Dean G. Karalis

Recognition and embolic potential of intraaortic atherosclerotic debris.

Atherosclerotic disease of the thoracic aorta is common in the elderly and patients with clinical coronary artery disease. Although embolization can occur from atherosclerotic debris within the thoracic aorta, it is not commonly considered in the differential diagnosis of the source of a systemic embolism. In the current study, the prevalence, clinical significance and embolic potential of intraaortic atherosclerotic debris as detected by transesophageal echocardiography was determined. Intraaortic atherosclerotic debris was identified in 38 (7%) of 556 patients undergoing transesophageal echocardiography. An embolic event occurred among 11 (31%) of the 36 study patients with intraaortic atherosclerotic debris. The incidence of an embolic event was higher when the debris was pedunculated and highly mobile (8 [73%] of 11 patients) than when it was layered and immobile (3 [12%] of 25 patients) (p less than 0.002). Among 15 patients undergoing an invasive procedure of the aorta, the incidence of embolism was 27%. In conclusion, in a patient with an embolic event, the thoracic aorta should be considered as a potential source. Transesophageal echocardiography can reliably detect intraaortic atherosclerotic debris, and when it is identified, an invasive aortic procedure should be avoided if possible.

Risk of catheter-related emboli in patients with atherosclerotic debris in the thoracic aorta

The aim of this study was to evaluate the risk of performing cardiac catheterization or intraaortic balloon pump placement in patients with transesophageal echocardiographically detected atherosclerotic aortic debris. Cardiac catheterization was performed in 70 patients with atherosclerotic aortic debris (in 11 via the brachial approach and in 59 via the femoral approach) and in 71 control patients. An embolic event occurred in 10 (17%) of 59 patients with atherosclerotic aortic debris after femoral catheterization compared to 2 (3%) of 71 control patients without atherosclerotic aortic debris (p = 0.01). None of the 11 patients with atherosclerotic aortic debris who underwent brachial catheterization had an embolic event. An intraaortic balloon pump was placed in 10 patients with atherosclerotic aortic debris and in 12 control patients. An embolic event related to placement of the intraaortic balloon pump occurred in 5 (50%) of 10 patients with atherosclerotic aortic debris; no control patient had an embolic event (p = 0.02). Patients with mobile atherosclerotic aortic debris were at the highest risk for catheter-related embolism. The strongest clinical predictors of atherosclerotic aortic debris were advanced age and peripheral vascular disease. Transesophageal echocardiographic recognition of atherosclerotic aortic debris identifies patients at high risk of stroke or peripheral embolism after cardiac catheterization or intraaortic balloon pump placement. If the aortic debris is mobile, the risk is particularly high. When atherosclerotic aortic debris is detected, especially if the debris is mobile, substituting brachial for femoral catheterization and avoiding placement of an intraaortic balloon pump may reduce the risk of embolism.

Three-dimensional transesophageal echo imaging of the descending thoracic aorta

Abstract Transesophageal 2-dimensional echocardiography provides high-quality images of the thoracic aorta. 1,2 Although this display technique is generally quite adequate for diagnosis, it does not optimally communicate the 3-dimensional nature of the anatomy and the full extent of pathology. Therefore, the purpose of this study was (1) to evaluate the feasibility of generating 3-dimensional images of the descending thoracic aorta from sequential 2-dimensional transesophageal echocardiographic images in vivo, and (2) to assess the optimal display technique to communicate the morphologic information.

Severe right ventricular contusion mimicking cardiac tamponade: The value of transesophageal echocardiography in blunt chest trauma

Clinically, severe right ventricular contusion may mimic cardiac tamponade. We report two cases of suspected cardiac tamponade after blunt chest trauma in which the diagnosis of severe right ventricular contusion was made only by transesophageal echocardiography, avoiding unnecessary and hazardous pericardiocentesis. These cases illustrate the value of transesophageal echocardiography in diagnosing blunt chest trauma.

Prognostic significance of valvular regurgitation in patients with infective endocarditis

Purpose Doppler ultrasound is a sensitive modality for detecting and quantitating valvular regurgitation in patients with infective endocarditis. Because valvular regurgitation leads to heart failure, we evaluated the prognostic significance of Doppler-detected valvular regurgitation in patients with endocarditis who had not yet developed clinical heart failure. Patients and methods We reviewed the medical records of 65 patients with a clinical diagnosis of infective endocarditis from May 1985 to March 1990. A total of 49 patients were included in the study: 33 patients with native valve endocarditis and 16 patients with prosthetic valve endocarditis. The initial Doppler echocardiogram was examined in these patients to determine the presence and degree of valvular regurgitation. RESULTS: Significant (moderate to severe) valvular regurgitation was detected in 23 (47%) patients. The presence or absence of significant valvular regurgitation did not predict the development of congestive heart failure, the need for surgery, or death (p = NS). The development of congestive heart failure was significantly associated with the need for surgery (p Conclusion We conclude that the detection of significant valvular regurgitation in patients with infective endocarditis who have not yet developed heart failure is not predictive of future complications nor does the absence of significant valvular regurgitation identify a group of patients with a more favorable prognosis. In our series, patients who developed congestive heart failure had a significantly higher incidence of surgery and death. Therefore, decisions regarding clinical management in patients with infective endocarditis should not be made solely on the presence or absence of echocardiographically detected valvular regurgitation.

The role of transesophageal echocardiography in the acute onset of paraplegia.

Background and Purpose: Acute paraplegia must be investigated promptly to exclude reversible causes. In this report we illustrate the usefulness of transesophageal echocardiography in identifying the vascular etiologies of acute paraplegia. Case Descriptions: Two patients presented with acute paraplegia, one spontaneously and the other after removal of an intra-aortic balloon pump catheter. Through the use of transesophageal echocardiography, we excluded aortic dissection and identified protruding atherosclerotic plaques in the descending thoracic aorta of each patient. Embolization of atheromatous material from the thoracic aorta was considered the most likely etiology of paraplegia in both cases. Conclusions: Embolization from atherosclerotic plaques in the thoracic aorta may be an underestimated cause of acute paraplegia. Transesophageal echocardiography provides a safe, rapid, and reliable tool for investigating a vascular etiology of acute paraplegia.

Improved diagnosis of coexisting types II and III aortic dissection with multiplane transesophageal echocardiography.

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Severe stenosis involving a congenitally bicuspid aortic valve in the tenth decade of life.

Abstract Acongenitally bicuspid aortic valve (BAV) is present in at least 1% of persons. 1 The most common complication of a BAV is stenosis, and this congenital malformation represents the most common cause of isolated aortic stenosis in the patient group aged 16 to 65. 2 In patients over the age of 65, aortic stenosis superimposed on a BAV occurs with a frequency of approximately 10%. We recently encountered a 92-year-old man with severe aortic stenosis due to a congenitally BAV. To our knowledge, this is the oldest reported patient with severe stenosis involving a congenitally BAV.