Use of transesophageal echocardiography to predict significant coronary artery disease in aortic stenosis

Mitral Annular Calcification and Aortic Valve Calcification May Help in Predicting Significant Coronary Artery Disease

Mitral annular calcification (MAC) and aortic valve calcification (AVC) are manifestations of atherosclerosis. To determine whether mitral annular calcification and aortic valve calcification detected by transthoracic echocardiography (TTE) might help in predicting significant coronary artery disease (CAD), 123 patients with significant CAD and 93 patients without CAD detected by coronary angiography were investigated. MAC and AVC identified CAD with a sensitivity and specificity of 60.2%, 55.9% and 74.8%, 52.7%, respectively, and with a negative and a positive predictive values of 51.5%, 64.3% and 61.3% and 67.6%, respectively. The positive predictive value of MAC was greater than gender, hypertension, and hypercholesterolemia. AVC showed a positive predictive value greater than gender, hypertension, family history, and hypercho lesterolemia. The negative predictive values of MAC and AVC for CAD were greater than those of all risk factors except diabetes mellitus. In conclusion, presence of MAC and AVC on TTE may help in predicting CAD and should be added to conventional risk factors. Absence of MVC and AVC is a stronger predictor for absence of CAD than all conventional risk factors, except diabetes mellitus. Patients with MAC and AVC should be taken into consideration for the presence of significant CAD and thereby for diagnostic and therapeutic interventions in order to improve the prognosis.

Impact of concomitant coronary artery disease on atherosclerotic plaques in the aortic arch in patients with severe aortic stenosis

BACKGROUND

Coronary artery disease (CAD) often occurs concurrently in patients with severe aortic stenosis (AS). However, the influence of concomitant CAD on the presence of atherosclerotic complex plaques in the aortic arch, which is associated with increased stroke risk, has not been fully assessed in patients with severe AS.

HYPOTHESIS

We hypothesized that concomitant CAD would be associated with the presence of complex arch plaques in patients with severe AS.

METHODS

The study population consisted of 154 patients with severe AS who had undergone transesophageal echocardiography (TEE) and coronary angiography (71 male; mean age, 72 ± 8 years; mean aortic valve area, 0.67 ± 0.15 cm(2) ). Aortic arch plaques were assessed using TEE, and complex arch plaques were defined as large plaques (≥4 mm), ulcerated plaques, or mobile plaques.

RESULTS

The prevalence of aortic arch plaques (87% vs 70%; P = 0.03) and complex arch plaques (48% vs 20%; P < 0.001) was significantly greater in AS patients with CAD than in those without CAD. After adjustment for traditional atherosclerotic risk factors, we found that concomitant CAD was independently associated with the presence of complex arch plaques (odds ratio: 2.86, 95% confidence interval: 1.23-6.68, P = 0.01).

CONCLUSIONS

In patients with severe AS, concomitant CAD is associated with severe atherosclerotic burden in the aortic arch. This observation suggests that AS patients with concomitant CAD are at a higher risk for stroke, and that careful evaluation of complex arch plaques by TEE is needed for the risk stratification of stroke in these patients.

Association between carotid and coronary artery disease in patients with aortic valve stenosis: an angiographic study

BACKGROUND

Patients with aortic stenosis have a high prevalence of coronary artery disease, but there is little information about the association of coronary artery disease and carotid artery disease.

METHODS

The study includes 317 consecutive patients with aortic stenosis, who underwent carotid and coronary angiography during the same catheterization before aortic valve replacement.

RESULTS

At univariate analysis, the prevalence of coronary artery disease was associated with (1) presence of carotid artery disease (P < .001); (2) angina pectoris as presentation symptom (P < .001); (3) age more than 65 years (P < .05); and (4) hypertension (P < .05). At multivariate analysis, only carotid artery disease, angina, and age emerged as independent predictors of coronary artery disease. The combination of 2 variables (carotid artery disease, angina) allowed the identification of 4 groups, with decreasing prevalence of coronary artery disease: (1) angina+/carotid artery disease+: 85%; (2) angina-/ carotid artery disease+: 50%; (3) angina+/carotid artery disease-: 41%; (4) angina-/carotid artery disease-: 21% (P < .001).

CONCLUSION

In patients with symptomatic aortic stenosis, the presence of significant carotid artery disease is a strong marker of significant coronary artery disease.

Thoracic aorta atherosclerosis burden index predicts coronary artery disease in patients undergoing transesophageal echocardiography

AIMS

The severity of thoracic aortic atherosclerosis (TAA) is associated with the extent of coronary artery disease (CAD). The aim of this study is to quantitative this relationship by developing a novel atherosclerotic index.

METHODS AND RESULTS

Two hundred and forty six consecutive patients underwent transesophageal echocardiography (TEE) and coronary angiography. A grading system was used to define the extent of TAA for individual segment of the thoracic aorta. TAA burden index (TAABI) was defined as the sum of the grading for each segment. Of the derived values TAABI had the greatest specificity and sensitivity in predicting CAD. A TAABI of greater than 6 was associated with 16-fold increase in the probability of CAD with a specificity of 88% and a sensitivity of 81%. The positive predictive value was 77% and the negative predictive value 90%.

