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Chapter 23: Aorta

This chapter describes TEE-based diagnosis of aortic disease, including dissection, aneurysm, and trauma. Anatomic reconstructions and TEE clips will aid interpretation.

1

Figures

TEE thoracic aorta examination. These diagrams show the relationship between the TEE probe and the structures displayed during the thoracic aorta examination. (A-D) ME Asc Ao SAX view. In this position, the dual rotating knob position is anterior at 12 o’clock and the US beam is at 0°. In the 2D image, the right screen (red line) has the left anterior anatomic structures like the MPA and the left screen (green line) the right anterior anatomic structures like the SVC. The Ao lies anterior to the esophagus. (E-H) UE aortic arch SAX view. The dual rotating knob position is to the left of the patient at 9 o’clock and the US beam is at 0°. In the 2D image, the right screen (red line) corresponds to the left inferior anatomic structures like the LPA and the left screen (green line) to the left superior anatomic structures like the RPA. (I-L) DE descending aorta SAX view. The dual rotating knob position is in the back of the patient, posteriorly at 6 o’clock and the US beam is at 0°. In the 2D image, the right screen (red line) corresponds to the right inferior anatomic structures like the IVC and the left screen (green line) to the left inferior anatomic structures like the LV.<em> Abbreviations</em>: 2D, two-dimensional; Ant, anterior; Ao, aorta; Asc Ao, ascending aorta; DE, deep esophageal; E, esophagus; Inf, inferior; IVC, inferior vena cava; LPA, left pulmonary artery; LV, left ventricle; ME, mid-esophageal; MPA, main pulmonary artery; Post, posterior; RPA, right pulmonary artery; SAX, short-axis; Sup, superior; SVC, superior vena cava; UE, upper esophageal; US, ultrasound. Adapted from Denault at al. <strong><sup>71</sup></strong> Artwork courtesy of Hugo Babin. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 23.6

TEE thoracic aorta examination. These diagrams show the relationship between the TEE probe and the structures displayed during the thoracic aorta examination. (A-D) ME Asc Ao SAX view. In this position, the dual rotating knob position is anterior at 12 o’clock and the US beam is at 0°. In the 2D image, the right screen (red line) has the left anterior anatomic structures like the MPA and the left screen (green line) the right anterior anatomic structures like the SVC. The Ao lies anterior to the esophagus. (E-H) UE aortic arch SAX view. The dual rotating knob position is to the left of the patient at 9 o’clock and the US beam is at 0°. In the 2D image, the right screen (red line) corresponds to the left inferior anatomic structures like the LPA and the left screen (green line) to the left superior anatomic structures like the RPA. (I-L) DE descending aorta SAX view. The dual rotating knob position is in the back of the patient, posteriorly at 6 o’clock and the US beam is at 0°. In the 2D image, the right screen (red line) corresponds to the right inferior anatomic structures like the IVC and the left screen (green line) to the left inferior anatomic structures like the LV. Abbreviations: 2D, two-dimensional; Ant, anterior; Ao, aorta; Asc Ao, ascending aorta; DE, deep esophageal; E, esophagus; Inf, inferior; IVC, inferior vena cava; LPA, left pulmonary artery; LV, left ventricle; ME, mid-esophageal; MPA, main pulmonary artery; Post, posterior; RPA, right pulmonary artery; SAX, short-axis; Sup, superior; SVC, superior vena cava; UE, upper esophageal; US, ultrasound. Adapted from Denault at al. 71 Artwork courtesy of Hugo Babin.

