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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
Movement in the Arch
Case#: 46
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
76 y.o. male with a history of chest pain. Cardiac Cath showed a Ramus 90%, Cx 80%, OM1
 80%, and a RCA 100%.

 Please review the TEE and consider the following questions:

 What is the severity of atherosclerosis?
 Is he at a high risk of embolization and stroke?
 What would be your recommendations for cannulation?
 Any other recommendations?

Case Discussion/CME Questions
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%.

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