CONCLUSION

A TAABI value of greater than 6 accurately predicts the presence of CAD. Patients with no or mild TAA are at low risk of having angiographically significant CAD.

Grade of aortic atherosclerosis: a valuable adjunct to coronary flow velocity reserve in the evaluation of coronary artery disease

BACKGROUND

Atherosclerosis is a generalized disease of the arterial vasculature; among thus it manifests in the descending aorta and the coronary arteries. We tested whether known risk factors, the coronary flow velocity reserve and the grade of aortic atherosclerosis detected by transoesophageal echocardiography in the course of the same semi-invasive examination is able to distinguish between patients with significant left anterior descending coronary artery (LAD) stenosis or with multivessel disease.

METHODS AND RESULTS

The present study involved 125 consecutive patients (mean age: 56 +/- 11 years, range: 22-73) with chest pain undergoing coronary angiography. Grade of aortic atherosclerosis was obtained by means of transoesophageal echocardiography, and the coronary flow velocity reserve was calculated in the left anterior descending coronary artery. The age (ROC area, 63%, p<0.01), the gender (ROC area, 63%, p<0.02) and the grade of aortic atherosclerosis (ROC area, 64%, p<0.01) exhibited good power for the prediction of patients with multivessel disease from among all other patients. Only the grade of aortic atherosclerosis (ROC area, 63%, p<0.05) appears useful to distinguish patients with left anterior descending coronary artery disease from those with multivessel disease.

CONCLUSIONS

These results demonstrate that grade of aortic atherosclerosis furnishes additional help in the prediction of patients with severe coronary artery disease. It can differentiate patients with multivessel disease from those with significant left anterior descending coronary artery stenosis. Coronary flow velocity reserve has no any prognostic power in this evaluation.

Atherosclerosis of the descending aorta predicts cardiovascular events: a transesophageal echocardiography study

Purpose

Previous studies have shown that atherosclerosis of the descending aorta detected by transesophageal echocardiography (TEE) is a good marker of coexisting coronary artery disease. The aim of our study was to evaluate whether the presence of atherosclerosis on the descending aorta during TEE has any prognostic impact in predicting cardiovascular events.

Material and Methods

The study group consisted of 238 consecutive in-hospital patients referred for TEE testing (135 males, 103 females, mean age 58 +/- 11 years) with a follow up of 24 months. The atherosclerotic lesions of the descending aorta were scored from 0 (no atherosclerosis) to 3 (plaque >5 mm and/or "complex" plaque with ulcerated or mobile parts).

Results

Atherosclerosis was observed in 102 patients, (grade 3 in 16, and grade 2 in 86 patients) whereas 136 patients only had an intimal thickening or normal intimal surface. There were 57 cardiovascular events in the follow-up period. The number of events was higher in the 102 patients with (n = 34) than in the 136 patients without atherosclerosis (n = 23, p < 0.01). The frequency of events was in close correlation with the severity of the atherosclerosis of the descending aorta. Fifty percent of the patients with grade 3 experienced cardiovascular events. Excluding patients with subsequent revascularization, the multivariate analysis only left ventricular function with EF < 40% (HR 3.0, CI 1.3–7.1) and TEE atherosclerotic plaque >=2 (HR 2.4, CI 1.0–5.5) predicted hard cardiovascular events.

Conclusion

Atherosclerosis of the descending aorta observed during transesophageal echocardiography is a useful predictor of cardiovascular events.

Significance of the intima-media thickness of the thoracic aorta in patients with coronary atherosclerosis

BACKGROUND

The prevalence and clinical significance of atherosclerotic aortic disease have now been documented in a variety of patient populations by use of transesophageal echocardiography (TEE). There are many reports that atherosclerotic aortic plaques detected by TEE are a marker for coronary artery disease (CAD).

HYPOTHESIS

The study was undertaken to evaluate the significance of the intima-media thickness (IMT) and formation of atherosclerotic plaques of the thoracic aorta (TA) in patients with CAD, especially in terms of a correlation between the IMT of the TA and the extent of coronary atherosclerosis.

METHODS

The IMT of the TA was measured using TEE. The study population comprised 100 patients (68 men, mean age 59 years). The extent of coronary atherosclerosis was divided into four groups (0, 1, 2, 3) according to the number of coronary arteries narrowed > or = 50%.

RESULTS

There was no significant difference in the IMT of the ascending TA according to the presence of significant (> 50% narrowed) coronary stenosis, but there was a significant difference in the IMT of the descending TA (1.39 vs. 1.88 mm, p = 0.005). There was a significant correlation between the extent of coronary atherosclerosis and the IMT of the ascending and descending TA (r = 0.24, p < 0.05; r = 0.352, p < 0.001, respectively). The plaques in the TA were seen in 7, 41, 52, and 65% of patients in Groups 0, 1, 2, and 3, respectively. Among atherosclerosis risk factors, hyperlipidemia was the only factor analyzed that affected the IMT of the descending TA (2.11 vs. 1.78 mm, p < 0.05).

