Transesophageal echocardiography during surgery of the thoracic aorta in adults

Abstract

Thoracic aortic surgery poses significant challenges due to the complex anatomy and potential for life-threatening complications. Transesophageal echocardiography (TEE) has emerged as a crucial imaging tool in the management of patients undergoing these operations. TEE offers real-time, high-resolution imaging of the heart and aorta, enabling accurate assessment of aortic pathology, evaluation of cardiac function, and monitoring of intraoperative hemodynamics. Its semi-invasive nature, immediate availability, and ability to provide dynamic information make TEE an indispensable adjunct during these intricate procedures. One of the primary indications for TEE during thoracic aortic surgery is the assessment of aortic pathology, including aneurysms, dissections, and aortic valve diseases. TEE allows precise visualization of the extent, location, and severity of aortic lesions, facilitating decision-making regarding repair strategies, graft sizing, and intraoperative guidance. Furthermore, TEE aids in identifying associated cardiac abnormalities such as valvular or ventricular dysfunction, which may impact surgical planning and outcomes. This review aims to summarize the current evidence supporting the use of TEE during thoracic aortic surgical interventions and highlight its invaluable contributions to perioperative patient care.

Keywords

Transesophageal echocardiography / thoracic aorta / aorta surgery / cardiovascular surgery / cardiac anesthesia

References

[1] MacKay EJ,Fleisher LA.Transesophageal echocardiography, mortality, and length of hospitalization after cardiac valve surgery.J Am Soc Echocardiogr2020;33:756-62.e1 PMCID:PMC7276287

[2] MacKay EJ,Augoustides JG,Desai ND.Association of intraoperative transesophageal echocardiography and clinical outcomes after open cardiac valve or proximal aortic surgery.JAMA Netw Open2022;5:e2147820 PMCID:PMC8829659

[3] Dieleman JM,Bulfone L.Cost-effectiveness of routine transoesophageal echocardiography during cardiac surgery: a discrete-event simulation study.Br J Anaesth2020;124:136-45

[4] Vegas A.Three-dimensional transesophageal echocardiography: principles and clinical applications.Ann Card Anaesth2016;19:S35-43 PMCID:PMC5100241

[5] van Ramm OT, Smith SW. Real time volumetric ultrasound imaging system.J Digit Imaging1990;3:261-6

[6] Sugeng L,Salgo IS.Live 3-dimensional transesophageal echocardiography initial experience using the fully-sampled matrix array probe.J Am Coll Cardiol2008;52:446-9

[7] Purza R,Walker C.Transesophageal echocardiography complications in adult cardiac surgery: a retrospective cohort study.Ann Thorac Surg2017;103:795-802

[8] Huang CH,Lin TY,Wang MJ.Complications of intraoperative transesophageal echocardiography in adult cardiac surgical patients - experience of two institutions in Taiwan.J Formos Med Assoc2007;106:92-5

[9] Kallmeyer IJ,Fox JA,Shernan SK.The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients.Anesth Analg2001;92:1126-30

[10] Patel KM,Trivedi K,Krishnan S.Complications of transesophageal echocardiography: a review of injuries, risk factors, and management.J Cardiothorac Vasc Anesth2022;36:3292-302

[11] Nicoara A,Ad N.Guidelines for the use of transesophageal echocardiography to assist with surgical decision-making in the operating room: a surgery-based approach: from the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons.J Am Soc Echocardiogr2020;33:692-734

[12] Hahn RT,Adams MS.Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.J Am Soc Echocardiogr2013;26:921-64

[13] American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Practice guidelines for perioperative transesophageal echocardiography.Anesthesiology2010;112:1084-96

[14] Flachskampf FA,Edvardsen T.European Association of Cardiovascular Imaging Document reviewers: Erwan Donal and Fausto RigoRecommendations for transoesophageal echocardiography: EACVI update 2014.Eur Heart J Cardiovasc Imaging2014;15:353-65

[15] Sievers HH,Beyersdorf F.Working Group for Aortic Valve Surgery of German Society of Thoracic and Cardiovascular SurgeryThe everyday used nomenclature of the aortic root components: the tower of Babel?.Eur J Cardiothorac Surg2012;41:478-82

