ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Michael J. Wilson
Philip G. Lisagor
David J. Cohen
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Wilson, M. J.
Right arrow Articles by Cohen, D. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Wilson, M. J.
Right arrow Articles by Cohen, D. J.

Ann Thorac Surg 2000;70:25-30
© 2000 The Society of Thoracic Surgeons

Original articles: Cardiovascular

Ascending aortic atheroma assessed intraoperatively by epiaortic and transesophageal echocardiography1

Michael J. Wilson, MDa, Sheri Y.N. Boyd, MDa, Philip G. Lisagor, MDa, Bernard J. Rubal, PhDa, David J. Cohen, MDa

a Cardiology and Cardiothoracic Surgery Services, Brooke Army Medical Center, Fort Sam Houston, Texas, USA

Address reprint requests to Dr Wilson, Cardiology Service, Madigan Army Medical Center, Tacoma, WA—98431-5055


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Data analysis
 Results
 Comment
 References
 
Background. The presence of ascending aortic atheroma is a known risk for systemic emboli or early saphenous vein graft failure if unrecognized at the time of cardiopulmonary bypass.

Methods. This study prospectively compared intraoperative omniplane transesophageal echocardiography (TEE) and epiaortic ultrasound (EAU) images in 22 patients (6 women, 16 men, age 66 ± 8 years) before surgical manipulation of the ascending aorta. Atheroma lesion severity was scored: 1 = normal, 2 = nonprotruding intimal thickening (> 2 mm), 3 = atheroma less than 4 mm ± Ca++, 4 = atheroma greater than or equal to 4 mm ± Ca++, and 5 = any size mobile or ulcerated lesion ± Ca++. The ascending aorta between the aortic valve and innominate artery was divided into proximal, middle, and distal segments. A total of 66 segments were evaluated.

Results. Although the overall agreement of scores between procedures was 75.8%, significantly more lesions were identified by EAU (15) than by TEE (5) (p < 0.03). TEE failed to identify lesions in the middle and distal segments of the aorta with a score of more than 3.

Conclusions. Although atheromatous lesions were identified in the ascending aorta by both ultrasound modalities, the results suggest that intraoperative EAU may have an advantage over TEE for surgeons assessing target sites for surgical procedures involving the ascending aorta.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Data analysis
 Results
 Comment
 References
 
Aortic arteriosclerosis is a known risk factor for stroke [1–3], and the incidence of ascending aortic atheroma increases with age. It is present in 20% of patients between 50 and 59 years of age, in 60% of those 60 to 69 years, and in 80% of those 75 years or older [4]. Autopsy studies have shown that atheroemboli are present in 37% of patients with severe ascending aortic atheroma versus 2% of those without significant disease [5]. Several investigators have associated aortic atheroma with an increased risk of stroke and other complications following cardiac operations [1–3, 6–8].

Stroke incidence following coronary bypass also is known to increase with age. Patients between 51 and 60 years have a 1% incidence of stroke after bypass compared with 9% of those older than 80 years [9]. With the increasing age of patients undergoing cardiac surgical procedures in the United States, surgeons are encountering more patients with significant arteriosclerosis of the thoracic aorta. Commonly surgeons inspect and palpate the ascending aorta before bypass procedures. However, visual inspection and palpation underestimate the prevalence and severity of aortic arteriosclerosis compared with direct ultrasonographic examination [4, 10]. Thus ultrasonic imaging of the ascending aorta may be of value in reducing perioperative stroke risk [4, 10–13].

Both epiaortic ultrasonography (EAU) and transesophageal echocardiography (TEE) have been used to identify ascending aortic atheroma [1, 10, 12–16]. It is unclear whether the clinical information provided by these modalities is comparable [14–16]. More recently multiplane TEE has been used to interrogate the aorta [17–20]. Although multiplane TEE is superior to biplane TEE for obtaining detailed views of the aorta [21], both approaches are limited in their ability to view distal segments of the ascending aorta, which are sites frequently instrumented by cardiac surgeons. The objective of the present study was to compare the efficacy of multiplane TEE with intraoperative EAU in identifying significant atheroma in the ascending aorta.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Data analysis
 Results
 Comment
 References
 
We studied 22 consecutive patients undergoing open heart operations with both TEE and EAU imaging to identify atherosclerotic lesions in the ascending aorta. Patients with esophageal strictures and those requiring an esophageal pacing wire were excluded. Table 1 summarizes clinical characteristics of the study group. All patients gave informed consent before participation in this study and the study protocol was approved by the Institutional Review Board and Human Use Committees at our institution (September 11, 1997). Patients were taken to the operating room and underwent imaging following induction of general anesthesia.


