Diagnostic accuracy of modified transoesophageal echocardiography for pre-incision assessment of aortic atherosclerosis in cardiac surgery patients

• Published in: British journal of anaesthesia : BJA Vol. 105; no. 2; pp. 131 - 138
• Main Authors: van Zaane, B, Nierich, A.P., Brandon Bravo Bruinsma, G.J., Rosseel, P.M.J., Ramjankhan, F.Z., de Waal, E.E.C., Buhre, W.F., Moons, K.G.M.
• Format: Journal Article
• Language: English
• Published: Oxford Elsevier Ltd 01.08.2010; Oxford University Press
• Subjects: Aged; Aged, 80 and over; Anesthesia; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Aortic Valve Stenosis - complications; Aortic Valve Stenosis - diagnostic imaging; Atherosclerosis - complications; Atherosclerosis - diagnostic imaging; Biological and medical sciences; brain; brain, ischaemia; Cardiac Surgical Procedures - adverse effects; cardiovascular; echocardiography; Echocardiography, Transesophageal - adverse effects; Echocardiography, Transesophageal - methods; embolism; embolism, thromboembolism; Epidemiologic Methods; Female; Humans; ischaemia; Male; Medical sciences; monitoring; monitoring, echocardiography; Preoperative Care - methods; Sternum - surgery; Stroke - etiology; Stroke - prevention & control; surgery; surgery, cardiovascular; thromboembolism; embolism, thromboembolism; brain, ischaemia; monitoring, echocardiography; surgery, cardiovascular; Nervous system diseases; Echocardiography; Cardiovascular disease; Thrombosis; Embolism; Cerebral disorder; Vascular disease; Surgery; Central nervous system disease; Atherosclerosis; Brain ischemia; Anesthesia; Aorta; Diagnosis; Thromboembolism; Cerebrovascular disease; Monitoring
• ISSN: 0007-0912; 1471-6771
• DOI: 10.1093/bja/aeq122

Epiaortic ultrasound scanning (EUS) is regarded as the reference standard for detecting atherosclerosis in the ascending aorta (AA). Combined with appropriate surgical modifications, EUS use can significantly reduce the incidence of postoperative stroke when detecting severe AA atherosclerosis. A recently introduced modification of conventional transoesophageal echocardiography (TOE), known as the A-View method, has proven capable of inspecting the distal AA. The objective of this study was to quantify the diagnostic accuracy of modified TOE in assessing atherosclerosis of the distal AA. After approval by the institutional medical ethical committee and after obtaining written informed consent, 465 consecutive patients above 65 yr old, undergoing elective cardiac surgery with a median sternotomy, were included. The study followed a cross-sectional diagnostic design. All consecutive patients underwent modified TOE followed by EUS (reference standard) to assess the severity of distal AA atherosclerosis. We constructed contingency tables to compare the presence (and severity) of atherosclerosis, detected by the two techniques. The positive predictive value of modified TOE for the detection of clinically significant atherosclerosis was 67%, and the negative predictive value was 97%. The sensitivity was 95% and the specificity was 79%. One patient suffered a pulmonary haemorrhage, although he recovered without further sequelae. We did not observe any clinical significant haemodynamic or ventilatory effects. The high negative predictive value and sensitivity show that modified TOE yields adequate diagnostic accuracy for excluding clinically relevant aorta atherosclerosis without significant cardiopulmonary side-effects, provided that the A-View catheter is introduced carefully.