[16] Popieluszko P,Sanna B.A systematic review and meta-analysis of variations in branching patterns of the adult aortic arch.J Vasc Surg2018;68:298-306.e10

[17] Evangelista A,Jondeau G.Multimodality imaging in thoracic aortic diseases: a clinical consensus statement from the European Association of Cardiovascular Imaging and the European Society of Cardiology Working Group on aorta and peripheral vascular diseases.Eur Heart J Cardiovasc Imaging2023;24:e65-85

[18] Erbel R,Boileau C.ESC Committee for Practice Guidelines2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the european society of cardiology (ESC).Eur Heart J2014;35:2873-926

[19] Zafar MA,Rizzo JA.Height alone, rather than body surface area, suffices for risk estimation in ascending aortic aneurysm.J Thorac Cardiovasc Surg2018;155:1938-50

[20] Goldstein SA,Abbara S.Multimodality imaging of diseases of the thoracic aorta in adults: from the American Society of Echocardiography and the European Association of Cardiovascular imaging: endorsed by the society of cardiovascular computed tomography and society for cardiovascular magnetic resonance.J Am Soc Echocardiogr2015;28:119-82

[21] Devereux RB,Arnett DK.Normal limits in relation to age, body size and gender of two-dimensional echocardiographic aortic root dimensions in persons ≥ 15 years of age.Am J Cardiol2012;110:1189-94 PMCID:PMC3462295

[22] Campens L,De Groote K.Reference values for echocardiographic assessment of the diameter of the aortic root and ascending aorta spanning all age categories.Am J Cardiol2014;114:914-20

[23] Davis AE,Holloway CJ.Observational study of regional aortic size referenced to body size: production of a cardiovascular magnetic resonance nomogram.J Cardiovasc Magn Reson2014;16:9 PMCID:PMC3899403

[24] Murillo H,Punn R,Restrepo CS.Imaging of the aorta: embryology and anatomy.Semin Ultrasound CT MR2012;33:169-90

[25] Grewal N,Lindeman JH.Normal and abnormal development of the aortic valve and ascending aortic wall: a comprehensive overview of the embryology and pathology of the bicuspid aortic valve.Ann Cardiothorac Surg2022;11:380-8 PMCID:PMC9357963

[26] Koc AS.Increased aortic intima-media thickness may be used to detect macrovascular complications in adult type II diabetes mellitus patients.Cardiovasc Ultrasound2018;16:8 PMCID:PMC5996542

[27] Järvisalo MJ,Näntö-Salonen K.Increased aortic intima-media thickness: a marker of preclinical atherosclerosis in high-risk children.Circulation2001;104:2943-7

[28] Davis PH,Blecha MB,Sonka M.Measurement of aortic intimal-medial thickness in adolescents and young adults.Ultrasound Med Biol2010;36:560-5 PMCID:PMC2851193

[29] Ender J,Nakahira J,Thiele H.Echo didactic: visualization of the circumflex artery in the perioperative setting with transesophageal echocardiography.Anesth Analg2012;115:22-6

[30] Maxwell C,Daneshmand M,Nicoara A.Assessment of coronary blood flow by transesophageal echocardiography.J Cardiothorac Vasc Anesth2016;30:258-60

[31] Salerno P,Shaw M,Jansz P.Transesophageal echocardiographic imaging of the branches of the aorta: a guide to obtaining these images and their clinical utility.J Cardiothorac Vasc Anesth2009;23:694-701

[32] Kondo N,Kihara K,Miyashita K.Intraoperative transesophageal echocardiography for coronary artery assessment.Circ Rep2020;2:517-25 PMCID:PMC7819661

[33] Hagendorff A,Fehske W.Improvement in the assessment of aortic valve and aortic aneurysm repair by 3-dimensional echocardiography.JACC Cardiovasc Imaging2019;12:2225-44

[34] Faletra FF,Flachskampf FA.Three-dimensional transoesophageal echocardiography: how to use and when to use-a clinical consensus statement from the European Association of Cardiovascular Imaging of the European Society of Cardiology.Eur Heart J Cardiovasc Imaging2023;24:e119-97

