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(A) (B)
FIGURE 16.2 Color Doppler transesophageal echocardiography (TEE) long axis view in a patient with significant aortic regurgitation (A). The twodimensional TEE measurements (performed in long axis view); (B): annulus dimension (x) 23 mm, sinotubular junction dimension (y) 43 mm, ratio
annulus/sinotubular junction >1.6, coaptation high (h) 10 mm, are suggesting function of aortic regurgitation.
(A) (B) (C)
FIGURE 16.3 Type II aortic regurgitation by cusp prolapse visualized in two-dimensional transesophageal echocardiography long axis view: partial
cusp prolapses—a part of a cusp prolapsing into the left ventricle outflow tract (A), whole cusp prolapses—free edge and entire cusp billowing into the
left ventricle outflow tract (B), and cusps flail—complete eversion of in cusp into the left ventricle outflow tract (C).
l IIb—free edge fenestration with eccentric aortic regurgitation jet but without evidence of cusp prolapse [24].
l Type III: leaflet restriction caused by fibrosis or calcification (degenerative disease, rheumatic disease) [30].
TRANSESOPHAGEAL ECHOCARDIOGRAPHY ROLE IN EVALUATION OF AORTIC STENOSIS
The actual recommendations for aortic stenosis severity are based on aortic jet peak velocity, mean transvalvular gradient, velocity ratio, aortic valve area, and aortic valve area indexed [26]. Due to the suboptimal alignment to aortic valve
flow in TEE the main method in this case for evaluating aortic stenosis severity is aortic valve area planimetry of the inner
leaflet edges at the time of maximal opening [31]. This method was evaluated and validated by multiple 2D/3D studies
[32] and its feasibility is 88%–96% [33]. By planimetry, the anatomic (geometric) aortic valve area is measured by direct
visualization. It is worth mentioning that by continuity equation the effective rather than anatomic orifice is evaluated and
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FIGURE 16.4 Measurement of aortic valve area by three-dimensional transesophageal echocardiography: the acquired volume is suitably aligned using
two orthogonal long axes view—the usual long axis view of aortic valve in the white plane and another orthogonal long axis view in the yellow plane; the
right short axis view at the level of the aortic cusps tips is obtained by translating the third plane (green one) using as landmarks the first two planes and
the measurement is performed mid-systole in the green plane.
this one is the primary predictor of the outcome [34,35]. However, planimetry may be inaccurate because of valve calcification and artifacts [26] or because of suboptimal cut plane. The latter limitations were overcome by using biplane [36] or
tridimensional echocardiography [37] that allows the adjustment of the cut plane exactly at the level of aortic cusps [38]
(Fig. 16.4). Therefore, aortic valve area by planimetry is the solution for estimating aortic valve stenosis when the Doppler
estimation of flow velocities is unreliable [26]: poor acoustic TTE windows, incomplete envelope of aortic stenosis due
to suboptimal alignment, concomitant subvalvular aortic stenosis, dynamic gradient in the left ventricle outflow tract, etc.
Aortic stenosis is considered severe when aortic valve area is less than 1 cm2. During the last years, new automated quantitative 3D models of the aortic valve have been developed based on TEE 3D images that allow the automated estimation
of aortic valve area [39] (Fig. 16.5).
TRANSESOPHAGEAL ECHOCARDIOGRAPHY ROLE IN EVALUATION OF AORTIC
REGURGITATION
The TEE in aortic regurgitation evaluation is recommended when TTE is insufficient for establishing the mechanism
of aortic regurgitation [24]. However, the quantitative assessment of aortic regurgitation by echo remains challenging
[40]. For aortic regurgitation severity assessment in everyday clinical practice, the data obtained from TTE are often
combined with those obtained from TEE. TEE offers high-quality long axis or short axis views of the aortic valve, but
it is more difficult to interrogate the valve by continuous wave Doppler from transgastric view, especially in the case of
patients without sedation. The new data obtained by 3D echocardiography comparing to gold standard CMR are promising (Table 16.2) [24].