View this table:
[in this window]
[in a new window]
  		Table 1. Patient Demographics

 
In all patients, TEE imaging of the ascending aorta, transverse arch, and descending aorta was performed using a 5.0/7.5 MHz multiplane probe and Sonos 2500 (Hewlett-Packard, Andover, MA). The ascending aorta was interrogated from the aortic valve to the transverse aortic arch. The probe was manipulated to obtain short and long axis images of the proximal, middle, and distal segments of the ascending aorta. Further angle adjustments were made to image lesions optimally when identified. Following imaging of the ascending aorta, the TEE probe was advanced to the level of the diaphragm (approximately 40 to 50 cm) and the descending aorta was imaged at 2-cm increments proximally to the level of the transverse aortic arch.

Epiaortic imaging was performed by the surgeon (P.G.L. or D.J.C.) immediately before invasive instrumentation of the ascending aorta for cardiopulmonary bypass. A 5.0/7.5 MHz vascular imaging probe (Hewlett-Packard) was inserted into a sterile plastic sleeve (Civco, Kalona, IA) with a small volume of sterile saline added. The saline provided an acoustic medium through which images could be obtained without the probe being placed directly on the anterior surface of the aorta. This "stand-off" technique permitted the visualization of the anterior aspect of the aorta. The epiaortic probe was then manipulated to obtain both transverse and longitudinal images along the entire ascending aorta.

The aorta was instrumented surgically at various levels depending on the patient’s surgical procedure and anatomy. For example, the aorta bypass cannula is commonly placed in the distal third of the ascending aorta, the antegrade cardioplegia cannula in the proximal to middle third, and the aortic cross-clamp in the middle to distal segments. The partial occluder clamp is placed on, and the proximal graft anastomoses sewn into the proximal to middle segments. For patients requiring aortic valve replacement, aortotomies are performed in the proximal one third of the ascending aorta. Surgeons were provided results of both imaging modalities before aortic instrumentation and were able to adjust surgical procedures accordingly.

Before surgical procedures were undertaken, medical records were reviewed to determine whether patients had a history of stroke. Their hospital records were also reviewed following discharge to determine the incidence of perioperative cerebral vascular events. Inpatient postoperative care included prophylactic 5000 U twice daily subcutaneous heparin doses until ambulating for all patients. They were also treated postoperatively with aspirin. Patients with dyslipidemias were treated with appropriate lipid-lowering therapy. Patients developing postoperative atrial fibrillation were given a weight-adjusted intravenous heparin bolus and an infusion acutely to achieve a partial thromboplastin time of 60 to 80 seconds, until either the atrial fibrillation resolved, or oral warfarin dosing reached therapeutic levels ( ).


   Data analysis
Top
 Abstract
 Introduction
 Material and methods
 Data analysis
Results
 Comment
 References
 
Parametric data are presented as mean ± SD. The TEE and EAU images were interpreted by an experienced cardiologist (S.Y.N.B.) in a blinded fashion utilizing offline analysis. Lesion severity was graded on a 5-point scale (Table 2) [22]. For analysis, the ascending aortic images were divided into proximal, middle, and distal segments consistent with target areas for surgical intervention. Chi square test was used to determine differences in the ability of the two imaging techniques to identify lesions (>= grade 2). A p value of less than 0.05 was considered significant. A Bland-Altman test [23] was used to assess agreement between these two imaging modalities (mean ± 95% confidence interval). Cohen’s kappa was also calculated to assess agreement [24].


