgery is commonly performed in the current era. We describe a clinical scenario in a patient with a patent left internal thoracic artery to left anterior descending artery graft, requiring replacement of ascending aortic aneurysm with previous coronary artery bypass operation complicated by mediastinitis. A pre-operative 64 slice computed tomographic scan helped us plan and perform replacement of ascending aorta safely.     

Value of transesophageal echocardiography combined with computed tomography for assessing repaired type A aortic dissection.

Thirty-two patients with repaired type A aortic dissection were examined by transthoracic echocardiography (TTE) (n = 32), transesophageal echocardiography (TEE) (n = 30), computed tomography (CT) (n = 29), or a combination of all 3, to assess course and complications as a function of the surgical procedure. The mean follow-up period was 55.7 months (range 3 to 132). Surgery consisted of a replacement of the ascending aorta in 25 patients (group 1) with extension to the transverse aorta in 7 (group 2). The transverse diameter of the aorta, the persistence of the false lumen, thrombus formation and flow dynamics in the false lumen were evaluated by TEE. Ten patients (31%) had a dilation in the initial ascending aorta (sinus of Valsalva aneurysm in 6 patients, and a false aneurysm in the other 4). Three of 4 patients with a proximal pseudoaneurysm underwent operation after TEE and CT evaluation. In the descending thoracic aorta, there was good agreement between TEE and CT scan determinations of transverse vessel diameter. Persistence of flow within the false lumen was significantly more frequent in patients with a dilated aorta (p < 0.05), whereas thrombosis was seen more often and false lumen less often in patients with nondilated aorta. No significant differences in vessel status or outcome were observed between the 2 groups, although this may have been due to the small size of group 2. TEE is thus a well-tolerated method for postoperative follow-up of type A aortic dissection whatever the type of surgery. For the upper ascending aorta, CT provided sufficient data.     

Pulmonary artery origin of the left coronary artery: diagnosis by transoesophageal echocardiography in infancy

In two infants the anomalous origin of the left coronary arteryfrom the pulmonary artery (ALCAPA) was detected prospectivelyby transoesophageal echocardiography (TEE). Colour flow mappingand pulsed Doppler ultrasound revealed a predominant right-to-leftshunt from the pulmonary artery to the left coronary artery.These findings were confirmed by angiography. Transihoracic echocardiography (TTE)failed to show the anomalousorigin of the left coronary artery or any abnormal pulmonaryflow pattern. TEE may be useful in the diagnosis of ALCAPA in selected cases,when TTE is inconclusive.     

Accuracy of Transthoracic Echocardiography for the Measurement of the Ascending Aorta: Comparison With Transesophageal Echocardiography

Background

There has been a substantial increase in the number of imaging studies performed to assess thoracic aortic pathology. We sought to determine the accuracy of transthoracic echocardiography (TTE) compared to transesophageal echocardiography (TEE) for measuring ascending aortic size.

Hypothesis

Transthoracic echocardiography is reasonably accurate for assessing ascending aortic dimension.

Methods

Fifty‐two patients with or without aortic disease underwent both TTE with nonstandard views and TEE. The ascending aorta was measured at 4 levels by 2 blinded observers for each modality. Pearson's correlation coefficients were determined and Bland‐Altman plots and analyses were constructed. Inter‐ and intraobserver variability was determined in a random subgroup of patients.

Results

The mean age of the group was 65.5 years old and 15% had aortic dilation >4.0 cm. A strong positive correlation between the 2 imaging modalities was seen at all levels with the highest correlation for the maximum diameter of the ascending aorta (r = 0.936, P < 0.0001). Interobserver and intraobserver variability showed a good intraclass correlation among readers and among the same reader at all levels.

