Usefulness of transesophageal echocardiography in the assessment of aortic dissection.

The acute dissection of the ascending aorta requires prompt and reliable diagnosis to reduce the high risk of mortality; in addition, prognosis is influenced by long-term complications. The aim of this article is to discuss transesophageal echocardiography (TEE) and (1) its diagnostic accuracy in the presurgical evaluation of patients, (2) its role in reducing time of diagnosis and surgery, and (3) its ability to reduce hospital mortality. TEE has also been tested as a screening method in the postsurgical follow-up of these patients. The retrospective investigation concerns a sample of 80 cases of acute dissection of the aorta, submitted for surgical intervention from April 1986 to February 1999. TEE has allowed a precise estimation of aortic diameters and optimal visualization of intimal flap and tear entry with a fine distinction between true and false lumen. A direct comparison of the results of TEE and of transthoracic echocardiography has demonstrated that some elements (visualization of flap and diameters in descending aorta, sites of entry and reentry, direction of jet trough intimal tears, phasic intimal flap movement, diastolic collapse of flap on the valvular plane, false lumen thrombosis, coronary involvement, intramural hematoma, and aortic fissuration) were identified only by TEE, whereas other additional diagnostic elements (cardiac tamponade, aortic valve insufficiency, left ventricular function) show a similar pattern of significance. Routine employment of this method has confirmed a reduction of hospitalization time (about 1.5 hours of waiting time), and hospital mortality has changed from 42.8% to 17.3%. In the follow-up of patients operated on for aortic dissection, fundamental information may be obtained from TEE (assessment of the progression of thrombosis in the false lumen with its complete obliteration and modifications in aortic diameter with a consequent, possible worsening of aortic valve insufficiency). In conclusion, our study demonstrated that TEE may provide fast and efficient detection of acute aortic dissection. In the postsurgical follow-up, TEE has confirmed detection of major complications that can influence long-term prognosis and may be proposed as a method with easy access-one that is repeatable and inexpensive for the screening of aortic dissection surgical patients.

Comparative evaluation of TEE, conventional MRI and contrast-enhanced 3D breath-hold MRA in the post-operative follow-up of dissecting aneurysms.

PURPOSE: To verify the diagnostic potentialities of conventional magnetic resonance imaging (MRI), breath-hold 3D contrast enhanced MR angiography (C3D MRA) and transesophageal echocardiography (TEE) in patients surgically treated for type A aortic dissection. MATERIALS AND METHODS: Twenty-nine patients (21 males and 8 females), surgically treated for type A aortic dissection, were evaluated with MRI using a 1.5 T (GE Horizon Echospeed 8.2) with standard gated SE sequences and breath-hold 3D fast SPGR after intravenous Gd injection (0.2 mmol/kg). 3D MIP reconstruction was obtained. TEE evaluation was performed with a HP 2000 system and a biplane 5 MHz probe. The sizes of aortic root, distal anastomosis, descending aorta and periprosthetic thickening were measured. Regional false lumen and aortic branch involvement were also evaluated. RESULTS: Concordance among TEE, conventional MRI and C3D MRA was observed in the evaluation of aortic root (MRI vs. C3D MRA r = 0.93; MRI vs. TEE r = 0.84; C3D MRA vs. TEE r = 0.84) and descending aorta (r = 0.94, 0.91 and 0.92, respectively). The interobserver variability was also very low. Inadequate agreement was observed for distal anastomosis. C3D MRA was inadequate in the evaluation of periprosthetic thickening; r = 0.73 was obtained between MRI and TEE. For qualitative data: TEE was inadequate in the evaluation of the abdominal aorta and branches. C3D MRA depicted supra-aortic vessel involvement in more cases than the other techniques. CONCLUSION: C3D MRA is a fast and accurate technique in the evaluation of the endoluminal alterations and involvement of the aortic branches. Conventional MRI allows a direct evaluation of the aortic wall and periaortic tissue. TEE is less accurate in the evaluation of aortic branches and abdominal aorta.

Optimal ("stent-like") acute angiographic results pursuable by traditional PTCA.