View this table:
[in this window]
[in a new window]
  		Table 2. Grading Aortic Atherosclerosis

 

   Results
Top
 Abstract
 Introduction
 Material and methods
 Data analysis
 Results
Comment
 References
 
The mean age of our patient population was 66 ± 8 years. Sixteen patients were men and 6 were women. Most of our patients (17 of 22) 77% had two-vessel or three-vessel coronary artery disease. Risk factors for coronary artery disease and stroke are presented in Table 1. Two or more stroke risk factors were present in 98% of our patients. There were 2 patients (9%) with a prior stroke history. Eight patients (36%) had arteriosclerotic peripheral vascular disease, with 4 having cerebrovascular disease. Four patients (18%) had a history of atrial fibrillation before undergoing operation, and 4 patients developed atrial fibrillation postoperatively. One of these patients had a transient episode of atrial fibrillation preoperatively, only to have it recur in the postoperative period. Four patients had left ventricular dysfunction before operation (Table 3), with 1 patient having severe left ventricular dysfunction ( ). Five patients had congestive heart failure preoperatively. Nineteen patients underwent an operation for coronary artery bypass and 3 had an aortic valve replacement. Two patients with valve replacement also had coronary artery bypass grafting. Fifteen (68%) of the patients had two or more proximal vein graft anastomoses. One patient underwent simultaneous carotid endarterectomy and coronary artery bypass grafting.


View this table:
[in this window]
[in a new window]
  		Table 3. Distribution of Cardiac Diseases in Study Group

 
Of the 66 segments interrogated in the ascending aorta, 16 lesions (>= grade 2) were found by EAU compared with 5 by TEE (p < 0.03). All grade 4 and 5 atheromas were identified by EAU, but none by TEE. Figure 1 illustrates a high grade atheroma found by EAU and missed with TEE. TEE identified 2 grade 2 and 3 grade 3 lesions in the proximal aorta. No middle or distal segment lesions were detected by TEE. EAU identified 4 proximal, 6 middle, and 6 distal segment lesions. Lesions identified by EAU included 9 grade 2, 3 grade 3, 4 grade 4, and 1 grade 5. In only one case was a lesion >= grade 2 identified in the proximal aorta by TEE that was not found by EAU. Although the overall agreement of the lesion scores in the ascending aorta was 75.8%, Cohen’s kappa value was not significantly different from chance (kappa = 0.14, p = NS). The Bland-Altman test of agreement (Fig 2) also reflects the disparity between lesion scores using the two imaging modalities. These data suggest that ascending aortic lesions may be underestimated by TEE (Fig 3).



View larger version (130K):
[in this window]
[in a new window]
  		Fig 1. Epiaortic ultrasound image of grade 5 atheroma in ascending aorta. The image was obtained from the middle segment of the ascending aorta, approximately 4 cm distal to the aortic valve. The lesion lies on the posterior surface between the arrowheads. There is a mobile thrombus evident near the left arrowhead. The depth markers indicate 1 cm depth.

 


View larger version (15K):
[in this window]
[in a new window]
  		Fig 2. Bland-Altman test of agreement between transesophageal echocardiography (TEE) and epiaortic ultrasound (EAU). The mean difference is depicted as a light solid line and the 95% confidence intervals (CI) as dashed lines.

 


View larger version (70K):
[in this window]
[in a new window]
  		Fig 3. Epiaortic ultrasound and transesophageal echo image of the ascending aorta in patient no. 17. A grade 5 lesion was identified by epiaortic ultrasound showing a small thrombus in the ulcer crater (A, arrowheads). This lesion was not identified by transesophageal echocardiography (B). The double arrowhead (A) identifies an imaging artifact: Acoustic shadow created by a wrinkle in the sterile plastic sleeve with image dropout just above the double arrowhead.

 
TEE identified lesions in the transverse ( ) and descending aorta ( ) (Fig 4). It is of interest to note that of the 9 patients with lesions greater than grade 3 in the descending aorta, 3 had significant atheroma (> grade 3) in the ascending aorta. No patient with lesion scores less than 3 in the descending aorta had lesions more than grade 2 in the ascending aorta. Three grade 4 lesions were found in the transverse arch, 11 grade 4, and 4 grade 5 lesions were found in the descending aorta (Fig 5).



View larger version (12K):
[in this window]
[in a new window]
  		Fig 4. Number and location of lesions identified by transesophageal echocardiography in 22 patients. A total of 61 lesions grade more than 2 were identified in 22 patients.

 


View larger version (91K):
[in this window]
[in a new window]
  		Fig 5. Transesophageal echo images of the descending aorta. The images were both obtained from the same patient. A grade 4 lesion (A, arrowhead) was identified with the esophageal imaging probe at approximately 20 cm (cm) from the incisors. A mobile atheroma (grade 5) was identified at 30 cm (B, arrowhead).

