Three-Dimensional Transesophageal Echocardiographic Evaluation of Coronary Involvement in Patients with Acute Type A Aortic Dissection

Background: Acute Stanford type A aortic dissection (AAD) with coronary involvement is associated with high mortality. However, coronary involvement is not always successfully visualized by computed tomography and two-dimensional (2D) transesophageal echocardiography (TEE). The aim of this study was to test the hypothesis that three-dimensional (3D) TEE can detect coronary involvement in patients with AAD. Methods: Fifty-one consecutive patients with AAD who underwent intraoperative TEE using an iE33 system during emergency surgery were enrolled. Using computed tomographic images, conventional 2D transesophageal echocardiographic images, and a 3D transesophageal echocardiographic data set, the status of coronary ostia was evaluated and classified into four types-branching from true lumen, branching from false lumen, dissection, and unclear-and these results were compared with operative findings. Results: In six patients, coronary involvement was diagnosed operatively by surgeons. They comprised dissection at three left coronary ostia and branching from false lumen at three right coronary ostia. All six cases were successfully detected by both 2D TEE and 3D TEE before instituting cardiopulmonary bypass. However, in 45 patients (90 ostia) confirmed operatively as having no coronary involvement, 69 ostia by computed tomography (36 in the left and 33 in the right coronary artery) and 16 ostia by 2D TEE (four in the left and 12 in the right coronary artery) were evaluated as unclear coronary involvement. On the other hand, 3D TEE clearly depicted no coronary involvement in all but one (right coronary ostium) of the unclear cases. Conclusions: Three-dimensional TEE reduced the number of cases evaluated as unclear coronary involvement by computed tomography and 2D TEE. In patients with AAD, 3D TEE allows evaluation of the status of coronary ostia in the operating room.