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(A) (B)
(C)
(D)
(E)
FIGURE 16.5 Automated quantitative three-dimensional (3D) models of the aortic valve (B,E) are automated obtained using the specific software from
3D volume acquisition by recognition and reconstruction of aortic valve and root components (A). The mathematical model is dynamic during cardiac
cycle and can be visualized form different angles. The software also offers the automated measurements of aortic valve area and aortic annulus and root
diameters (C) and the dynamic evolution of aortic valve area during cardiac cycle (D). Another important information offered by the software is the distance between aortic annulus and coronary ostia (D).
TABLE 16.2 Transesophageal Echocardiographic Assessment of Aortic Regurgitation (Fig. 16.6)
Mild Moderate Severe
Qualitative
Aortic valve morphology Normal/Abnormal Normal/Abnormal Abnormal/Flail/Large
Coaptation Defect
Color flow AR jet width/
LVOT width
CW signal of AR jet Deep transgastric or trans-
Diastolic flow reversal in
the descending aorta
Semiquantitative
VC width (mm) [41] Long axis view <3 mm 3–6 mm >6 mm
Pressure half-time (ms) Deep or long axis trans-
Three-dimensional (3D) VC
area [42,43]
Quantitative
EROA (mm2)—PISA method <0.1 0.1–0.3 >0.3
R Vol (mL)—PISA method <30 30–60 >60
3D R vol (mL) [44] Best agreement with CMR
Long axis view <0.25 0.25–0.65 >0.65
Incomplete/faint Dense Dense
gastric long axis view
Descending thoracic aorta
long axis view
gastric view
Brief, early diastolic flow reversal
>500 200–500 <200
Best agreement with cardiac magnetic resonance (CMR)
Its advantage over two-dimensional TTE is particularly evident in patients
with eccentric jets.
Intermediate Holodiastolic flow
reversal (end-diastolic
velocity >20 cm/s)
AR, aortic regurgitation; CW, continuous wave Doppler; EROA, effective regurgitation orifice area; LV, left ventricle; LVOT, left ventricle outflow tract;
TTE, transthoracic echocardiography; VC, vena contracta.
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(A) (B)
(D)(C)
FIGURE 16.6 Aortic regurgitation quantification by transesophageal echocardiography: calculation of the ratio between color flow aortic regurgitation
and left ventricle outflow tract dimension in the long axis view (A), vena contracta measurement in long axis view (B), PISA radius measurement in long
axis view and the estimation of regurgitate orifice and volume (C), evaluation of diastolic reversal flow in descending thoracic aorta, and the measurement
of end-diastolic velocity of the reversal flow in the long axis view of the descending thoracic aorta (D).
TRANSESOPHAGEAL ECHOCARDIOGRAPHY ROLE IN THE MORPHOLOGICAL
ASSESSMENT OF AORTIC ROOT DISEASE
Echocardiography is an excellent modality for imaging aortic root and TEE is clearly superior to TTE for aortic wall
visualization being comparable to computed tomography (CT) or magnetic resonance imaging (MRI) [5,45]. Therefore,
echocardiography is frequently used for screening, diagnosis, and follow-up of patients with aortic dilatation. Aortic ectasia
is defined as a dilatation with less than 50% than the normal artery, whereas the aneurysm is a dilatation having at least
50% increase in diameter compared with normal artery [46]. Comparing with a true aneurysm where all three layers of
aortic wall are intact, a pseudoaneurysm (false aneurysm) contains blood resulting from the disruption of the arterial wall
and consecutive extravasation in periarterial connective tissue [46]. The ascending aorta thoracic aneurysms are classified
according to morphological appearance as annulo-aortic ectasia or marfanoid type, being specific for Marfan syndrome,
Ehlers–Danlos syndrome, Loeys–Dietz syndrome or aortic bicuspid valve (the aortic root is dilated at the level of Valsalva
sinuses with normal dimension of sinotubular junction and ascending aorta), supracoronary type (the aorta is dilated after
the origin of coronary arteries, involving the sinotubular junction and the ascending aorta), and tubular type (the global
dilatation of ascending aorta involving the Valsalva sinuses and the sinotubular junction) [47,48]. Another ascending aorta
aneurysm is the Valsalva sinus aneurysm [49] (Fig. 16.7).
