Case Presentation:

A 68–year–old male with history of coronary artery disease, diabetes and hypertension presented with worsening of dyspnea on exertion. Initial assessment showed new onset atrial fibrillation with RVR and patient underwent transesophageal echo–guided (TEE) cardioversion. TEE did not show a thrombus in the left atrium including left atrial appendage. A large atheroma was noted incidentally in the mid descending thoracic aorta with 2D mode. Due to the difficulty to fully evaluate this atheroma, the real time 3D TEE mode was employed and it revealed two large ulcerated craters on the atheroma. Maximum height of this atheroma was 8mm and consisted of two craters with maximum diameter of 7mm and 8mm and depth of 3 mm for both respectively.

Discussion:

In 1990, Kronzon et al. first described three patients with neurological and peripheral arterial embolic syndromes in whom TEE showed a large protruding atherosclerotic plaque in aortic arch and descending aorta. Since then several studies have been published over the last two decades assessing the risk of stroke and peripheral emboli in patients with aortic plaques based on the imaging characteristics and location of these plaques. Clinical data indicates that the plaques with thickness equal to or more than 4 mm have a high risk for embolization. Plaques with a thrombus or a mobile component are usually referred to as complex atheromas. Until recently, the full visualization of these complex atheromas was very challenging due to the limited scanning planes inherited to 2D TEE system. This and other similar cases, clearly illustrate that limitation and advantage of using 3D mode TEE. In this particular case, a catheterization from a femoral artery approach, if needed, should be performed very carefully in the future and renal function should be carefully monitored to detect possible renal artery embolism. The patient should also be monitored for development of aortic aneurysm and dissection. A systematic study to evaluate the efficacy of evaluating atheromas in thoracic aorta with 3D TEE to prevent embolic episodes is warranted.

Conclusions:

Recent development and application of real time 3D TEE provides excellent volumetric display of aortic atheromas and enables us to fully assess the degree of complexity and speculate thrombotic potential. More large scale studies are needed to establish guidelines regarding its use and fully assess its utility in clinical practice.

Figure 1Plaque on 2D TEE of the descending aorta.

Figure 2Ulcerated plaque in the descending aorta on Real Time 3D TEE.