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      Transesophageal Echocardiographic Evaluation of Coronary Blood Flow and the Initial Flap Assisting in the Surgical Decision-Making: A Case of Acute Type A Aortic Dissection

      case-report
      Author(s): 1 , , 1 , 1 , 1
      Editor(s): ,
      Publication date (Electronic, pub):
      Publication date (Electronic, collection):
      Journal: Cureus
      Publisher: Cureus
      Keywords: pulsed doppler, transesophageal echocardiography, coronary artery blood flow, aortic flap, aortic dissection

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          Abstract

          Acute aortic dissection is a life-threatening condition. Myocardial ischemia associated with dissection occurs due to direct extension into the coronary artery or indirect involvement of the coronary ostia secondary to the dissection flap. Thus, the surgical procedure may require coronary reconstruction, in addition to aortic replacement. We experienced a case in which coronary artery reconstruction could be avoided because intraoperative transesophageal echocardiography showed that the aortic flap did not obstruct the right coronary artery in systole, and pulsed Doppler imaging indicated that there was sufficient coronary blood flow. This case shows that it is critical to establish a correct and early diagnosis and to proceed with the appropriate treatment for patients with myocardial ischemia.

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          Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis.

          Y Ohe, C. C. Apfel, T Inoue … (2006)
          Patients with suspected thoracic aortic dissection require early and accurate diagnosis. Aortography has been replaced by less invasive imaging techniques including transesophageal echocardiography (TEE), helical computed tomography (CT), and magnetic resonance imaging (MRI); however, accuracies have varied from trial to trial, and which imaging technique should be applied to which risk population remains unclear. We systematically reviewed the diagnostic accuracy of these imaging techniques in patients with suspected thoracic aortic dissection. Published English-language reports on the diagnosis of thoracic aortic dissection by TEE, helical CT, or MRI were identified from electronic databases. Sensitivity, specificity, and positive and negative likelihood ratios were pooled in a random-effects model. Sixteen studies involving a total of 1139 patients were selected. Pooled sensitivity (98%-100%) and specificity (95%-98%) were comparable between imaging techniques. The pooled positive likelihood ratio appeared to be higher for MRI (positive likelihood ratio, 25.3; 95% confidence interval, 11.1-57.1) than for TEE (14.1; 6.0-33.2) or helical CT (13.9; 4.2-46.0). If a patient had shown a 50% pretest probability of thoracic aortic dissection (high risk), he or she had a 93% to 96% posttest probability of thoracic aortic dissection following a positive result of each imaging test. If a patient had a 5% pretest probability of thoracic aortic dissection (low risk), he or she had a 0.1% to 0.3% posttest probability of thoracic aortic dissection following a negative result of each imaging test. All 3 imaging techniques, ie, TEE, helical CT, and MRI, yield clinically equally reliable diagnostic values for confirming or ruling out thoracic aortic dissection.
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            Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection.

            Robert Bonser, Aaron M. Ranasinghe, Mahmoud Loubani … (2011)
            Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or techniques have ever been performed, and novel therapies-particularly with regard to extent of surgery-are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes. Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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              Proximal aortic dissection with coronary malperfusion: presentation, management, and outcome.

              C Sassi, D Buklas, E Tucci … (2001)
              Acute myocardial ischemia and infarction due to retrograde dissection of the aortic root reaching the coronary ostia is a potentially fatal condition. Surgical treatment of these patients relies on the re-establishment of an adequate coronary blood flow and on the rescue of jeopardized myocardium. This article reports the results of a selected group of 24 patients with type A acute aortic dissection and coronary artery dissection. We review our experience and illustrate our approach to this condition, which evolved over a 15-year period. Between July 1985 and March 2000, 24 patients from a total of 211 (11.3%) treated for acute type A aortic dissection had dissection of at least one of the coronary ostia. There were 14 men and 10 women. The mean age was 65.5 years (median 61.7; range 41-78 years). The right coronary artery was involved in 11 patients, the left in 4 patients, and both coronary arteries in 9 patients. At admission, 16 patients had Q waves (66%), inferior in 6 (25%) and anterior, lateral, septal, or posterior in 10 (41%). All procedures were done on an emergency basis within 10 hours (median 4 hours) after initial chest pain and within 2 hours after the patient's arrival. Hospital mortality was 20% (5 patients); 3 patients could not be weaned from cardiopulmonary bypass and died intraoperatively, and 2 patients died postoperatively of low cardiac output. As illustrated in this study, direct coronary repair is a safe alternative to bypass grafting. Aggressive myocardial resuscitation together with early operation is a key factor in the management of these patients.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cureus
                Journal ID (iso-abbrev): Cureus
                Journal ID (issn): 2168-8184
                Title: Cureus
                Publisher: Cureus (Palo Alto (CA) )
                ISSN (Electronic): 2168-8184
                Publication date (Electronic, pub): 7 June 2024
                Publication date (Electronic, collection): June 2024
                Volume: 16
                Issue: 6
                Electronic Location Identifier: e61872
                Affiliations
                [1 ] Anesthesiology, Saitama International Medical Center, Saitama Medical University, Saitama, JPN
                Author notes
                Article
                DOI: 10.7759/cureus.61872
                PMC ID: 11227659
                PubMed ID: 38975408
                SO-VID: b54ec549-9921-453d-a108-5a30441b62d8
                Copyright © Copyright © 2024, Sumii et al.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date accepted : 6 June 2024
                Categories
                Subject: Anesthesiology
                Subject: Cardiac/Thoracic/Vascular Surgery

                Keywords: pulsed doppler,transesophageal echocardiography,coronary artery blood flow,aortic flap,aortic dissection
                Data availability:
                Keywords: pulsed doppler, transesophageal echocardiography, coronary artery blood flow, aortic flap, aortic dissection

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