TEE is a main imaging tool for the diagnosis of aortic dissection, especially when the ascending aorta is involved.
Having a sensitivity of 99% and a specificity of 89% [50], and positive and negative predictive values of 89% and 99%
[51], TEE is comparable with CT or MRI for the aortic dissection diagnosis. TEE has the great advantage of being a quick
and easy to use method, inclusive for unstable patients in intensive care unit or cardiac theater [52]. The echocardiographic
diagnosis of aortic dissection is based on aortic flap visualization (linear structure, visualized in at least two views, having its own movement unrelated to adjacent structures) [53]. The recognition of artifacts determined by reverberation of
posterior wall of pulmonary artery or posterior wall of left atrium mainly in patients with dilated ascending aorta may
be sometimes difficult: the distance between the structure that determines the reverberation and the aortic wall is equal
to the distance between the reverberation and the aortic wall and the reverberation movement is parallel to the structure
movement [54] (Fig. 16.8). TEE is also important for the identification of true and false lumens, entry and exit tears, or
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(A) (B) (C) (D)
(A) (B) (C)
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FIGURE 16.7 Graphic model and transesophageal echocardiography long axis view of different types of ascending aorta aneurysms: anulo-aortic ectasia (A), sinus Valsalva aneurysm (B), supracoronary aneurysm (C), and tubular aneurysm (D).
FIGURE 16.8 Graphic representation of the mechanism for reverberation artifact generation (A): the ultrasound beam generated by probe (black
arrow) is first reflected by aortic wall and during its normal way to the probe (blue arrow) it is then reflected by the structure that generates the
artifact and determines a new wave (red arrow). It is then reflected by the aortic wall and finally reaches the probe; therefore, the echo machine
cannot take into consideration this double interpolated reflection and will generate the false image of a new structure; the distance between this
false image and the aortic wall is equal with the distance between the structure that determines the additional reflection and the aortic wall. There
are two important criteria for the right diagnosis of an artifact at the level of ascending aorta: equal distances between the artifact and posterior
aortic wall and structures that generate the artifact and posterior aortic wall (B) and parallel but with double amplitude movement of reverberation
comparing to the mentioned structure.
aortic dissection complication (aortic regurgitation, pericardial fluid, coronary artery involvement) [55]. CT and CMR
are superior to TEE for intramural hematoma or penetrating aortic ulcer diagnosis and also for aortic dissection extension
and branch involvement visualization, whereas TEE is a better method for the identification of tears localization and flow
across tears [45]. TEE can identify the entry and the exit tears in 78%–100% of cases, information that are mandatory for
the surgeon [56] (Fig. 16.9).
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(A) (B)
(C) (D)
FIGURE 16.9 Two-dimensional transesophageal echocardiography visualization of the aortic flap in the long axis view as a linear structure with independent movement (A) and entry point (*) visualization (B). Evaluation by color Doppler of aortic valve function in patient with aortic dissection proving
severe aortic regurgitation (C). Visualization of true lumen (smaller, central one) and false lumen (larger one) and of an additional entry point (&) at the
level of descending aorta (D).
TEE is very useful for the diagnosis of infective endocarditis at the level of aortic valve (vegetation of valve perforation
presence) and at the level of aortic root too (abscess, pseudoaneurysm, fistula). An abscess is represented by a perivalvular
cavity with necrosis and purulent material that does not communicate with the surrounding structure, being visualized as a
thickened, nonhomogeneous perivalvular area. A pseudoaneurysm is a perivalvular cavity visualized as a pulsatile perivalvular
echo-free space that communicates with the cardiovascular lumen detected on color Doppler examination (Fig. 16.10). A
fistula represents a communication between two cavities through a perforation, generally between ascending aorta and left
ventricle or right atrium [57].
Aortic atheromas and aortic wall calcifications can be also visualized by TEE. The advantage of TEE over noninvasive modalities is the possibility to estimate the plaque mobility [5]. A special entity is represented by porcelain
aorta—an extensive calcification of ascending aorta or aortic arch [58] that is almost circumferential and precludes save
cross-clamping or entry to the ascending aorta. Although the preoperative diagnosis is established by multislice CT, TEE
may be helpful [59].
