Pitfalls in the diagnosis of thoracic aortic aneurysm by transesophageal echocardiography

Transesophageal echocardiography in the diagnosis of acute aortic syndrome

In recent years, technological advances in echocardiography have led to improvements in the diagnosis of acute aortic disease. With transesophageal echocardiography (TEE) and, particularly, bi- and multiplane probes, the physiopathologic understanding of these diseases has widened. Thus, new entities such as penetrating ulcer and intramural hematoma have been described and differentiated from classical aortic dissection.

Diagnosis of esophageal varices by transesophageal echocardiography: a mimicker of aortic disease

The use of transesophageal echocardiography is well established in the emergency department diagnosis of traumatic aortic diseases. It has very high sensitivity and specificity compared with those of other tests. The physician performing transesophageal echocardiography should be aware of conditions that can mimic aortic pathologic conditions, thus leading to an incorrect diagnosis. We report a case in which the presence of previously undiagnosed esophageal varices mimicked traumatic aortic disease.

Imaging the thoracic aorta

Images

Critical appraisal of transesophageal echocardiography: limitations and pitfalls

As with any imaging technology, there are limitations and pitfalls to TEE. The limitations and pitfalls of TEE can be minimized best by experience. Initial training should not be circumvented, and maintenance of competency should be monitored strictly. Physicians with less than level II echocardiography training should work in close collaboration with an active echocardiography laboratory and have an appropriate review of current examinations. Both individual and laboratory standards for maintenance of competency should be established. Because of the new presentation of cardiac and extracardiac anatomy, unfamiliar but normal anatomy initially may be confused as abnormal. Additionally, certain structures are viewed in a manner that may mimic pathologic conditions. Because of the superior resolution offered by TEE, phenomena such as spontaneous contrast and ghosting are observed much more commonly than they are with transthoracic imaging. Highly detailed anatomic structures, such as atrial muscle bundles, sutures, and adipose tissue, are to be recognized and differentiated from thrombi, vegetation, and masses. Although TEE has been a dramatic step forward in diagnostic imaging, there is a potential for serious misinterpretation. This article discusses most of these potential problems; however, there always will be unique situations in which the findings must be addressed consistently and differentiated as normal, artifact, new observation, or misinterpretation.

Thoracic Aortic Aneurysms: Role of Echocardiography

This article describes the evolving role of echocardiography for the detection and evaluation of thoracic aortic aneurysms. A brief summary of the clinical, anatomical, and pathological features of the etiologic categories of thoracic aneurysms is presented. The advantages and limitations of echocardiography and its comparison with other techniques (computed tomographic scanning, magnetic resonance imaging, and aortography) are discussed. (ECHOCARDIOGRAPHY, Volume 13, March 1996)

Transesophageal echocardiographic artifact mimicking pseudoaneurysm of the aorta

Transesophageal echocardiography (TEE) is a sensitive and specific procedure that gives detailed images of the thoracic aortic anatomy and blood flow; however, there are few reports on pitfalls with TEE. This case describes a patient with a typical history of a possible aortic rupture; artifacts in the TEE mimicked aortic rupture and development of a pseudoaneurysm. Echocardiographers should know this possible pitfall to make the correct diagnosis.

Clinical significance and origin of artifacts in transesophageal echocardiography of the thoracic aorta

OBJECTIVES

The aim of this study was to identify the mechanism and features of artifacts encountered during transesophageal echocardiography of the aorta.

BACKGROUND

Artifacts are an important potential limitation of transesophageal echocardiography of the aorta.

METHODS

The mechanism of the artifacts was examined by in vitro modeling. The frequency and clinical correlates of artifacts were examined by retrospective review of transesophageal echocardiograms in 36 patients with aortic pathologic lesions.

RESULTS

Two classes of artifact were seen: linear artifacts in the ascending aorta, which may mimic intimal flaps, and mirror image artifacts in the transverse and descending thoracic aorta. Linear artifacts in the ascending aorta, seen in 44% of patients, were shown in vitro to be multiple path artifacts caused by reflection of ultrasound within the left atrium. Linear artifacts in the ascending aorta were associated with dilatation of the ascending aorta and were more frequent when the aortic diameter exceeded the left atrial diameter (p < 0.001). The mirror image artifacts of the transverse and descending thoracic aorta give the appearance of a double-barrel aorta and were shown in vitro to be caused by the aorta-lung interface, which acts as a total reflector of ultrasound. Mirror image artifacts were seen in > 80% of patients. Artifacts were equally frequent with the sagittal and transverse imaging planes when biplane transesophageal echocardiography was used.

CONCLUSIONS

Artifacts occur frequently during transesophageal echocardiography of the aorta. An understanding of why they occur and the features that distinguish them from true abnormalities should enhance the diagnostic accuracy of transesophageal echocardiography for aortic disease.

Critical appraisal of transesophageal echocardiography: limitations, pitfalls, and complications

Because transesophageal echocardiography is invasive, it has the potential for serious complications. Limitations occur because of the restricted transducer mobility within transducers for special situations. Pitfalls (potential erroneous diagnoses resulting from misinterpretation of normal and abnormal anatomy) are prevalent with this new technology. This report critically reviews transesophageal echocardiography and discusses and illustrates commonly encountered limitations, pitfalls, and complications.