TEE blind spot. Interposition of the trachea (A,B), carina (C,D) and LMSB (E,F) anterior to the TEE probe creates blind areas where several cardiac structures (1 to 7) may not be identified clearly.<em> Abbreviations</em>: Asc Ao, ascending aorta; LAA, left atrial appendage; LMSB, left main stem bronchus; LPA, left pulmonary artery; MPA, main pulmonary artery; RPA, right pulmonary artery; SVC, superior vena cava; TEE, transesophageal echocardiography. Adapted from Sharma et al. <strong><sup>72</sup></strong>

eFigure 23.7

TEE blind spot. Interposition of the trachea (A,B), carina (C,D) and LMSB (E,F) anterior to the TEE probe creates blind areas where several cardiac structures (1 to 7) may not be identified clearly. Abbreviations: Asc Ao, ascending aorta; LAA, left atrial appendage; LMSB, left main stem bronchus; LPA, left pulmonary artery; MPA, main pulmonary artery; RPA, right pulmonary artery; SVC, superior vena cava; TEE, transesophageal echocardiography. Adapted from Sharma et al. 72

A-View balloon catheter. This sagittal cross-section view illustrates the anatomic relationship of structures with the A-View balloon catheter (DeRoyals, TN, USA), and TEE probe.<em> Abbreviations</em>: Ao, aorta; ETT, endotracheal tube; LCCA, left common carotid artery; LSCA, left subclavian artery; RBCA, right brachiocephalic artery; TEE, transesophageal echocardiography. Source: Adapted with permission from van Zaane et al.<sup>10</sup>

eFigure 23.8

A-View balloon catheter. This sagittal cross-section view illustrates the anatomic relationship of structures with the A-View balloon catheter (DeRoyals, TN, USA), and TEE probe. Abbreviations: Ao, aorta; ETT, endotracheal tube; LCCA, left common carotid artery; LSCA, left subclavian artery; RBCA, right brachiocephalic artery; TEE, transesophageal echocardiography. Source: Adapted with permission from van Zaane et al.10

Aortic atheroma algorithm. This algorithm demonstrates the management of Asc Ao atheroma during cardiac surgery.<em> Abbreviations</em>: Asc Ao, ascending aorta; CT, computed tomography; DHCA, deep hypothermic cardiac arrest; TEE, transesophageal echocardiography; US, ultrasound.

eFigure 23.15

Aortic atheroma algorithm. This algorithm demonstrates the management of Asc Ao atheroma during cardiac surgery. Abbreviations: Asc Ao, ascending aorta; CT, computed tomography; DHCA, deep hypothermic cardiac arrest; TEE, transesophageal echocardiography; US, ultrasound.

Aneurysm morphology. (A,B) These diagrams illustrate the two morphologic types of aortic aneurysms, (A) saccular and (B) fusiform. Adapted from Isselbacher et al.<strong><sup>68</sup></strong>

eFigure 23.17

Aneurysm morphology. (A,B) These diagrams illustrate the two morphologic types of aortic aneurysms, (A) saccular and (B) fusiform. Adapted from Isselbacher et al.68

Saccular aneurysm. (A-C) Desc Ao SAX view with CFI shows a saccular aneurysm with a thrombus.<em> Abbreviations</em>: Ao, aorta; CFI, color flow imaging; Desc Ao, descending aorta; SAX, short-axis. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 23.19

Saccular aneurysm. (A-C) Desc Ao SAX view with CFI shows a saccular aneurysm with a thrombus. Abbreviations: Ao, aorta; CFI, color flow imaging; Desc Ao, descending aorta; SAX, short-axis.

Pseudo-aortic dissection. A 57-year-old man undergoing coronary bypass surgery experiences problematic aortic cannula insertion, giving rise to suspicion of an aortic dissection. (A, B) ME Ao LAX view shows a mobile linear shadow suggestive of an intimal flap. (C) Corresponding M-mode of the suspected intimal flap (arrow) below the aortic wall. (D, E) ME Asc Ao LAX shows a PAC in the RPA. (F) On M-mode, the PAC motion (arrow) has an excursion quite like the suspected intimal flap. (G–J) Epiaortic scanning of the ascending Ao in G, H) LAX and (I, J) SAX fails to show a dissection flap, excluding an aortic dissection. The linear shadow represents a reverberation artifact in the aorta from the PAC in the RPA.<em> Abbreviations</em>: Ao, aorta; Asc Ao, ascending aorta; LAX, long-axis; ME, mid-esophageal; PAC, pulmonary artery catheter; RPA, right pulmonary artery; SAX, short-axis. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 23.24