CONCLUSIONS
Although TEE is a semi-invasive procedure, it remains a very quick, accurate, and cost-effective diagnostic tool involving
no radiation, being a method of choice for patients with aortic valve or aortic root disease.
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(A) (B)
(C) (D)
(E) (F)
FIGURE 16.10 Infective endocarditis at the level of aortic valve and aortic root: aortic valve vegetation (A) visualized in long axis view, attached to
posterior cusp in a patient with bicuspid aortic valve that generates aortic cusp flail and consecutive sever aortic regurgitation on Color Doppler examination (B), aortic root abscess visualized in short axis view (C) that clearly has no communication with left ventricle outflow tract or ascending aorta in
Color Doppler long axis view (D); aortic root pseudoaneurysm visualized in short axis view (E) that communicates with left ventricle outflow tract in
Color Doppler long axis view (F).
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Chapter 17
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3D Virtual Intravascular Endoscopy of
Aortic Disease
Zhonghua Sun
Curtin University, Perth, WA, Australia
Chapter Outline
Introduction 181
Virtual Intravascular Endoscopy 181
Virtual Intravascular Endoscopy of Aortic Aneurysm 183
Virtual Intravascular Endoscopy of Aortic Dissection 185
INTRODUCTION
Cardiovascular disease is the leading cause of morbidity and mortality in advanced countries. Aortic disease refers to the
large vessel disease, mainly including aortic dissection and aortic aneurysm. These diseases represent life-threatening
conditions; thus early diagnosis is essential to improve patient treatment and reduce disease-related complications and
mortality.
Invasive angiography is the gold standard technique for diagnosing cardiovascular disease; however, it is an invasive
procedure with associated morbidity and mortality [1]. Further, a short hospital stay is usually required for invasive angiography, which causes discomfort for the patients. Therefore, less invasive imaging techniques for diagnosis of cardiovascular disease are desirable. Presently, computed tomography (CT) is a fast-evolving technique reflected in the rapid
development and wide availability of multislice CT (MSCT) scanners [2–7]. CT angiography (CTA) with MSCT systems
has become the preferred imaging modality in the diagnostic assessment of cardiovascular disease with high sensitivity
and specificity [7].
CTA allows for excellent visualization of cardiovascular disease with a combination of 2D and 3D reconstructions.
These visualizations are sufficient to enable clinical diagnosis in most situations. However, they are limited to providing
only external views of the cardiovascular system, without showing intraluminal changes of the arterial wall. This limitation
is overcome with another visualization tool, virtual intravascular endoscopy (VIE).
VIE presents a unique application of virtual endoscopy by providing intraluminal views of the hollow organs and structures. Virtual endoscopy is commonly used in the diagnosis of colonic polyps, with virtual colonoscopy being widely used
as a screening tool for polyp detection [8–10]. VIE has been shown to be a valuable tool for visualizing vascular diseases,
such as aortic aneurysm and endovascular stent grafts [11–14]. This chapter provides an overview of VIE applications in
aortic disease, mainly focusing on aortic aneurysm, aortic dissection, and endovascular stent graft repair of the aortic aneurysm and dissection.
Virtual Intravascular Endoscopy of Endovascular Stent Grafts 187
Summary 191
References 191
VIRTUAL INTRAVASCULAR ENDOSCOPY
Generation of VIE images is different from virtual endoscopic views of other structures such as virtual colonoscopy or
virtual bronchoscopy as air in the trachea and colon creates natural background contrast, which makes it easier to produce
intraluminal views. Fig. 17.1A is an example of virtual colonoscopy looking at the transverse colon with fecal content
resulting in false lumen stenosis, and this is confirmed by multiplanar orthogonal views (Fig. 17.1B). The minimum threshold is selected (−300 HU [Hounsfield unit]) to generate intraluminal views.
New Approaches to Aortic Diseases from Valve to Abdominal Bifurcation. http://dx.doi.org/10.1016/B978-0-12-809979-7.00017-1
Copyright © 2018 Elsevier Inc. All rights reserved.
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