AMA Category 1 Credit for Physicians Only.
ASRT CME is not available.
|Go to the COTW Archive|
The TEE showed:
The TEE showed an LVEF of 60% with no RWMA.
The descending and arch aorta had grade 5 atherosclersosis.
We do know that descending aortic atherosclerotic disease is a good marker for coronary artery disease.
However, is descending aortic (and/or arch) atherosclerotic disease an indication of ascending atherosclerosis? What is the best method to determine ascending atherosclerosis: Palpation, TEE, or Epiaortic Echocardiography?
Stroke occurs from 1.9%-3.8%-4.8%-8.8% of patients undergoining OPCABs, On-Pump CAB, aortic valve, or mitral valve opertions respectively. Risk factors for CVA are age, female sex, history of cerebral vascular disease, peripheral vascular disease, preoperative infection, previous cardiac surgery, urgent operation, pump time > 2 hours, transfusion, calcified aorta, atrial fibrillation, carotid disease, or ascending aortic atherosclerosis. Decreased manipulation of the ascending aorta can reduce the incidence of stroke by 30-50%.
Grading of aortic atheromas was introduced by Katz:
Grade 1: Intimal Thickening < 3 mm
Grade 2: Intimal Thickening > 3 mm
Grade 3: Protruding Atheroma < 5 mm
Grade 4: Protruding Atheroma > 5 mm
Grade 5: Mobile Atheroma
The patients that are at the highest risk are those with ascending aortic disease, plaque that is greater than 3 mm, and is mobile. Severe atherosclerosis, which puts a patient at risk for a stroke, is present in 0.2%, 2.2%, and 6.0% of patients in the ascending, arch, and descending aorta respectively. If a patient has severe atherosclerosis in the aortic arch the 1 year risk of stroke is 10-12%. Severe atherosclerosis in the ascending aorta is rarely seen despite severe atherosclerosis in the aortic arch or descending aorta. Only about 1% of patients with severe arch and/or descending aortic atherosclerosis will have severe atherosclerosis in the ascending aorta.
TEE has been shown to be able to find ascending aortic atherosclerosis. However, TEE underestimates the degree and severity of the atherosclerosis, especially in the distal ascending aorta. Palpation also underestimated the presence and severity of ascending atherosclerosis of the ascending aorta. Epiaortic (EAU) ultrasound was superior to TEE and palpation for detection of the degree and severity of ascending aortic atherosclerosis. TEE was superior to palpation in the detection of the degree and severity of ascending aortic atherosclerosis. TTE is less accurate than TEE in the diagnosis of the degree and severity of aortic atherosclerosis. The disadvantage of EAU is that the chest has to be open and the arch may not be able to be completely scanned.
Arch endarterectomy has been shown to increase the risk of stroke. Therefore, arch endarterectomy is not indicated in severe aortic arch disease.
Our recommendation was to perform epiaortic ultrasound on this patient to determine the degree and severity of the atherosclerosis and for placement of the aortic cross clamp, selection of the vein placment and/or consideration of alternative methods of performing a CAB (OPCAB or Axillary cannuluation). Also, aortic arch replacement should be considered since his risk of stroke in 1 year is > 10%.
|Please answer the following questions correctly to obtain your CME.|
Atherosclerosis of the descending aorta predicts cardiovascular events: a transesophageal echocardiography study
Guidelines for the Performance of a Comprehensive Intraoperative Epiaortic Ultrasonographic Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists; Endorsed by the Society of Thoracic S
Intraoperative Transesophageal Echocardiography and Epiaortic Ultrasound for Assessment of Atherosclerosis of the Thoracic Aorta
Aortic Atherosclerotic Disease and Stroke
Echocardiography in aortic diseases: EAE recommendations for clinical practice
Thoracic aortic plaques, transoesophageal echocardiography and coronary artery disease
Atherosclerosis of the aorta: Risk factor, risk marker, or innocent bystander?