Conclusions

Transthoracic echocardiography using nonstandard imaging windows is accurate in comparison to TEE for measurement of the ascending aorta at multiple levels in patients with or without aortic pathology. The findings of this study provide support for selected serial follow‐up of patients with aortic disease by TTE only. Copyright © 2008 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Imaging the ascending aorta and aortic arch using transesophageal echocardiography: the expanded aortic view

Transesophageal echocardiography (TEE) imaging of the aorta requires multiple views and is limited by its inability to visualize the distal ascending aorta and proximal aortic arch ("blind spot"). Recent advances in ultrasound technology allow improved imaging of cardiac structures. In this study we describe the ability to image the aortic valve, entire ascending aorta, and aortic arch in one view, the "expanded aortic view" obtained from a novel proximal transgastric window. In 22 patients, an expanded aortic view was acquired with the transducer positioned in a proximal transgastric position using new generation ultrasound system with a TEE probe that incorporates increased range of mobility. Fluoroscopy imaging was performed to confirm the position of transducer in relation to the cardiac anatomy. In 7 of 22 patients, the ability to achieve this view was also tested using an older echocardiography system. The novel proximal transgastric plane allowed reliable images of the aortic valve, ascending aorta including the "blind spot," and aortic arch in a single view-the expanded aortic view.     

Diagnosis of Congenital Unicuspid Aortic Valve in Adult Population: The Value and Limitation of Transesophageal Echocardiography

Background: This study aimed to assess the accuracy of two‐dimensional echocardiography (echo) in diagnosing unicuspid aortic valve (UAV) and to determine echo features that could improve the diagnosis. Method: We reviewed transthoracic/transesophageal echoes (TTE/TEE) from our hospital database for adult patients who had aortic valve surgery with a preoperative echo diagnosis of UAV or equivocal diagnosis of bicuspid aortic valve (BAV) BAV/UAV. Morphological characteristics of AV and ascending aortic dimensions were evaluated. Results: Nineteen patients were identified, 13 (11 Male, 2 Female, mean age 47 ± 10 years) had surgically confirmed diagnosis of UAV, six had BAV. The incidence of UAV was 2.6%. For diagnosing UAV, the sensitivity and specificity of TTE was 27% and 50% and those of TEE was 75% and 86%, respectively. For TTE, positive predictive value (PPV) was 60% and negative predictive value (NPV) was 20%. By TEE, PPV was 90% and the NPV was 67%. In UAV patients, 85% had severe aortic stenosis (mean gradient 45 ± 16 mmHg, AVA: 0.9 ± 0.2 cm²). 46% had ascending aorta aneurysm (mean aortic root, sinutubular junction, ascending aorta dimensions: 36 ± 3 mm, 31 ± 4 mm and 41 ± 8 mm). Patients with ascending aortic aneurysm were younger (41 ± 11 years vs. 52 ± 5 years, P < 0.05) All UAV were unicommissural with a posteriorly positioned commissural attachment, 69% were heavily calcified. Diagnostic accuracy was limited by quality of images, severity, and distribution of calcification. Conclusion: TEE is the diagnostic modality of choice in UAV. Identifying several echo features may improve its diagnostic accuracy. (Echocardiography 2010;27:1107‐1112)     

Thrombosis and endocarditis in prosthetic heart valves, a case report.

The authors report the case of a 49-year-old female with a history of rheumatic valvular heart disease who underwent valve surgery in 1997, with implantation of St. Jude prosthetic valves in aortic and mitral position. She was asymptomatic until the end of July 2001, when she was admitted to Garcia de Orta Hospital emergency unit because of heart failure, fever and suspicion of endocarditis. Cardiologic evaluation was requested and the transthoracic (TTE) and transesophageal (TEE) echocardiograms revealed vegetations on the prosthetic mitral valve. Blood cultures were negative. She started empiric antibiotic therapy and the clinical course stabilized in the first week. After ten days of medical therapy her symptoms became worse and TTE and TEE were repeated. TTE showed significant left ventricular-aortic gradient, suggesting aortic valve obstruction. Decreased left ventricular function was now present with hypokinesia in the anterior descending coronary artery territory. In the TEE, a large thrombotic process on the mitral prosthesis valve was seen, with a prosthesis disk blocked. There were similar findings in the aortic valve. Cardiac fluoroscopic images were obtained at the mitral and aortic position confirming the TEE report. The coronary angiogram was normal. Promptly transferred to a cardiac surgery center, the patient underwent aortic and mitral prosthetic valve replacement. The intraoperative findings were compatible with those from echocardiography and cardiac fluoroscopy.     

Splenic and mesenteric emboli in a patient with protruding aortic arch atheroma

Protruding atheromas in the thoracic aorta are an important cause of embolic disease. Transesophageal echocardiography (TEE) is the modality of choice for diagnosis of these lesions. We present a patient with splenic infarction in whom TEE revealed a large mobile atheroma in the aortic arch. A few hours following the disappearance of this mass from the aortic arch, the patient developed mesenteric artery embolism requiring subtotal small-bowel resection. We discuss the importance of the aortic arch as a source of peripheral emboli and the treatment modalities in these patients.     

