A novel parasternal transthoracic echocardiographic window for detecting coronary ostial dilation after modified Bentall surgery

Abstract

BackgroundDuring the modified Bentall surgery (aortic root replacement), a cuff of native aorta is implanted, together with the coronary ostium, into the aortic graft. Multi-detector computed tomography (MDCT) imaging can accurately assess the coronary ostial anastomosis site post-surgery. In this study, we assessed the feasibility of imaging the coronary ostial anastomosis site using transthoracic echocardiography (TTE).MethodsPatients (n = 14, mean age 65 ± 12 years, 79% males) with previous Bentall surgery underwent TTE study, with MDCT (64-slice) as the reference standard. TTE used conventional and novel acoustic windows to interrogate the coronary ostia.ResultsAll coronary ostia (n = 28) were well-visualized with MDCT. The optimum TTE acoustic window for visualizing the coronary ostia was a superiorly positioned parasternal short-axis view with the probe tilted towards the left shoulder, medially angulated for the right coronary artery ostia (RCAos) and laterally angulated for the left main coronary artery (LMAos). In this off-axis position, 10 (71%) LMAos and 13 (93%) RCAos could be visualized. In the conventional parasternal views, only 5 (36%) RCAos and no LMAos could be visualized. TTE underestimated the diameter of the LMAos (10.0 ± 2.4 mm TTE vs. 13.4 ± 2.7 mm MDCT, p = 0.007), but was similar to MDCT for the RCAos (9.8 ± 3.1 mm TTE vs. 11.1 ± 3.2 mm MDCT, p = 0.10).ConclusionsWe report a novel TTE acoustic window to image the coronary ostia of post-Bentall surgery patients. Although TTE underestimates the left coronary ostium size, recognition of the ostial dilation with TTE appears feasible in most patients. Those that cannot be imaged will require alternative imaging modality such as MDCT.

Re‐emphasis on the role of echocardiography in diagnosis of aortic root surgery complications

“…From this position, angulating the probe to the left and to the right will result in the detection of the ostia of left and right coronary arteries, respectively. In this method, evaluation of the coronary artery ostial diameter is comparable with MDCT, with a similar RCA ostial diameter but an underestimated LM ostial size 8 . Video S5 presents an example of a normal coronary artery ostial that can be interrogated in TTE after the Bentall operation is provided.…”

The Left Main Complication of the Bentall’s Procedure

“…We have previously reported ostial coronary pseudoaneurysm formation in a consecutive series of patients following Bentall’s surgery [1, 2]. This condition is considered to be mostly benign.…”

“…The Bentall’s procedure involves a composite graft and coronary artery reimplantation to treat both an aneurysm of the aorta and aortic valve disease. We have previously reported ostial coronary pseudoaneurysm formation in a consecutive series of patients following Bentall’s surgery [ 1 , 2 ]. This condition is considered to be mostly benign.…”