OBJECTIVES: This study was undertaken: 1) to assess the efficacy of traditional PTCA in affording "optimal" initial dilatation (OID) of coronary stenoses (as assessed by on-line quantitative angiography) defined as a post-procedure residual lumen narrowing < or = 20%; 2) to determine clinical and angiographic correlates of these types of successes. BACKGROUND: Recent reports have shown that acute angiographic results achieved by traditional PTCA, resembling those obtainable by elective stenting, carry low risks of restenosis. However, safety and the ability of conventional PTCA to consistently provide acute stent-like results are still practically unknown. PATIENTS AND METHODS: Using a "standardized" procedural protocol intended to optimize acute angiographic results, 878 consecutive non-selected patients, 750 men and 128 women aged 29-78 years (mean 60.5 yrs) underwent PTCA on 1054 lesions. Compliant balloons reaching nominal dimensions at 6 atm and predicted balloon-artery ratios of 0.92-1.05 (mean 1.02) were used. An inflation pressure of 5 atm was gradually and slowly applied initially (usually sufficient to reach the point of plaque fracture). Inflation times of 60 seconds and step-increases in inflation pressure of 1 atm were subsequently utilized, until a large lumen with smooth contours (the nearest to normal) or any wall damage were detected by angiographic tests performed at each step. Inflations were stopped when, even in the presence of sub-optimal dilatation, the inflation pressure of 14 atm was reached (which usually corresponded to an effective balloon/artery ratio < 1.15). RESULTS: Overall traditional primary successes were 830 (94.5%) for patients and 1001 (95%) for lesions. Major complications, without mortality, were 24 (2.7%). CABS was necessary in 17 patients (1.9%) while acute myocardial infarction occurred in 7 patients (0.8%). OID was obtained in 65.4% of the treated lesions: 77.9% in type A, 73.9% in B1, 54.0% in B2 and 32.5% in C lesion subgroups of the AHA/ACC classification scheme. Multivariate analysis showed that no clinical variables significantly influenced OID. Lesion-related variables such as chronic occlusion, diffuse disease, length > 10 mm, heavily calcified and markedly angulated lesions emerged as (negative) determinants of success. CONCLUSIONS: Acute stent-like angiographic results are obtainable by conventional PTCA in a consistent percentage of eligible coronary lesions. Following a safe modality of balloon-stress application in performing angioplasty, probability of safely achieving OID of coronary stenoses is related to specific angiographic lesion characteristics.

Coronary restenosis after optimal (stent-like) initial angiographic results obtained by traditional balloon angioplasty.

BACKGROUND AND OBJECTIVE: Elective native coronary artery stenting has shown its efficacy in lowering restenosis rates (RR) usually occurring after balloon angioplasty (PTCA). However ability of conventional PTCA to consistently provide low RR, through the achievement of large acute stent-like angiographic results, has not been investigated. This study was conducted to: (1) assess ability of optimal initial dilatation (OID), defined by residual lumen narrowing < or = 20%, significantly reduce current high RR following traditional PTCA; (2) evaluate the efficacy of OID obtainable by conventional PTCA in influencing adverse effects of single variables predisposing to restenosis. METHODS: Of consecutive 601 patients who underwent PTCA, 569 (94.6%), 483 men and 86 women, aged 38-76 years, had a successful procedure on 645/678 lesions (95.1%). After a plaque fracture was obtained by the first inflation, step-increases in pressure of 1 atm and 60 second-inflation-times were applied, until a large lumen (the nearest to normal) and smooth contours were seen, or any wall damage detected by using step-by-step angiographic tests. Acute optimal results (group A) were 450 (69.7%) and sub-optimal results (group B) were 203 (30.3%). After a mean time of 9 +/- 1.8 months, 543 patients (95.4%) had angiographic restudy on 611 (94.7%) successfully treated lesions. RESULTS: Restenosis (> 50% stenosis at restudy) occurred in 27.1% of patients and in 24.5% of lesions. RR was 18.8% in group A and 37.8% in group B (p < 0.0001). Significant lower RR were observed in group A in comparison with group B, for single variables examined, except for length > 10 mm. By multivariate analysis of all treated lesions, sub-optimal initial dilatation, unstable angina, lesion length > 10 mm and eccentricity emerged as major determinants of restenosis. Following OID only length > 10 mm was highly predictive of this event and, in the absence of this adverse variable, RR was only 13.6%. CONCLUSION: Counterbalancing adverse effects of many variables predisposing to restenosis, OID obtained by traditional PTCA seem to significantly reduce the risk of recurrence, particularly in lesions no longer than 10 mm.