Korean Circ J.  2008 Nov;38(11):573-582. 10.4070/kcj.2008.38.11.573.

Transesophageal Echocardiographic Evaluation of Atherosclerosis

• Nishino M
• Tanouchi J

• KMID: 2225704
• DOI: http://doi.org/10.4070/kcj.2008.38.11.573

Abstract

Transesophageal echocardiography (TEE) is a promising method for evaluating thoracic aortic atherosclerosis and coronary atherosclerosis. The highest impact of TEE as a clinical tool is in searching for cardiac embolic sources in patients with stroke and atrial fibrillation and in conducting detailed evaluations in patients with valvular disease, especially those with mitral valvular disease. However, it is also clinically useful in the evaluation of thoracic aortic atherosclerosis and coronary atherosclerosis. TEE is capable of evaluating thoracic aortic atherosis (intima- media complex thickness) and sclerosis (stiffness parameter beta) simultaneously. In addition, TEE can evaluate coronary atherosclerosis by non-invasively revealing narrowing or occlusion of the coronary arteries and providing information about coronary flow reserve. TEE imaging has improved with the advent of harmonic imaging, multiplane probes, contrast agents, and three-dimensional TEE. Future technology, including integrated backscatter (IBS), tissue Doppler, and strain imaging, will lead to further improvements in TEE. Thoracic aortic atherosclerosis and coronary atherosclerosis assessment should be performed in any patient undergoing TEE.

Keyword

Transesophageal echocardiography; Atherosclerosis; Aorta, thoracic; Coronary artery disease

MeSH Terms

Aorta, Thoracic
Atherosclerosis
Atrial Fibrillation
Contrast Media
Coronary Artery Disease
Coronary Vessels
Echocardiography, Transesophageal
Humans
Sclerosis
Sprains and Strains
Stroke
Contrast Media

Figure

• 

  Fig. 1 The thoracic aorta was divided into six segments as depicted in the illustration on the left (length of one segment 5 cm). The maximum (Max) intima-media complex thickness (IMT) was measured in each segment, and the mean value for the maximum IMT among the 6 segments was used as an index of aortic atherosis.

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  Fig. 2 Measurement of stiffness parameter β. M-mode transesophageal echocardiography of the descending aorta at a depth of 15 cm under the arch showed the minimum aortic dimension during the pre-ejection period (Dd) and the maximum aortic dimension during the ejection period (Ds). The formula for the stiffness parameter β is shown in the text. APW: aortic pressure wave, PAPW: pulmonary artery pressure wave, ECG: electrocardiogram.

• 

  Fig. 3 The upper panel shows measurements for calibrated integrated backscatter (CIB). The circular region of interest (ROI) was placed in the intima-media complex of the aortic wall and vessel lumen. We measured the average power of the integrated backscatter (IBS) signal contained in the ROI. CIB={IBS value of intima-media complex of the aortic wall (black circle)}-{(IBS values obtained from a reference ROI placed within the vessel lumen (white circle}. Lower panels show representative cases with high and low CIB. The CIB of the case on the left is 36 (CIB=38-2), and that of the case on the right is 17 (CIB=18-1).

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  Fig. 4 Pathological examination. In a trunk filled with a saline solution, the aorta in which TEE examinations were performed to measure calibrated integrated backscatter (CIB) were delimited by a metallic pin (pins are shown in the upper panels). This marker remained fixed in the specimens (Masson trichrome stain) so the same segment that was imaged by TEE could be evaluated pathologically. The left panel case shows low CIB (22). There was fibrofatty change on pathologic examination. The right case shows high CIB (41) and fibrotic change.

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  Fig. 5 Left upper panel: contrast-enhanced transesophageal echocardiography (TEE) revealed no color Doppler flow (black arrow) just proximal to the right coronary artery (RCA), while the wall of the coronary artery was visualized clearly. Left lower panel: small amounts of retrograde flow (white arrows) were found in the proximal RCA on contrast-enhanced pulsed Doppler TEE. The findings in the left panels suggest functional occlusion of the proximal RCA area. Right panels: coronary angiography showed abrupt proximal occlusion (black arrow) of the RCA (upper panel) and relatively poor retrograde RCA flow (black arrows) consisting of collateral flow from the left coronary artery (lower panel).

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  Fig. 6 A: contrast-enhanced transesophageal echocardiography (TEE) showed abrupt disappearance of color Doppler flow (black arrow) in the left circumflex coronary artery (LCX). B: coronary angiogram showed the location of total occlusion (black arrow), which corresponded with the results of contrast-enhanced TEE.

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  Fig. 7 The upper panel shows a sample point of coronary sinus (CS) flow (arrow). The lower panels show representative cases (a diabetic patient and a control patient) for measuring coronary flow reserve (CFR) of CS flow. Adenosine triphosphate was used to induce hyperemia in this study. RA: right atrium, S: maximum antegrade systolic flow velocity, D: maximum antegrade diastolic flow velocity.

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