© 2015, Wiley Periodicals, Inc. DOI: 10.1111/echo.12952
Echocardiography
IMAGE SECTION
An Unexpected Guest in the Proximal Ascending Aorta Laura Toffetti, M.D.,* Alice Pugno, M.D.,* Laura Massironi, M.D.,* Silvia Tresoldi, M.D.† and Antonio G. Mantero, M.D.* *Cardiology and Coronary Care Unit, Department of Emergency, University of Milan, Milan, Italy; and †Department of Diagnostic and Interventional Radiology, San Paolo Hospital, Milan, Italy
(Echocardiography 2015;00:1–2) Key words: intracoronary stent, ascending aorta, transthoracic echocardiography, transesophageal echocardiography
A 72-year-old asymptomatic woman with history of ischemic heart disease presented to our outpatient cardiovascular ultrasound laboratory for a routine follow-up echocardiographic examination. Three years earlier, she had undergone placement of a drug-eluting coronary stent (Nobori 25 9 24 mm; Terumo Corporation, Tokyo, Japan) in the proximal left anterior descending coronary artery for anterior ST elevation myocardial infarction, followed by elective placement of 2 drug-eluting stents in the ostial (Abbott, Xience 3.0 9 15 mm) and medium (Xience 2.75 9 23 mm; Abbott Vascular, Abbott Park, IL, USA ) right coronary artery (RCA). Transthoracic echocardiogram (TTE) showed infero-posterior hypokinesia of the left ventricle, near normal left ventricular ejection fraction (LVEF 50%) and a 9-mm long, fixed, echo dense mass in the proximal ascending aorta, close to the right coronary cusp (Figs. 1 and 2). Given these findings, the patient underwent a two and three-dimensional (2D and 3D) transesophageal echocardiogram (TEE) (Fig. 3). There was no dissection flap, intimal tear or flow, and the mass was not mobile. Therefore, she underwent a cardiac computed tomography (CT) with electrocardiographic gating, which revealed the unexplained mass to be the ostial RCA stent protruding 9 mm into the ascending aorta (Fig. 4). TEE visualization of intracoronary stents has been described in a few cases.1–3 To our knowledge, there is only one report of transthoracic visualization of coronary stent protrusion, a left main coronary artery ostial stent that was Address for correspondence and reprint: Laura Toffetti, M.D., Cardiology Clinic, Azienda Ospedaliera San Paolo, University of Milan, 8, via di Rudinı, 20142 Milan, Italy. Fax: 0039/ 0281844261; E-mail: [email protected]
detected by 3DTTE.4 Coronary stent protrusion is a very unusual finding observed during routine 2DTTE, but it has many potential clinical consequences, such as aortic dissection, aortic cusp perforation, intra-stent restenosis and thrombosis, and even peripheral embolization of the stent; furthermore, they make repeat percutaneous interventions technically challenging for cardiac interventionalists. We preferred a conservative approach for this patient, because the CT scan showed no signs of intimal hyperplasia or
Figure 1. Transthoracic parasternal long-axis view showing an echo dense mass (white arrow) in the proximal ascending aorta, just distal to the right coronary cusp of the aortic valve. Ao = ascending aorta; LA = left atrium; LV = left ventricle; RV = right ventricle.
1
Toffetti, et al.
Figure 2. The mass (white arrow) was clearly visualized in this transthoracic parasternal short-axis view (aortic level). AV = aortic valve; LA = left atrium; PV = pulmonary valve; RA = right atrium.
Figure 4. Pure transaxial CT image at the level of the sinuses of Valsalva showing the origin of the RCA. The stent in the proximal tract of the vessel (white arrow), protruding for 9 mm into the aortic right coronary sinus is clearly detectable, and there are no signs of intimal hyperplasia or in-stent restenosis. Ao = ascending aorta; LA = left atrium; RA = right atrium; RV = right ventricle.
This case suggests that 2D TTE is feasible and useful for identification and follow-up of protruding ostial coronary stents. References
Figure 3. 3D transesophageal image demonstrating the proximity of the mass (white arrow) to the right coronary sinus of Valsalva. Ao = ascending aorta; LV = left ventricle.
in-stent restenosis three years after the stent implantation.
2
1. Pohlel K, Lerakis S, Arita T, et al: Intracoronary stent visualized on transesophageal echocardiogram in a case of coronary dissection complicated by aortic dissection. J Am Soc Echocardiogr 2006;19:229.e1–229.e3. 2. Nixdorff U, Erbel R, Rupprecht HJ, et al: Noninvasive visualization of an apparent patent intracoronary stent by transesophageal echocardiography. Echocardiography 1995;12:391–395. 3. Lerner AB, Subramaniam B, Mahmood F, et al: An unusual echodensity in the ascending aorta: transesophageal echocardiographic visualization of a protruding coronary stent. Anesth Analg 2006;103:854–855. 4. Chen HC, Lee WC, Fu M: ‘Rail track picture’: diagnosis of the protruding of left main coronary stent by transthoracic echocardiography especially with three-dimensional images. Eur Heart J Cardiovasc Imaging 2014;15:946.