Hypoplastic right retro-oesophageal aortic arch: similarities to interrupted aortic arch.

At echocardiography a dysmorphic neonate was found to have a hypoplastic mitral valve, left ventricle, and ascending aorta with interruption of the aortic arch between the left common carotid and the left subclavian arteries--the left subclavian artery arose from a normal sized left descending aorta. Cardiac catheterisation and subsequent necropsy confirmed this arrangement but also showed a tortuous right retro-oesophageal aortic arch. This arch was severely hypoplastic distal to the right subclavian artery. These cardiovascular anomalies occurred in the child of a family in which other members showed the velo-cardio-facial syndrome, a condition known to be associated with right aortic arch. This aortic arch arrangement may be impossible to distinguish from simple aortic interruption by echocardiography alone.     

Value of echocardiography in patient follow-up after surgically corrected type A aortic dissection.

BACKGROUND: To identify patients (pts) at risk of late complications, follow-up after surgery for type A aortic dissection is essential. We assessed the value of echocardiography to monitor patients after surgery for type A aortic dissection. METHODS: 80 out of 108 pts operated between 1989 and 1999 for type A aortic dissection survived surgery. 62 pts with at least one TEE, CT or MRI examinations during follow-up were included in this study. All pts had transthoracic echocardiography (TTE), 53 transesophageal echocardiography (TEE), 51 had CT, and 39 had MRI. RESULTS: At the first follow-up, 12 of 48 pts with aortic valve sparing surgery presented with aortic insufficiency >I degrees detected using echocardiography. 16 pts evolved a distal aortic aneurysm of over 5 cm, all seen in TEE, CT and MRI. A distal intimal flap was present in 39 pts and could be seen in TEE, CT and MRI in all patients. A new proximal aortic root dissection took place in 5 pts. Progressive aortic pathology led to reoperation in 9 pts. TEE was especially useful in 2 pts to confirm redissection, in 1 pt to rule out redissection assumed by CT, and in 1 with paraprosthetic blood flow after ascending aortic replacement. MRI led to additional information in 1 patient with false aneurysm of the distal anastomosis and 1 with redissection not seen in TEE 6 month before. CT and MRI were superior to TEE in demonstrating aortic arch pathology, whereas TEE was more effective in showing the flow pattern and residual entry sites. CONCLUSIONS: Echocardiography is an effective and cost-saving diagnostic tool to monitor pts after surgery for type A aortic dissection, and should be the method of choice to ascertain aortic pathology initially after surgery. Follow-up intervals and need for additional CT or MRI should be determined afterwards according to specific pathologies.     

Clinical usefulness of transesophageal Doppler echocardiography

The usefulness of transesophageal Doppler echocardiography (TEE) was assessed in patients with various cardiovascular diseases including 15 patients with dissecting aortic aneurysm (DAA), two with thoracic aneurysm, 16 with ischemic heart disease and 14 with acquired valvular diseases. In dissecting aortic aneurysms, TEE provided clear images of the intimal flaps even in the aortic arch and descending aorta in which clear images could not be obtained by conventional external Doppler echocardiography. The entry site was detected in 11 of the 15 (73%) cases using TEE, but in only three of the 15 cases using conventional Doppler technique. In two cases of true aortic aneurysms, TEE provided clear images of the aneurysm in the descending thoracic aorta, which was discriminated precisely from DAA. In valvular disease, all four valves (aortic, pulmonary and atrio-ventricular valves) were easily observed without disturbance by any other tissues using a transesophageal approach. In addition, valve aneurysms in the posterior mitral leaflets were detected using TEE in two cases. In two cases of mitral stenosis, a thrombus was observed in the left atrial appendage. These findings were confirmed during surgery, but could not be obtained by the conventional external studies. In 16 cases, TEE was performed during aorto-coronary bypass surgery under general anesthesia. In two of these cases, left ventricular assist devices were applied after surgery. In these cases, where conventional Doppler echocardiography was not applicable, cardiac function could be monitored by TEE. Thus, TEE is useful not only in evaluating morphological function in the cardiovascular system but also in monitoring cardiac hemodynamics during and after heart surgery.