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CLINICAL STUDY: ATHEROSCLEROSIS

Transcutaneous detection of aortic arch atheromas by suprasternal harmonic imaging

Ehud Schwammenthal, MD^*,, Yvonne Schwammenthal, MD^,*,, David Tanne, MD^,, Alexander Tenenbaum, MD^*,, Alex Garniek, MD^,, Michael Motro, MD, FACC^*,, Babeth Rabinowitz, MD, FACC^*,, Michael Eldar, MD, FACC^*, and Micha S. Feinberg, MD^*,

^* Heart Institute and Cardiac Rehabilitation Institute, Tel Hashomer, Israel
Department of Neurology, Chaim Sheba Medical Center, Tel Hashomer, Israel
Department of Radiology, Chaim Sheba Medical Center, Tel Hashomer, Israel
Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

Manuscript received September 10, 2001; revised manuscript received December 26, 2001, accepted January 10, 2002.

^* Reprint requests and correspondence: Dr. Ehud Schwammenthal, Heart Institute, Sheba Medical Center, Tel Hashomer, Israel
sehud{at}post.tau.ac.il

OBJECTIVES: The goal of the present study was to examine whether suprasternal harmonic imaging (SHI) (i.e., harmonic imaging from the suprasternal windows) can visualize protruding arch atheromas (PAAs) and reliably predict the presence or absence of significant lesions.

BACKGROUND: Protruding arch atheromas are a major source of cerebral and peripheral embolism and probably the most frequent cause of stroke during cardiac catheterization and open-heart surgery. Preprocedural screening by transesophageal echocardiography (TEE) would be desirable but is limited by the nature of the examination.

METHODS: Of 354 patients who underwent a TEE study in our laboratory during the study period, 106 were referred for detection of a source of embolism. Findings were classified based on the French Aortic Plaque study criteria as: 1) no or minimal atherosclerotic changes; 2) PAAs <4 mm; 3) PAAs 4 mm or presence of a mobile component.

RESULTS: Adequate transcutaneous image quality could be achieved in 89 patients (84%). Protruding arch atheromas were present in 42 patients (47%) and absent in 47 (53%). Positive and negative predictive values for large PAAs on TEE were 91% and 98%, respectively. In one case, SHI detected a complex PAA inaccessible for TEE due to interposition of the left bronchus as demonstrated by dual helical computed tomography. Inter-observer agreement for SHI was 91%.

CONCLUSIONS: Suprasternal harmonic imaging reliably predicted or excluded the presence of PAAs in a sizable, consecutive group of patients referred to TEE for detection of a source of embolism. It represents an excellent screening test and provides complimentary views of regions, which may be blind spots for TEE.

Abbreviations and Acronyms   DHCT   dual helical computed tomography   PAA   protruding aortic arch atheroma   SHI   suprasternal harmonic imaging   TEE   transesophageal echocardiography

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