[35] van Zaane B, Nierich AP, Buhre WF, Brandon Bravo Bruinsma GJ, Moons KG. Resolving the blind spot of transoesophageal echocardiography: a new diagnostic device for visualizing the ascending aorta in cardiac surgery.Br J Anaesth2007;98:434-41

[36] Nierich AP,Buhre WF,Spanjersberg AJ.Visualization of the distal ascending aorta with A-mode transesophageal echocardiography.J Cardiothorac Vasc Anesth2008;22:766-73

[37] Glas KE,Reeves ST.Council for Intraoperative Echocardiography of the American Society of EchocardiographySociety of Cardiovascular AnesthesiologistsGuidelines for the performance of a comprehensive intraoperative epiaortic ultrasonographic examination: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists; endorsed by the Society of Thoracic Surgeons.J Am Soc Echocardiogr2007;20:1227-35

[38] Orihashi K,Sueda T.Aortic arch branches are no longer a blind zone for transesophageal echocardiography: a new eye for aortic surgeons.J Thorac Cardiovasc Surg2000;120:466-72

[39] Agrawal G,Nanda NC.Identification of the aortic arch branches using transesophageal echocardiography.Echocardiography1997;14:461-6

[40] Patil TA.Transesophageal echocardiography evaluation of the aortic arch branches.Ann Card Anaesth2018;21:53-6 PMCID:PMC5791488

[41] Ravi BS,Htay T,Agrawal G.Transesophageal echocardiographic identification of normal and stenosed posterior intercostal arteries.Echocardiography2003;20:609-15

[42] Howard A,Howard C.Estimating the volume of chronic pleural effusions using transesophageal echocardiography.J Cardiothorac Vasc Anesth2011;25:229-32

[43] Capper SJ,Sandström E,Morgan-Hughes NJ.Transoesophageal echocardiography for the detection and quantification of pleural fluid in cardiac surgical patients.Br J Anaesth2007;98:442-6

[44] Rodríguez-Palomares JF,Galuppo V.Multimodality assessment of ascending aortic diameters: comparison of different measurement methods.J Am Soc Echocardiogr2016;29:819-26.e4

[45] Lang RM,Mor-Avi V.Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.J Am Soc Echocardiogr2015;28:1-39.e14

[46] Muraru D,Kocabay G.Ascending aorta diameters measured by echocardiography using both leading edge-to-leading edge and inner edge-to-inner edge conventions in healthy volunteers.Eur Heart J Cardiovasc Imaging2014;15:415-22

[47] Otto CM,Bonow RO.2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.Circulation2021;143:e35-71

[48] Van Dyck MJ, Watremez C, Boodhwani M, Vanoverschelde JL, El Khoury G. Transesophageal echocardiographic evaluation during aortic valve repair surgery.Anesth Analg2010;111:59-70

[49] Ouzounian M,Chung J.Canadian Thoracic Aortic CollaborativeHybrid arch frozen elephant trunk repair: evidence from the Canadian Thoracic Aortic Collaborative.Ann Cardiothorac Surg2020;9:189-96 PMCID:PMC7298239

[50] Wallet F,Fléron MH.Elephant trunk prosthesis kinking: transesophageal echocardiography diagnosis.Anesth Analg2008;106:67-9

[51] Kayali F,Jubouri M,Tan SZCP.Kinking of frozen elephant trunk hybrid prostheses: incidence, mechanism, and management.Front Cardiovasc Med2022;9:912071 PMCID:PMC9091648

[52] Kronzon I.Aortic atherosclerotic disease and stroke.Circulation2006;114:63-75

[53] Knol WG,Mahtab EAF,Bogers AJJC.Intimal aortic atherosclerosis in cardiac surgery: surgical strategies to prevent embolic stroke.Eur J Cardiothorac Surg2021;60:1259-67 PMCID:PMC8643442

[54] Cohen A,Delgado V.Reviewers: this document was reviewed by members of the 2018-2020 EACVI Scientific Documents Committeechair of the 2018-2020 EACVI Scientific Documents CommitteeEACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography.Eur Heart J Cardiovasc Imaging2021;22:e24-57