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie Clip S1: Figure 1. Cinepak Codec.
Echocardiography
IMAGE SECTION
An Unexpected Guest in the Proximal Ascending Aorta Laura Toffetti, M.D.,* Alice Pugno, M.D.,* Laura Massironi, M.D.,* Silvia Tresoldi, M.D.† and Antonio G. Mantero, M.D.* *Cardiology and Coronary Care Unit, Department of Emergency, University of Milan, Milan, Italy; and †Department of Diagnostic and Interventional Radiology, San Paolo Hospital, Milan, Italy
(Echocardiography 2015;00:1–2) Key words: intracoronary stent, ascending aorta, transthoracic echocardiography, transesophageal echocardiography
A 72-year-old asymptomatic woman with history of ischemic heart disease presented to our outpatient cardiovascular ultrasound laboratory for a routine follow-up echocardiographic examination. Three years earlier, she had undergone placement of a drug-eluting coronary stent (Nobori 25 9 24 mm; Terumo Corporation, Tokyo, Japan) in the proximal left anterior descending coronary artery for anterior ST elevation myocardial infarction, followed by elective placement of 2 drug-eluting stents in the ostial (Abbott, Xience 3.0 9 15 mm) and medium (Xience 2.75 9 23 mm; Abbott Vascular, Abbott Park, IL, USA ) right coronary artery (RCA). Transthoracic echocardiogram (TTE) showed infero-posterior hypokinesia of the left ventricle, near normal left ventricular ejection fraction (LVEF 50%) and a 9-mm long, fixed, echo dense mass in the proximal ascending aorta, close to the right coronary cusp (Figs. 1 and 2). Given these findings, the patient underwent a two and three-dimensional (2D and 3D) transesophageal echocardiogram (TEE) (Fig. 3). There was no dissection flap, intimal tear or flow, and the mass was not mobile. Therefore, she underwent a cardiac computed tomography (CT) with electrocardiographic gating, which revealed the unexplained mass to be the ostial RCA stent protruding 9 mm into the ascending aorta (Fig. 4). TEE visualization of intracoronary stents has been described in a few cases.1–3 To our knowledge, there is only one report of transthoracic visualization of coronary stent protrusion, a left main coronary artery ostial stent that was Address for correspondence and reprint: Laura Toffetti, M.D., Cardiology Clinic, Azienda Ospedaliera San Paolo, University of Milan, 8, via di Rudinı, 20142 Milan, Italy. Fax: 0039/ 0281844261; E-mail: [email protected]
detected by 3DTTE.4 Coronary stent protrusion is a very unusual finding observed during routine 2DTTE, but it has many potential clinical consequences, such as aortic dissection, aortic cusp perforation, intra-stent restenosis and thrombosis, and even peripheral embolization of the stent; furthermore, they make repeat percutaneous interventions technically challenging for cardiac interventionalists. We preferred a conservative approach for this patient, because the CT scan showed no signs of intimal hyperplasia or
Figure 1. Transthoracic parasternal long-axis view showing an echo dense mass (white arrow) in the proximal ascending aorta, just distal to the right coronary cusp of the aortic valve. Ao = ascending aorta; LA = left atrium; LV = left ventricle; RV = right ventricle.
1
Toffetti, et al.
Figure 2. The mass (white arrow) was clearly visualized in this transthoracic parasternal short-axis view (aortic level). AV = aortic valve; LA = left atrium; PV = pulmonary valve; RA = right atrium.
Figure 4. Pure transaxial CT image at the level of the sinuses of Valsalva showing the origin of the RCA. The stent in the proximal tract of the vessel (white arrow), protruding for 9 mm into the aortic right coronary sinus is clearly detectable, and there are no signs of intimal hyperplasia or in-stent restenosis. Ao = ascending aorta; LA = left atrium; RA = right atrium; RV = right ventricle.
This case suggests that 2D TTE is feasible and useful for identification and follow-up of protruding ostial coronary stents. References
Figure 3. 3D transesophageal image demonstrating the proximity of the mass (white arrow) to the right coronary sinus of Valsalva. Ao = ascending aorta; LV = left ventricle.
in-stent restenosis three years after the stent implantation.
2
1. Pohlel K, Lerakis S, Arita T, et al: Intracoronary stent visualized on transesophageal echocardiogram in a case of coronary dissection complicated by aortic dissection. J Am Soc Echocardiogr 2006;19:229.e1–229.e3. 2. Nixdorff U, Erbel R, Rupprecht HJ, et al: Noninvasive visualization of an apparent patent intracoronary stent by transesophageal echocardiography. Echocardiography 1995;12:391–395. 3. Lerner AB, Subramaniam B, Mahmood F, et al: An unusual echodensity in the ascending aorta: transesophageal echocardiographic visualization of a protruding coronary stent. Anesth Analg 2006;103:854–855. 4. Chen HC, Lee WC, Fu M: ‘Rail track picture’: diagnosis of the protruding of left main coronary stent by transthoracic echocardiography especially with three-dimensional images. Eur Heart J Cardiovasc Imaging 2014;15:946.
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie Clip S1: Figure 1. Cinepak Codec.