CONCLUSION

The IMT of the TA correlates significantly with coronary atherosclerosis, and correlation of the descending TA IMT with coronary atherosclerosis is better than that of ascending TA IMT. Age is associated with coronary atherosclerosis, and TA IMT and hyperlipidemia are associated with descending TA IMT. Therefore, although TEE is not recommended for measuring TA IMT or for evaluating aortic plaques in patients with CAD, measurement of TA IMT as well as carotid artery IMT is very helpful for understanding the extent of coronary atherosclerosis.

Aortic valve sclerosis, mitral annular calcium, and aortic root sclerosis as markers of atherosclerosis in men

Aortic valve sclerosis (AVS) and mitral annular calcium (MAC) as detected by transthoracic echocardiography have been associated with atherosclerosis. Aortic root sclerosis (ARS) may have a similar association, but has not been studied. This study evaluates, by transesophageal echocardiography, the association of AVS, MAC, and ARS with aortic atheromatous disease and cardiovascular disease. Multiplane transesophageal echocardiography with evaluation of AVS, MAC, ARS, and aortic atheromatous disease by 2 experienced observers unaware of clinical data was performed in 157 male patients > or =50 years old. The presence of cardiovascular disease, defined as coronary, carotid, or peripheral artery disease, was determined by specific criteria. The prevalence of AVS, MAC, ARS, and aortic atheromatous disease was 42%, 30%, 48%, and 71%, respectively. The presence of AVS, MAC, or ARS was highly associated with aortic atheromatous disease (odds ratio 4.9 to 12.0, confidence interval 1.4 to 35.8, p <0.001). ARS was also associated with cardiovascular disease (odds ratio 2.2, confidence interval 1.0 to 4.5, p = 0.038). The presence of AVS, MAC, or ARS had a sensitivity of 77%, specificity of 72%, a positive predictive value of 88%, and a negative predictive value of 55% for aortic atheromatous disease. We concluded that the prevalence of AVS, MAC, or ARS by transesophageal echocardiography in men is common, and their presence is highly associated with aortic atheromatous disease and coronary, carotid, or peripheral artery disease.

Aortic Stenosis: The Role of Transesophageal Echocardiography

Noninvasive assessment of aortic valve area by echocardiography has become the standard of practice over the past few years. The advent of transesophageal echocardiography (TEE) has provided a new method for the assessment of aortic valve area (AVA) using planimetry by two-dimensional imaging. Clear visualization of the anatomy of the valve, as well as accuracy of AVA assessment, makes TEE an invaluable tool for the evaluation of aortic valve stenosis. TEE is especially helpful in clinical settings when there is a discrepancy between the AVA obtained by transthoracic echocardiography and cardiac catheterization. TEE is particularly helpful in the assessment of the aortic valve during intraoperative echocardiography. This review discusses the techniques, imaging planes, and details for assessing AVA by TEE. The role of TEE in AVA assessment is described, with specific clinical case examples cited.

Transesophageal echocardiographic detection of thoracic aortic plaque could noninvasively predict significant obstructive coronary artery disease

OBJECTIVE

Previous pathologic and roentgenographic studies have suggested a relation between aortic plaque and coronary artery disease but have lacked clinical utility. The study was undertaken to elucidate whether atherosclerotic aortic plaque detected by transesophageal echocardiography can be a clinically useful marker for significant obstructive coronary artery disease.

METHODS

Clinical and angiographic features and intraoperative transesophageal echocardiographic findings were prospectively analyzed in 131 consecutive patients (58 women and 73 men, aged 17 to 75 years [mean 54 +/- 12]) undergoing open heart surgery. Significant obstructive coronary artery disease was defined as > or = 50% stenosis of > or = 1 major branch.

RESULTS

Seventy-six (58%) of 131 patients were found to have obstructive coronary artery disease. In 76 patients with significant coronary artery disease, 71 had thoracic aortic plaque. In contrast, aortic plaque existed in only 10 of the remaining 55 patients with normal or minimally abnormal coronary arteries. The presence of aortic plaque on transesophageal echocardiographic studies had a sensitivity of 93%, a specificity of 82% and positive and negative predictive values of 88% and 90%, respectively, for significant coronary artery disease. There was a significant relationship between the degree of aortic intimal changes and the severity of coronary artery disease (r = 0.74, P < 0.0001). Multivariate logistic regression analysis of patient age, sex, risk factors of cardiovascular disease and transesophageal, echocardiographic findings revealed that atherosclerotic aortic plaque was the most significant independent predictor of coronary artery disease.

CONCLUSION

This study indicates that transesophageal echocardiographic detection of atherosclerotic plaque in the thoracic aorta is useful in the noninvasive prediction of the presence and severity of coronary artery disease.