 
Only 1 patient had a stroke following operation. This patient was a 65-year-old man who underwent simultaneous right carotid endarterectomy and three-vessel coronary artery bypass grafting. The right carotid artery had complex, ulcerated plaques that involved both the internal and external carotids from the bifurcation. This patient also had a grade 2 plaque in the proximal, a grade 4 atheroma in the middle, and a grade 5 atheroma in the distal segment of ascending aorta, noted by EAU (Fig 3). TEE imaging identified none of these lesions. Although it is unclear whether the stroke was due to the carotid or the aortic disease, this patient had an embolic right cerebral hemisphere stroke with left hemiparesis. The distribution of his neurologic injury was consistent with the right carotid disease. There were no other perioperative embolic complications documented in this study population.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Data analysis
 Results
 Comment
References
 
Among the potential complications of cardiac surgical procedures, stroke is one of the most dreaded. The incidence of stroke has been reported to range from 4.7% to 5.2% after coronary artery bypass grafting and from 4.2% to 13.0% following intracardiac operation [9]. Barbut and Caplan [9] showed the risk of overt neurologic deficits complicating combined coronary bypass and intracardiac operations is twice as high as in coronary operations alone. The Warm Heart Investigators’ randomized trial comparing normothermic versus hypothermic coronary artery bypass operation found that increased mortality following coronary operations was due to neurologic injury [25]. The incidence of death in patients having a stroke after cardiac operation has been reported to be as high as 36% [26]. Several investigators have reported an increased risk of stroke complicating cardiac operation in patients with complex atheroma in the ascending aorta [1, 2, 4, 9]. Previously, biplane TEE and EAU have been reported to be of value in identifying atheroma in the ascending aorta. However, controversy exists regarding the equivalence of these modalities in assessing aortic atheroma [14–16].

In recent studies, EAU identified the presence and extent of ascending and transverse aortic atheroma more often than biplane TEE [14, 15]. However, Konstadt and coworkers [16] reported that TEE could be used to image the ascending aorta to a mean distance of 7.4 cm from the aortic annulus. They also reported that the aortic cannulation site was typically 7.2 cm (range, 5.5 to 9.2 cm) from the aortic annulus. In contrast, EAU consistently imaged the entire length of the ascending aorta from annulus to innominate artery [16]. Biplane TEE was reported to visualize the aortic cannula in 1 of 14 patients in this study. Despite these limitations, Konstadt and Reich [14] concluded that EAU was unlikely to add significantly to the TEE examination in the vast majority of cases. These investigators suggested that only when significant disease was identified by TEE would further study with EAU be warranted [14].

More recently studies of the ascending aorta have been conducted using multiplane TEE imaging probes. TEE is reported to be an useful imaging modality for identifying and following the natural history of atherosclerosis in the ascending aorta in patients who have had stroke and peripheral atheroembolic events [17–20]. However, the interposition of the trachea and/or right mainstem bronchus as well as the distance of the probe from the aortic arch often prevent adequate visualization of the middle to distal segments of the ascending aorta. This is important because these regions are the target sites for cross-clamp and aortic cannulation. Our study results are consistent with others [14, 15] and suggest that TEE and EAU are not equivalent in their ability to identify severe atheroma in the ascending aorta, particularly in more distal segments.

In our study, TEE was useful in interrogating the descending aorta. Our findings suggest that the absence of significant lesions in the descending thoracic aorta by TEE may imply a low likelihood of significant ascending aorta disease. However, the finding of significant atheroma in the descending aorta is likely to warrant further interrogation of the ascending aorta by EAU. These findings are consistent with previous reports that describe a relative sparing of the thoracic aorta until late in the atherosclerotic process [27]. Further study is recommended to define the value of TEE-delineated atheroma in the descending aorta to predict significant atheroma at common surgical sites in the ascending aorta.

In contrast to earlier studies [16], our study suggests that EAU imaging of the ascending aorta for arteriosclerosis is superior to TEE. Significant (> grade 3) lesions were missed by TEE, particularly in the middle and distal segments of the ascending aorta. Although EAU imaging requires additional time before institution of bypass, it may prove useful in reducing perioperative complications.


   Acknowledgments
 
The authors express their gratitude to James Bulgrin, BSEE, for his assistance in acquiring the images presented in this study. The authors also thank Suzy Kai for her assistance in preparing this manuscript.