Pseudo-aortic dissection. A 57-year-old man undergoing coronary bypass surgery experiences problematic aortic cannula insertion, giving rise to suspicion of an aortic dissection. (A, B) ME Ao LAX view shows a mobile linear shadow suggestive of an intimal flap. (C) Corresponding M-mode of the suspected intimal flap (arrow) below the aortic wall. (D, E) ME Asc Ao LAX shows a PAC in the RPA. (F) On M-mode, the PAC motion (arrow) has an excursion quite like the suspected intimal flap. (G–J) Epiaortic scanning of the ascending Ao in G, H) LAX and (I, J) SAX fails to show a dissection flap, excluding an aortic dissection. The linear shadow represents a reverberation artifact in the aorta from the PAC in the RPA. Abbreviations: Ao, aorta; Asc Ao, ascending aorta; LAX, long-axis; ME, mid-esophageal; PAC, pulmonary artery catheter; RPA, right pulmonary artery; SAX, short-axis.

Aortic dissection Stanford type A. (A) Biplane ME Desc Ao SAX view shows the TL has a smaller diameter and is more pulsatile compared with the FL. (B) Color M-mode can help identify the TL where most systolic aliasing occurs versus FL. (C-E) Biplane ME AoV SAX view with CFI shows flow in both the TL and FL.<em> Abbreviations</em>: AoV, aorta valve; CFI, color flow imaging; Desc Ao, descending aorta;FL, false lumen; ME, mid-esophageal; SAX, short-axis; TL, true lumen. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 23.27

Aortic dissection Stanford type A. (A) Biplane ME Desc Ao SAX view shows the TL has a smaller diameter and is more pulsatile compared with the FL. (B) Color M-mode can help identify the TL where most systolic aliasing occurs versus FL. (C-E) Biplane ME AoV SAX view with CFI shows flow in both the TL and FL. Abbreviations: AoV, aorta valve; CFI, color flow imaging; Desc Ao, descending aorta;FL, false lumen; ME, mid-esophageal; SAX, short-axis; TL, true lumen.

Aortic dissection Stanford type A. (A, B) ME descending aorta SAX view shows the TL has a smaller diameter and is more pulsatile compared with the FL. (C, D) ME AoV SAX view shows a proximal extension of the intimal flap to the level of the sinuses of Valsalva above the AoV.<em> Abbreviations</em>: AoV, aorta valve; FL, false lumen; LA, left atrium; LCC, left coronary cusp; ME, mid-esophageal; MPA, main pulmonary artery; RA, right atrium; RCC, right coronary cusp; SAX, short-axis; TL, true lumen. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 23.28

Aortic dissection Stanford type A. (A, B) ME descending aorta SAX view shows the TL has a smaller diameter and is more pulsatile compared with the FL. (C, D) ME AoV SAX view shows a proximal extension of the intimal flap to the level of the sinuses of Valsalva above the AoV. Abbreviations: AoV, aorta valve; FL, false lumen; LA, left atrium; LCC, left coronary cusp; ME, mid-esophageal; MPA, main pulmonary artery; RA, right atrium; RCC, right coronary cusp; SAX, short-axis; TL, true lumen.

Aortic dissection and AR. This 59-year-old woman experienced sudden excruciating chest pain and a CT scan diagnosed a Stanford type A aortic dissection. (A, B) ME ascending Ao SAX view shows the FL involving the proximal ascending aorta. (C) this is an intraoperative photo of the findings. (D-F) ME AoV LAX views without and with CFI show the dissection was associated with moderate AR.<em> Abbreviations</em>: Ao, aorta; AR, aortic regurgitation; AoV, aortic valve; CFI, color flow imaging; CT, computed tomography; FL, false lumen; LA, left atrium; LAX, long-axis; LPA, left pulmonary artery; ME, mid-esophageal; MPA, main pulmonary artery; RPA, right pulmonary artery; SAX, short-axis. Source: Photo C courtesy of Drs. Nicolas Noiseux and Raymond Cartier. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 23.32