[55] Evangelista A,Erbel R.Echocardiography in aortic diseases: EAE recommendations for clinical practice.Eur J Echocardiogr2010;11:645-58

[56] Klomp WW, Brandon Bravo Bruinsma GJ, van’t Hof AW, Grandjean JG, Nierich AP. Imaging techniques for diagnosis of thoracic aortic atherosclerosis.Int J Vasc Med2016;2016:4726094 PMCID:PMC4757718

[57] Ito A,Matsumura Y.Rapid and accurate assessment of aortic arch atherosclerosis using simultaneous multi-plane imaging by transesophageal echocardiography.Ultrasound Med Biol2013;39:1337-42

[58] Shimokawa T,Yamada N,Hisamatsu Y.Assessment of ascending aorta using epiaortic ultrasonography during off-pump coronary artery bypass grafting.Ann Thorac Surg2002;74:2097-100

[59] Biancari F,Tauriainen T.Epiaortic ultrasound to prevent stroke in coronary artery bypass grafting.Ann Thorac Surg2020;109:294-301

[60] Shapeton AD,Zorca SM.Epiaortic ultrasound for assessment of intraluminal atheroma; insights from the REGROUP trial.J Cardiothorac Vasc Anesth2020;34:726-32 PMCID:PMC7243360

[61] Paruchuri V,Kuzmik G.Aortic size distribution in the general population: explaining the size paradox in aortic dissection.Cardiology2015;131:265-72

[62] Isselbacher EM,Hamilton Black J 3rd.2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on clinical practice guidelines.Circulation2022;146:e334-482

[63] Pinard A,Milewicz DM.Genetics of thoracic and abdominal aortic diseases.Circ Res2019;124:588-606 PMCID:PMC6428422

[64] Boodhwani M,Glineur D.Repair-oriented classification of aortic insufficiency: impact on surgical techniques and clinical outcomes.J Thorac Cardiovasc Surg2009;137:286-94

[65] Weinreich M,Trost B.Sinus of valsalva aneurysms: review of the literature and an update on management.Clin Cardiol2015;38:185-9 PMCID:PMC6711005

[66] Carrel T,von Kodolitsch Y.Acute aortic dissection.Lancet2023;401:773-88

[67] Rylski B,Czerny M.Acute aortic dissection: evidence, uncertainties, and future therapies.Eur Heart J2023;44:813-21

[68] Meredith EL.Echocardiography in the emergency assessment of acute aortic syndromes.Eur J Echocardiogr2009;10:i31-9

[69] Evangelista A,Cuellar H.Usefulness of real-time three-dimensional transoesophageal echocardiography in the assessment of chronic aortic dissection.Eur J Echocardiogr2011;12:272-7

[70] Wang CJ,Trinh MA.Use of real-time three-dimensional transesophageal echocardiography in type A aortic dissections: advantages of 3D TEE illustrated in three cases.Ann Card Anaesth2015;18:83-6 PMCID:PMC4900319

[71] Kitamura T,Horai T.Direct true lumen cannulation (“Samurai” cannulation) for acute stanford type A aortic dissection.Ann Thorac Surg2017;104:e459-61

[72] Flachskampf FA,Daniel WG.Recommendations for transoesophageal echocardiography: update 2010.Eur J Echocardiogr2010;11:557-76

[73] Patel PA,Ghadimi K.Aortic regurgitation in acute type-A aortic dissection: a clinical classification for the perioperative echocardiographer in the era of the functional aortic annulus.J Cardiothorac Vasc Anesth2018;32:586-97

[74] Makhija N,Sarkar S.Transesophageal echocardiographic imaging of an aortic intramural hematoma: characterizing the crescent.Can J Anaesth2019;66:1415-6

[75] Machelart I,Wirth G.Graft infection after a Bentall procedure: a case series and systematic review of the literature.Diagn Microbiol Infect Dis2017;88:158-62

[76] Ram H,Green AE,Hessel EA 2nd.Iatrogenic aortic dissection associated with cardiac surgery: a narrative review.J Cardiothorac Vasc Anesth2021;35:3050-66

[77] Ram H,Dorfling J.Iatrogenic aortic intramural hematoma: guidance to intraoperative decision making: a case report.A A Pract2020;14:e01191

[78] Muhyieddeen K,Roberts M.A case of iatrogenic aortic intramural hematoma.Methodist Debakey Cardiovasc J2017;13:37-8 PMCID:PMC5385795

[79] Welch TD,Barsness GW.Iatrogenic aortic dissection ... or intramural hematoma?.Circulation2012;125:e415-8

[80] Vignon P,Vedrinne JM.Role of transesophageal echocardiography in the diagnosis and management of traumatic aortic disruption.Circulation1995;92:2959-68

[81] Miller-Hance WC.Transesophageal echocardiography (TEE) in congenital heart disease with focus on the adult.Cardiol Clin2000;18:861-92

[82] Cardoso G,Anjos R.Aortic coarctation repair in the adult.J Card Surg2014;29:512-8

[83] Duffy CI.Transesophageal echocardiographic assessment of aortic coarctation using color, flow-directed Doppler sampling.Chest1994;105:286-8

[84] Singh S,Sharma A.Hypoplasia, pseudocoarctation and coarctation of the aorta - a systematic review.Heart Lung Circ2015;24:110-8

[85] Habib G,Tribouilloy C.European Association of EchocardiographyRecommendations for the practice of echocardiography in infective endocarditis.Eur J Echocardiogr2010;11:202-19

[86] Bruun NE,Thuny F.Cardiac imaging in infectious endocarditis.Eur Heart J2014;35:624-32

[87] Mohananey D,Pettersson G.Association of vegetation size with embolic risk in patients with infective endocarditis: a systematic review and meta-analysis.JAMA Intern Med2018;178:502-10 PMCID:PMC5876809

[88] Deprèle C,Lemetayer F.Risk factors for systemic emboli in infective endocarditis.Clin Microbiol Infect2004;10:46-53

[89] Di Salvo G,Pergola V.Echocardiography predicts embolic events in infective endocarditis.J Am Coll Cardiol2001;37:1069-76

[90] Habib G,Antunes MJ.ESC Scientific Document Group2015 ESC guidelines for the management of infective endocarditis: the task force for the management of infective endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM).Eur Heart J2015;36:3075-128

[91] Berdejo J,Harada K.Evaluation of vegetation size and its relationship with embolism in infective endocarditis: a real-time 3-dimensional transesophageal echocardiography study.Circ Cardiovasc Imaging2014;7:149-54

[92] Hermanns H,Terwindt LE.Anesthesia considerations in infective endocarditis.Anesthesiology2022;136:633-56

[93] Anguera I,Vilacosta I.Aorto-cavitary Fistula in Endocarditis Working GroupAorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality.Eur Heart J2005;26:288-97

[94] Shapira Y,Vaturi M. The impact of intraoperative transesophageal echocardiography in infective endocarditis. Isr Med Assoc J 2007;9:299-302. Available from: https://www.ima.org.il/MedicineIMAJ/viewarticle.aspx?year=2007&month=04&page=299 [Last accessed on 22 Dec 2023]

[95] Wilson WR,Creager MA.Vascular graft infections, mycotic aneurysms, and endovascular infections: a scientific statement from the American Heart Association.Circulation2016;134:e412-60

[96] Van Hemelrijck M,Husmann L,Hasse B.Vascular graft infections.Vessel Plus2022;6:47

[97] Uslu A,Güner A.Multimodality imaging of an aortic graft infection.Echocardiography2019;36:2271-3

[98] Upchurch GR,Azizzadeh A.Society for vascular surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms.J Vasc Surg2021;73:55S-83S

[99] Czerny M,Aboyans V.Current options and recommendations for the use of thoracic endovascular aortic repair in acute and chronic thoracic aortic disease: an expert consensus document of the European Society for Cardiology (ESC) Working Group of Cardiovascular Surgery, the ESC Working Group on Aorta and Peripheral Vascular Diseases, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the European Association for Cardio-Thoracic Surgery (EACTS).Eur J Cardiothorac Surg2021;59:65-73

[100] Czerny M,Adler S.EACTS/ESVS scientific document groupCurrent options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS).Eur J Cardiothorac Surg2019;55:133-62

[101] Rocchi G,Biagini E.Transesophageal echocardiography-guided algorithm for stent-graft implantation in aortic dissection.J Vasc Surg2004;40:880-5

[102] Rapezzi C,Fattori R.Usefulness of transesophageal echocardiographic monitoring to improve the outcome of stent-graft treatment of thoracic aortic aneurysms.Am J Cardiol2001;87:315-9

[103] Fattori R,Rapezzi C.Primary endoleakage in endovascular treatment of the thoracic aorta: importance of intraoperative transesophageal echocardiography.J Thorac Cardiovasc Surg2000;120:490-5

[104] Reformato V,Kaczorowski D.Transesophageal echocardiography for ascending thoracic endovascular aortic repair of stanford type A aortic dissection.A A Pract2019;13:78-80

[105] Preventza O,Olive J,Coselli JS.Endovascular repair of the ascending aorta: the last frontier.Ann Cardiothorac Surg2022;11:26-30 PMCID:PMC8807413

[106] Garrido JM,Esteban-Molina M,Rodríguez-Serrano F.Endovascular technique for ascending aorta repair based on TEVAR and TAVI procedures.J Endovasc Ther2023;:15266028221148383

[107] Roselli EE,Johnston DR,Desai MY.Zone zero thoracic endovascular aortic repair: a proposed modification to the classification of landing zones.J Thorac Cardiovasc Surg2018;155:1381-9

[108] Wipper SH,Dumfarth J.A new hybrid graft for open thoracoabdominal aortic aneurysm repair.Ann Cardiothorac Surg2023;12:503-5 PMCID:PMC10561343

[109] Debus ES,Kölbel T.First in human implantation of the thoracoflo graft: a new hybrid device for thoraco-abdominal aortic repair.EJVES Vasc Forum2023;58:28-31 PMCID:PMC10053397

[110] Nyrnes SA,Wigen MS,Lovstakken L.Blood speckle-tracking based on high-frame rate ultrasound imaging in pediatric cardiology.J Am Soc Echocardiogr2020;33:493-503.e5

[111] Fadnes S,Nyrnes SA.In vivo intracardiac vector flow imaging using phased array transducers for pediatric cardiology.IEEE Trans Ultrason Ferroelectr Freq Control2017;64:1318-26

[112] Sørensen K,Mertens L.Assessment of early diastolic intraventricular pressure difference in children by blood speckle-tracking echocardiography.J Am Soc Echocardiogr2023;36:523-32.e3

[113] Wigen MS,Rodriguez-Molares A.4-D intracardiac ultrasound vector flow imaging-feasibility and comparison to phase-contrast MRI.IEEE Trans Med Imaging2018;37:2619-29

[114] Lowe C,Rogers S,Ghosh J.Three-dimensional contrast-enhanced ultrasound improves endoleak detection and classification after endovascular aneurysm repair.J Vasc Surg2017;65:1453-9

[115] Agricola E,Rinaldi E.Usefulness of contrast-enhanced transoesophageal echocardiography to guide thoracic endovascular aortic repair procedure.Eur Heart J Cardiovasc Imaging2016;17:67-75

[116] Agricola E,Bertoglio L.Contrast-enhanced TEE during thoracic endovascular aortic repair procedure.JACC Cardiovasc Imaging2015;8:980-2

[117] Rylski B,Bavaria JE,Moser W.Development of a single endovascular device for aortic valve replacement and ascending aortic repair.J Card Surg2014;29:371-6

[118] Felipe Gaia D,Castilho E.First-in-human endo-bentall procedure for simultaneous treatment of the ascending aorta and aortic valve.JACC Case Rep2020;2:480-5 PMCID:PMC8311619

[119] Gandet T,Conradi L.Modular endo-bentall procedure using a “rendez-vous access”.J Endovasc Ther2022;29:711-6

[120] Leshnower BG,Nicholson WJ.Endo-bentall procedure using off-the-shelf catheter devices to repair an aorto-atrial fistula.Circ Cardiovasc Interv2023;16:e012848