   Footnotes
 
1 The views expressed herein are those of the authors and do not necessarily reflect the views of the Department of the Army or the Department of Defense. Back


   References
Top
 Abstract
 Introduction
 Material and methods
 Data analysis
 Results
 Comment
 References
 

  1. Hosoda Y., Watanabe M., Hirooka Y., Ohse Y., Tanaka A., Watanabe T. Significance of atherosclerotic changes of the ascending aorta during coronary bypass surgery with intraoperative detection by echography. J Cardiovasc Surg 1991;32:301-306.[Medline]
  2. Blauth C.I., Cosgrove D.M., Webb B.W., et al. Atheroembolism from the ascending aorta. J Thorac Cardiovasc Surg 1992;103:1104-1112.[Abstract]
  3. Amarenco P., Duyckaerts C., Tzourio C., Henin D., Bousser M.G., Hauw J.J. The prevalence of plaques in the aortic arch in patients with stroke. N Engl J Med 1992;326:221-225.[Medline]
  4. Wareing T.H., Davila-Roman V.G., Barzilai B., Murphy S.F., Kouchoukos N.T. Management of the severely atherosclerotic ascending aorta during cardiac operations. J Thorac Cardiovasc Surg 1992;103:453-462.[Abstract]
  5. Gardner T.J., Homeffer P.J., Manolio T.A., et al. Stroke following coronary artery bypass grafting. Ann Thorac Surg 1985;40:574-581.[Abstract/Free Full Text]
  6. Mickleborough L.L., Walker P.M., Takagi Y., Ohashi M., Ivanov J., Tamariz M. Risk factors for stroke in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 1996;112:1250-1259.[Abstract/Free Full Text]
  7. Amarenco P., Cohen A., Tzourio C., et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med 1994;331:1474-1479.[Medline]
  8. Karalis D.G., Chandrasekaran K., Victor M.F., Ross J.J., Jr, Mintz G.S. Recognition and embolic potential of intraaortic atherosclerotic debris. J Am Coll Cardiol 1991;17:73-78.[Medline]
  9. Barbut D., Caplan L.R. Brain complications of cardiac surgery. Curr Probl Cardiol 1997;22:451-480.
  10. Marshall W.G., Jr, Barzalai B., Kouchoukos N.T., Saffitz J. Intraoperative ultrasonic imaging of the ascending aorta. Ann Thorac Surg 1989;48:339-344.[Abstract/Free Full Text]
  11. Wareing T.H., Davila-Roman V.G., Daily B.B., et al. Strategy for the reduction of stroke incidence in cardiac surgical patients. Ann Thorac Surg 1993;55:1400-1408.[Abstract/Free Full Text]
  12. Duda A.M., Letwin L.B., Sutter F.P., Goldman S.M. Does routine use of aortic ultrasonography decrease the stroke rate in coronary artery bypass surgery?. J Vasc Surg 1995;21:98-109.[Medline]
  13. Ribakove G.H., Katz E.S., Galloway A.C., et al. Surgical implications of transesophageal echocardiography to grade the atheromatous aortic arch. Ann Thorac Surg 1992;53:758-763.[Abstract/Free Full Text]
  14. Konstadt S.N., Reich D.L. Transesophageal echocardiography can be used to screen for ascending aortic atherosclerosis. Anesth Analg 1995;81:225-228.[Abstract/Free Full Text]
  15. Davila-Roman V.G., Phillips K.H., Daily B.B., Davila R.M., Kouchoukos N.T., Barzilai B. Intraoperative transesophageal echocardiography and epiaortic ultrasound for assessment of atherosclerosis of the thoracic aorta. J Am Coll Cardiol 1996;28:942-947.[Medline]
  16. Konstadt S.N., Reich D.L., Quintana C., Levy M. The ascending aorta. Anesth Analg 1994;78:240-244.[Free Full Text]
  17. Khatibzadeh M., Mitusch R., Stierle U., Gromoll B., Sheikhzadeh A. Aortic atherosclerotic plaques as a source of systemic embolism. J Am Coll Cardiol 1996;27:664-669.[Medline]
  18. Dressler F.A., Craig W.R., Castello R., Balovitz A.J. Mobile aortic atheroma and systemic emboli. J Am Coll Cardiol 1998;31:134-138.[Medline]
  19. Rauh G., Fischereder M., Spengel F.A. Transesophageal echocardiography in patients with focal cerebral ischemia of unknown cause. Stroke 1996;27:691-694.[Abstract/Free Full Text]
  20. Arko F., Buckley C., Baisden C., Manning L. Mobile atheroma of the aortic arch is an underestimated source of embolization. Am J Surg 1997;174:737-740.[Medline]
  21. Yvorchuk K.Y., Sochowski R.A., Chan K.L. A prospective comparison of the multiplane probe with biplane probe in structure visualization and Doppler examination during transesophageal echocardiography. J Am Soc Echocardiogr 1995;8:111-120.[Medline]
  22. Montgomery D.H., Ververis J.J., McGorisk G., Frohwein S., Martin R.P., Taylor W.R. Natural history of severe atheromatous disease of the thoracic aorta. J Am Coll Cardiol 1996;27:95-101.[Medline]
  23. Bland J.M., Altman D.G. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;1:307-310.[Medline]
  24. Cohen J. A coefficient of agreement for nominal scales. Educ Psychological Meas 1960;20:37-46.
  25. Warm Heart Investigators. Randomized trail of normothermic versus hypothermic coronary bypass surgery. Lancet 1994;343:559-563.[Medline]
  26. Tuman K.J., McCarthy R.J., Najafi H., Ivankovich A.D. Differential effects of advanced age on neurologic and cardiac risks of coronary artery operations. J Thorac Cardiovasc Surg 1992;104:1206-1208.
  27. Kaufman J.J.L. The shaggy aorta and the cardiovascular system. In: Hurst J.W., ed. Topics in clinical cardiology. New York: Igaku-Shoin, 1994:89-112.
Accepted for publication December 28, 1999.