Aortic dissection and AR. This 59-year-old woman experienced sudden excruciating chest pain and a CT scan diagnosed a Stanford type A aortic dissection. (A, B) ME ascending Ao SAX view shows the FL involving the proximal ascending aorta. (C) this is an intraoperative photo of the findings. (D-F) ME AoV LAX views without and with CFI show the dissection was associated with moderate AR. Abbreviations: Ao, aorta; AR, aortic regurgitation; AoV, aortic valve; CFI, color flow imaging; CT, computed tomography; FL, false lumen; LA, left atrium; LAX, long-axis; LPA, left pulmonary artery; ME, mid-esophageal; MPA, main pulmonary artery; RPA, right pulmonary artery; SAX, short-axis. Source: Photo C courtesy of Drs. Nicolas Noiseux and Raymond Cartier.

Dissection and coronary perfusion. (A, B) ME Asc Ao LAX view from a patient with type A aortic dissection illustrates the dissection flap (arrow) entering the ostium of the RCA.<em> Abbreviations</em>: Ao, aorta; Asc Ao, ascending aorta; LA, left atrium; LAX, long-axis; ME, mid-esophageal; RCA, right coronary artery; RPA, right pulmonary artery. With the permission of Goldstein et al. <strong><sup>65</sup></strong>

eFigure 23.34

Dissection and coronary perfusion. (A, B) ME Asc Ao LAX view from a patient with type A aortic dissection illustrates the dissection flap (arrow) entering the ostium of the RCA. Abbreviations: Ao, aorta; Asc Ao, ascending aorta; LA, left atrium; LAX, long-axis; ME, mid-esophageal; RCA, right coronary artery; RPA, right pulmonary artery. With the permission of Goldstein et al. 65

Aortic dissection and cerebral perfusion. (A) Axial slice of a CT angiogram shows dissection of the Asc Ao (arrow) extending to the Desc Ao. (B) Intraoperative brain oximetry monitoring after selective unilateral cerebral perfusion via the innominate artery shows an immediate profound decrease in right rSO<sub>2</sub> (arrow point #5). This required the establishment of perfusion via a right carotid artery cannula with the restoration of right rSO<sub>2</sub>. This unilateral desaturation is most probably because of an incomplete circle of Willis. (C, D) Surface transverse scan of the LICA shows partial occlusion from the extension of a Stanford type A aortic dissection. Note the partial occlusion of the LICA.<em> Abbreviations</em>: Asc Ao, ascending aorta; CPB, cardiopulmonary bypass; CT, computed tomography; Desc Ao, descending aorta; LICA, left internal carotid artery; LIJV, left internal jugular vein; rSO2, regional oxygen saturation. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 23.36

Aortic dissection and cerebral perfusion. (A) Axial slice of a CT angiogram shows dissection of the Asc Ao (arrow) extending to the Desc Ao. (B) Intraoperative brain oximetry monitoring after selective unilateral cerebral perfusion via the innominate artery shows an immediate profound decrease in right rSO2 (arrow point #5). This required the establishment of perfusion via a right carotid artery cannula with the restoration of right rSO2. This unilateral desaturation is most probably because of an incomplete circle of Willis. (C, D) Surface transverse scan of the LICA shows partial occlusion from the extension of a Stanford type A aortic dissection. Note the partial occlusion of the LICA. Abbreviations: Asc Ao, ascending aorta; CPB, cardiopulmonary bypass; CT, computed tomography; Desc Ao, descending aorta; LICA, left internal carotid artery; LIJV, left internal jugular vein; rSO2, regional oxygen saturation.

Carotid perfusion in aortic dissection. Surface ultrasound of the (A) left and (B) right carotid artery during clamping of the right innominate artery shows reduced RICV but minimal reduction in the right regional brain saturation using NIRS. (C, D) Internal carotid artery signals at the end of the procedure show the right was still lower than the left.<em> Abbreviations</em>: LICV, left internal carotid velocity; NIRS, near-infrared spectroscopy; RICV, right internal carotid velocity.

eFigure 23.37

Carotid perfusion in aortic dissection. Surface ultrasound of the (A) left and (B) right carotid artery during clamping of the right innominate artery shows reduced RICV but minimal reduction in the right regional brain saturation using NIRS. (C, D) Internal carotid artery signals at the end of the procedure show the right was still lower than the left. Abbreviations: LICV, left internal carotid velocity; NIRS, near-infrared spectroscopy; RICV, right internal carotid velocity.

