BJA Advance Access published online on March 2, 2007
British Journal of Anaesthesia, doi:10.1093/bja/aem009
Resolving the blind spot of transoesophageal echocardiography: a new diagnostic device for visualizing the ascending aorta in cardiac surgery
1 Department of (Thoracic) Anaesthesia and Intensive Care
2 Department of Cardiothoracic Surgery, Isala Clinics, PO Box 10500, 8000 GM Zwolle, The Netherlands
3 Division of Perioperative Care and Emergency Medicine
4 Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, PO Box 85500, 3808 GA Utrecht, The Netherlands
* Corresponding author: Department of (Thoracic) Anaesthesia and Intensive Care, Isala Clinics, Groot wezenland 20, 8011 JW Zwolle, PO Box 10500 8000 GM Zwolle, The Netherlands. E-mail: b.van.zaane{at}isala.nl
Background: Atherosclerosis of the ascending aorta (AA) and stroke after cardiac surgery are related. Knowledge of the location of AA-atherosclerosis pre-sternotomy allows changes in surgical strategy to avoid manipulation of the AA. The gold-standard for assessment of AA-atherosclerosis is intraoperative epiaortic ultrasound scanning (EUS). Transoesophageal echocardiography (TOE) is unable to detect atherosclerosis in the distal AA due to the ‘blind spot’. A new method [A-View® (Aortic-view) method] using a fluid-filled catheter may enhance the assessment of distal AA-atherosclerosis. The aim of this study was to evaluate whether the A-View® method indeed visualizes the distal AA and to assess the safety of this technology.
Methods: In a cross-sectional diagnostic study, 41 patients undergoing cardiac surgery including sternotomy underwent the same work-up including TOE, the A-View® method, EUS, and routine operative monitoring.
Results: With the A-View® method, the distal AA was visible in all (100%) patients. There were no clinical important side-effects associated with the use of the A-View® catheter; however, in one patient the endotracheal tube was accidentally dislocated leading to a decrease in SaO2. Severity of atherosclerosis visualized with the A-View® method compared with EUS results showed good agreement between the two methods [Kappa of 0.69 (0.50–0.88)]. The Bland–Altman analysis showed poor agreement in plaque-size measurements (bias 0.05 cm2, limits of agreement – 0.63 to 0.74 cm2).
Conclusions: The A-View® method offers a minimally invasive and safe approach to preoperatively resolving the blind spot of TOE. Compared with EUS, the A-View® method yielded satisfactory results in the detection of AA-atherosclerosis. The A-View® method seems a promising tool for patients undergoing cardiac surgery to direct surgical management.
Keywords: brain, ischaemia; embolism; monitoring, echocardiography; surgery, cardiovascular; thromboembolism
Declaration of interest. A.P. Nierich, MD, PhD is medical director of Cordatec Inc., Zoersel, Belgium. Bas van Zaane, MD, Arno P. Nierich, MD, PhD, Wolfgang F. Buhre, MD, PhD and Karel G.M. Moons, PhD, Professor of Clinical Epidemiology have received a grant of the Dutch Government for studying the diagnostic accuracy of the A-View® method.
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