This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
K. Chaudhuri, E. Storey, G. A. Lee, M. Bailey, J. Chan, F. L. Rosenfeldt, A. Pick, J. Negri, J. Gooi, A. Zimmet, et al.
Carbon dioxide insufflation in open-chamber cardiac surgery: A double-blind, randomized clinical trial of neurocognitive effects
J. Thorac. Cardiovasc. Surg., September 1, 2012; 144(3): 646 - 653.e1.
[Abstract] [Full Text] [PDF]

Home page
 Br J AnaesthHome page
B. van Zaane, A. P. Nierich, G. J. Brandon Bravo Bruinsma, P. M. J. Rosseel, F. Z. Ramjankhan, E. E. C. de Waal, W. F. Buhre, and K. G. M. Moons
Diagnostic accuracy of modified transoesophageal echocardiography for pre-incision assessment of aortic atherosclerosis in cardiac surgery patients
Br. J. Anaesth., August 1, 2010; 105(2): 131 - 138.
[Abstract] [Full Text] [PDF]

Home page
 SEMIN CARDIOTHORAC VASC ANESTHHome page
B. Jungwirth and G. B. Mackensen
Real-Time 3-Dimensional Echocardiography in the Operating Room
Seminars in Cardiothoracic and Vascular Anesthesia, December 1, 2008; 12(4): 248 - 264.
[Abstract] [PDF]

Home page
 Ann. Thorac. Surg.Home page
P. Rosenberger, S. K. Shernan, M. Loffler, P. S. Shekar, J. A. Fox, J. K. Tuli, M. Nowak, and H. K. Eltzschig
The Influence of Epiaortic Ultrasonography on Intraoperative Surgical Management in 6051 Cardiac Surgical Patients
Ann. Thorac. Surg., February 1, 2008; 85(2): 548 - 553.
[Abstract] [Full Text] [PDF]

Home page
 Br J AnaesthHome page
B. van Zaane, A. P. Nierich, W. F. Buhre, G. J. Brandon Bravo Bruinsma, and K. G. M. Moons
Resolving the blind spot of transoesophageal echocardiography: a new diagnostic device for visualizing the ascending aorta in cardiac surgery
Br. J. Anaesth., April 1, 2007; 98(4): 434 - 441.
[Abstract] [Full Text] [PDF]

Home page
 Br J AnaesthHome page
Y.- L. Li, D. T. Wong, W. Wei, and J. Liu
A novel acoustic window for trans-oesophageal echocardiography by using a saline-filled endotracheal balloon
Br. J. Anaesth., November 1, 2006; 97(5): 624 - 629.
[Abstract] [Full Text] [PDF]

Home page
 SEMIN CARDIOTHORAC VASC ANESTHHome page
D. Bainbridge
Aortic assessment for cardiac surgical procedures.
Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2006; 10(2): 158 - 161.
[Abstract] [PDF]

