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

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Original articles: Cardiovascular

Ascending aortic atheroma assessed intraoperatively by epiaortic and transesophageal echocardiography¹

^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

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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

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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

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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.

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

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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].

	Results

Top Abstract Introduction Material and methods Data analysis Results Comment References

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.

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).

	Comment

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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.

	References

Top Abstract Introduction Material and methods Data analysis Results Comment References

 

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