Ascending aorta hematoma. This is a 56-year-old hypertensive man with an acute aortic dissection. (A-D) ME AoV LAX and Asc Ao SAX views show an aortic hematoma in the anterior wall. (E, F) These are intraoperative photos of the (E) enlarged aorta and (F) mural hematoma.<em> Abbreviations</em>: Ao, aorta; AoV, aortic valve; Asc Ao, ascending aorta; LAX, long-axis; LPA, left pulmonary artery; ME, mid-esophageal; MPA, main pulmonary artery; RA, right atrium; RAA, right atrial appendage; RPA, right pulmonary artery; SAX, short-axis. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 23.39

Ascending aorta hematoma. This is a 56-year-old hypertensive man with an acute aortic dissection. (A-D) ME AoV LAX and Asc Ao SAX views show an aortic hematoma in the anterior wall. (E, F) These are intraoperative photos of the (E) enlarged aorta and (F) mural hematoma. Abbreviations: Ao, aorta; AoV, aortic valve; Asc Ao, ascending aorta; LAX, long-axis; LPA, left pulmonary artery; ME, mid-esophageal; MPA, main pulmonary artery; RA, right atrium; RAA, right atrial appendage; RPA, right pulmonary artery; SAX, short-axis.

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Tables

eTable 23.1 TEE views for assessing the aorta

TEE View

View-Technique

Utility/Disadvantages

ME Ascending aorta LAX
Angle: 120-140°
(See Figure 4.14)
  • Preferred view for LVOT, AoV and aortic root measurements

ME Ascending aorta SAX
Angle: 0-30°
(See Figure 4.15)
  • Useful to document proximal extension of type A dissection

Descending aorta SAX
Angle: 50-70°
(See Figure 4.25)
  • Thoracic and abdominal aneurysm, dissection, hematoma, and ulcer atheromatosis diagnosis

 

Descending aorta LAX Angle: 90-100°
(See Figure 4.25)
  • Thoracic and abdominal aneurysm, dissection, hematoma, and ulcer atheromatosis diagnosis
  • PWD interrogation for AR severity

UE Aortic arch LAX
Angle: 0-10°
(See Figure 4.26)
  • PWD interrogation for AR severity

UE Aortic arch SAX 
Angle: 70-90°
(See Figure 4.27)
  • Useful view to evaluate PDA and PV

UE LSCA
Angle: 80-100°
(Figure 23.10AB)

  • Distal position of branch vessels for PWD interrogation (See Figure 13.9)

UE LCCA
Angle: 80-100°
(Figure 23.10DE)
  • Distal position of branch vessels for PWD interrogation

UE RBCA
Angle: 80-100°
(Figure 23.10GH)
  • Distal position of branch vessels for PWD interrogation

DTG Aortic arch 
Angle: 0-20°
(See Figure 4.24)
  • LVOT and AoV PWD and CWD evaluation
  • Useful to interrogate aortic arch vessels (blind spot) 8 and see insertion of the aortic canula (See Figure 13.9)
  • Distal position of branch vessels for PWD interrogation

Abbreviations: AoV, aortic valve; AR, aortic regurgitation; CWD, continuous wave Doppler; DTG, deep transgastric; LAX, long-axis; LCCA, left common carotid artery; LSCA, left subclavian artery; LVOT, left ventricular outflow tract; ME, mid-esophageal; PDA, patent ductus arteriosus; PV, pulmonic valve; PWD, pulsed wave Doppler; RBCA, right brachiocephalic artery; SAX, short-axis; TEE, transesophageal echocardiography; UE, upper esophageal. Adapted from Hahn et al.66