Home page
 Ann. Thorac. Surg.Home page
S. F. Aranki, M. Nathan, P. Shekar, G. Couper, R. Rizzo, and L. H. Cohn
Hypothermic Circulatory Arrest Enables Aortic Valve Replacement in Patients With Unclampable Aorta
Ann. Thorac. Surg., November 1, 2005; 80(5): 1679 - 1687.
[Abstract] [Full Text] [PDF]

Home page
 SEMIN CARDIOTHORAC VASC ANESTHHome page
D. Bainbridge
3-D Imaging for Aortic Plaque Assessment
Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2005; 9(2): 163 - 165.
[Abstract] [PDF]

Home page
 SEMIN CARDIOTHORAC VASC ANESTHHome page
J. Fox, K. Glas, M. Swaminathan, and S. Shernan
The Impact of Intraoperative Echocardiography on Clinical Outcomes Following Adult Cardiac Surgery
Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2005; 9(1): 25 - 40.
[Abstract] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
O. Lev-Ran, R. Braunstein, R. Sharony, A. Kramer, Y. Paz, R. Mohr, and G. Uretzky
No-touch aorta off-pump coronary surgery: The effect on stroke
J. Thorac. Cardiovasc. Surg., February 1, 2005; 129(2): 307 - 313.
[Abstract] [Full Text] [PDF]

Home page
 Asian Cardiovascular and Thoracic AnnalsHome page
S. G. Raja, Z. Haider, and H. Zaman
Off-Pump Coronary Artery Bypass Surgery: Analysis of 5-Year Experience
Asian Cardiovascular and Thoracic Annals, December 1, 2004; 12(4): 306 - 311.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
B. Medalion, D. Meirson, E. Hauptman, L. Sasson, and A. Schachner
Initial experience with the Heartstring proximal anastomotic system
J. Thorac. Cardiovasc. Surg., August 1, 2004; 128(2): 273 - 277.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
O. Chavanon, M. Abdennadher, and D. Blin
Off-pump coronary artery bypass grafting using arterial grafts exclusively: aiming for an absolute "no-touch" aortic technique
Ann. Thorac. Surg., January 1, 2004; 77(1): 379 - 380.
[Full Text] [PDF]

Home page
 CirculationHome page
R. Sharony, C. S. Bizekis, M. Kanchuger, A. C. Galloway, P. C. Saunders, R. Applebaum, C. F. Schwartz, G. H. Ribakove, A. T. Culliford, F. G. Baumann, et al.
Off-Pump Coronary Artery Bypass Grafting Reduces Mortality and Stroke in Patients With Atheromatous Aortas: A Case Control Study
Circulation, September 9, 2003; 108(2011): II-15 - II-20.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
H. B. Hangler, G. Nagele, M. Danzmayr, L. Mueller, E. Ruttmann, G. Laufer, and J. Bonatti
Modification of surgical technique for ascending aortic atherosclerosis: impact on stroke reduction in coronary artery bypass grafting
J. Thorac. Cardiovasc. Surg., August 1, 2003; 126(2): 391 - 400.
[Abstract] [Full Text] [PDF]

Home page
 Card Surg AdultHome page
D. Spielvogel, M. N. Mathur, and R. B. Griepp
Aneurysms of the Aortic Arch
, January 1, 2003; 2(2003): 1149 - 1168.
[Full Text]

Home page
 Ann. Thorac. Surg.Home page
T. Shimokawa, N. Minato, N. Yamada, Y. Takeda, Y. Hisamatsu, and M. Itoh
Assessment of ascending aorta using epiaortic ultrasonography during off-pump coronary artery bypass grafting
Ann. Thorac. Surg., December 1, 2002; 74(6): 2097 - 2100.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
O. Chavanon, M. Durand, R. Hacini, H. Bouvaist, M. Noirclerc, T. Ayad, and D. Blin
Coronary artery bypass grafting with left internal mammary artery and right gastroepiploic artery, with and without bypass
Ann. Thorac. Surg., February 1, 2002; 73(2): 499 - 504.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
Z. S. Meharwal and N. Trehan
Aortocoronary bypass surgery and ascending aortic dissection: letter 2
Ann. Thorac. Surg., October 1, 2001; 72(4): 1445 - 1445.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Michael J. Wilson
Philip G. Lisagor
David J. Cohen
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Wilson, M. J.
Right arrow Articles by Cohen, D. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Wilson, M. J.
Right arrow Articles by Cohen, D. J.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS