Enhanced intra-operative grading of ascending aorta atheroma by epiaortic ultrasound vs echocardiography

Aims Intra-operative grading of atheromatous plaques in the ascending aorta by epiaortic ultrasound (EAU) and transesophageal echocardiography (TEE) in patients who have undergone CABG. Methods and results Sixty patients scheduled for elective CABG were prospectively enrolled to undergo intra-operative TEE and EAU ultrasound scanning of the ascending aorta. The ascending aorta was divided into three sections; proximal, middle and distal, and four segments; anterior, posterior, medial and lateral. Degree of atherosclerosis was graded according to a modified Montgomery scale. Epiaortic ultrasound was unable to provide images for a reliable assessment in 56 areas (7.7%; 56/720) vs 322 non-visualized areas by TEE (44.7%; 298/720) (p < 0.01). Out of 563 areas that scored ≥ 2, EAU visualized 379/720 areas (52.6%), whereas TEE visualized 184/720 areas (25.5%) (p < 0.01). EAU mean scores were significantly higher for the mid (p = 0.0001) and distal (p = 0.05) sections and for the posterior segment (p < 0.01) vs TEE. TEE had a higher mean score than EAU in the anterior segment. When all EAU areas were grouped the posterior segment reached a significantly higher mean score (p < 0.01), and the anterior segment was the second mostly diseased. Conclusions EAU is the intra-operative investigation of choice because it allowed a detailed grading of atheromatous lesions over the entire length of the ascending aorta. Accurate grading by TEE was restricted only to those areas that could be sufficiently visualized. TEE has a reduced power of investigation that limits its use, especially in the distal ascending aorta, a site of great surgical manipulation.