Modified transesophageal echocardiography of the dissected thoracic aorta; a novel diagnostic approach

Wouter W. Jansen Klomp, Linda M. Peelen, George J. Brandon Bravo Bruinsma, Arnoud W. J. van’t Hof, Jan G. Grandjean, Arno P. Nierich

Transesophageal echocardiography (TEE) is a key diagnostic modality in patients with acute aortic dissection, yet its sensitivity is limited by a "blind-spot" caused by air in the trachea. After placement of a fluid-filled balloon in the trachea visualization of the thoracic aorta becomes possible. This method, modified TEE, has been shown to be an accurate test for the diagnosis of upper aortic atherosclerosis. In this study we discuss how we use modified TEE for the diagnosis and management of patients with (suspected) acute aortic dissection. Modified TEE provides the possibility to obtain a complete echocardiographic overview of the thoracic aorta and its branching vessels with anatomical and functional information. It is a bedside test, and can thus be applied in hemodynamic instable patients who cannot undergo computed tomography. Visualization of the aortic arch allows differentiation between Stanford type A and B dissections and visualization of the proximal cerebral vessels enables a timely identification of impaired cerebral perfusion. During surgery modified TEE can be applied to identify the true lumen for cannulation, and to assure that the true lumen is perfused. Also, the innominate- and carotid arteries can be assessed for structural integrity and adequate perfusion during multiple phases of the surgical repair. Modified TEE can reveal the "blind-spot" of conventional TEE. In patients with (suspected) aortic dissection it is thus possible to obtain a complete echocardiographic overview of the thoracic aorta and its branches. This is of specific merit in hemodynamically unstable patients who cannot undergo CT. Modified TEE can guide also guide the surgical management and monitor perfusion of the cerebral arteries.