CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 4, May 2012
AFRICA
e3
Case Report
Mobile atheromatous plaque of the aortic arch diagnosed
by transthoracic echocardiography prior to coronary
artery bypass surgery
Which one would you choose: scepticism or wishful thinking?
AC HATEMI, O OMAY, M BASKURT, S KÜCÜKOGLU, B ÖZ, K SÜZER
Abstract
A routine pre-operative chest X-ray of a patient admitted to
our institution for an elective coronary artery bypass opera-
tion revealed a mildly dilated mediastinal silhouette, which
led the cardiovascular surgery resident to schedule emer-
gency transthoracic echocardiography (TTE), with a special
note asking for detailed evaluation of the ascending aorta
and aortic arch. TTE revealed a mobile atheroma at the
aortic arch, which obliged the cardiac surgery team to modi-
fy their strategy to combined hemi-arcus aortae replacement
and coronary artery bypass grafting (CABG). Although with
transoesophageal echocardiography (TEE) a small portion
of the ascending aorta may be obscured by the trachea, TEE
provides higher resolution images than TTE. Therefore one
can conclude that TEE is the imaging modality of choice for
detecting aortic atheromatous plaques but in patients with
low risk for stroke and aortic atheromas, a detailed TTE
may be sufficient for the pre-operative assessment.
Keywords:
aortic arch, atherosclerosis, aorta, echocardiogra-
phy, circulatory arrest, coronary artery bypass grafts, CABG
Submitted 26/1/10, accepted 3/6/11
Cardiovasc J Afr
2012;
23
: e3–e5
DOI: 10.5830/CVJA-2011-027
The aorta is an important source of athero-emboli, as recent
studies have confirmed the strong correlation between severe
aortic atheromatous plaques and stroke/death in the elderly.
1
The dimensions of the aortic arch atheroma (larger and thicker
than 4 mm) and the complexity of the plaque (ulcerative and/
or mobile) are important risk factors for unexplained arterial
embolic events such as stroke, transient ischaemic attack and
peripheral emboli, together with multi-organ failure and death.
Furthermore, mobile atheromas of the aortic arch are associated
with increased peri-operative strokes in patients undergoing
cardiac surgery.
2
Stroke incidence was found to be around 25%
in patients with mobile plaques of the aortic arch, while it was
only 2% in patients with quiescent non-mobile plaques.
3
Potential aetiological risks independently associated with
complex plaque formation are advanced age, history of
hypertension, hypercholesterolaemia, increased body mass index,
diabetes, and past or present tobacco use. Similarly, established
risk for stroke occurrence are advanced age, male gender, previous
stroke history, heredity, hypertension, smoking, diabetes mellitus,
carotidarterydisease,coronaryarterydiseaseandpolycythaemia.
4,5
We can clearly conclude that risk factors for atherosclerosis
and stroke overlap. In fact, in cardiac patients without clinical
evidence of severe atherosclerotic disease, a high prevalence of
combined aortic and carotid plaques was reported.
4
Surgeons
should consider these patients as strong candidates for
pre-operative and postoperative athero-embolic complications.
Transoesophageal echocardiography (TEE), which is a safe
and relatively less invasive procedure with a very low risk of
complication is the modality of choice for the diagnosis of aortic
atheromas, although CT, MRI and intra-operative epi-aortic
ultrasonography are known to be complementary examination
techniques.
6
The progress inTEE technology has enabled surgeons
to obtain a detailed view of the aorta pre- and peri-operatively, to
quantify atheromatous plaques according to their thickness and
the presence of mobile components, therefore classifying them
as simple or complex. In one study, TEE was able to find aortic
arch atheromatous disease in 55% of patients with a normal chest
X-ray, and 91% of those had heavily calcified aortic knobs.
7
We assumed that TEE evaluation of the aorta is useful in older
patients with risk factors for stroke and those with radiographic
evidence of aortic calcification, to determine the presence of
severe atheromatous disease of the aortic arch pre-operatively.
However, TEE is a semi-invasive procedure, which mostly
requires sedation, is not always readily available, and may not be
suitable for haemodynamically unstable patients. In this report,
we highlight that in some patients such as ours but not in all,
TTE may be used instead of TEE in this manner.
Department of Cardiovascular Surgery, Institute of
Cardiology, Istanbul University, Istanbul, Turkey
AC HATEMI, MD, PhD,
O OMAY, MD
K SÜZER, MD
Department of Cardiology, Institute of Cardiology, Istanbul
University, Istanbul, Turkey
M BASKURT, MD
S KÜCÜKOGLU, MD
Department of Pathology, Cerrahpasa Faculty of Medicine,
Istanbul University, Istanbul, Turkey
B ÖZ, MD
