Correspondence
Correction
Notice of Redundant Publication: Transesophageal Echocardiography in the Diagnosis of Traumatic Rupture of the Aorta
N Engl J Med 1995; 333:457-458August 17, 1995
- Article
To the Editor:
Smith et al. (Feb. 9 issue)1 report the use of transesophageal echocardiography to diagnose aortic trauma in a series of 121 patients at the University of Kentucky Medical Center over a 24-month period. The same authors have reported on two similar series in the past two years from the same institution.2,3 The first article, by Kearney et al., describes a series of 69 patients followed for 18 months, and the second, by Buckmaster et al., a series of 160 patients followed for 33 months. The findings in these studies are similar and demonstrate the high sensitivity and specificity of transesophageal echocardiography for the detection of traumatic rupture of the aorta.
The authors do not indicate in the most recent paper1 whether these series were consecutive or whether, in fact, these studies all involve the same patients. From the methods described, it would appear that the latter may be the case.
These are important studies, because they suggest that transesophageal echocardiography could replace aortography as the gold-standard investigation for aortic trauma. The conclusions of the papers will obviously be much stronger if the studies involved consecutive series with a total sample of 350 patients. We request that the authors describe more clearly the patients in these three series.
3 ReferencesR.J. Young, M.B., B.S.
G.M. Joynt, M.B., B.Ch.
C.D. Gomersall, M.B., B.S.
Chinese University of Hong Kong, Shatin, N.T., Hong Kong1
Smith MD ,Cassidy JM ,Souther S , et al. Transesophageal echocardiography in the diagnosis of traumatic rupture of the aorta. N Engl J Med 1995;332:356-362
Full Text | Web of Science | Medline2
Kearney PA ,Smith DW ,Johnson SB ,Barker DE ,Smith MD ,Sapin PM . Use of transesophageal echocardiography in the evaluation of traumatic aortic injury. J Trauma 1993;34:696-703
CrossRef | Web of Science | Medline3
Buckmaster MJ ,Kearney PA ,Johnson SB ,Smith MD ,Sapin PM . Further experience with transesophageal echocardiography in the evaluation of thoracic aortic injury. J Trauma 1994;37:989-995
CrossRef | Web of Science | Medline
To the Editor:
Smith and colleagues assert that transesophageal echocardiography is sensitive and specific enough to be used as the primary imaging method in patients with suspected traumatic rupture of the thoracic aorta. We agree with them that the distal portion of the ascending aorta, as well as the branches of the aortic arch, cannot be adequately assessed by transesophageal echocardiography. However, we do not agree that traumatic injury to these branches is “rare and usually apparent clinically.”
We reviewed our experience in patients with blunt chest trauma who underwent aortography because mediastinal blood was apparent on chest radiography. We identified 81 patients who had angiographic evidence of traumatic injury to the thoracic aorta or its branches (75 from motor vehicle accidents, 4 from falls, 1 from being hit by an automobile, and 1 from a crush injury). Among these 81 patients, 66 had only aortic rupture. Fifteen patients (18.5 percent) had injuries of the aortic branch vessels. Three of these patients had not only ruptures of the thoracic aorta but also a total of four injuries to the aortic branches. The other 12 had a total of 19 injuries to the aortic branches but had intact aortas. The 23 ruptured branches were the following arteries: brachiocephalic (5), right subclavian (3), left common carotid (4), left subclavian (7), vertebral (2), and internal thoracic (2). The mediastinal blood seen on chest radiography had an identical appearance whether the injury was to the thoracic aorta, its branches, or both.
Transesophageal echocardiography has completely replaced aortography at our institution in cases of suspected nontraumatic acute aortic dissection.1 However, until the major noncoronary branches of the thoracic aorta can be adequately and consistently evaluated by this method, aortography should remain the primary imaging method used to evaluate patients with mediastinal blood visible on chest radiography after blunt trauma. In this setting, transesophageal echocardiography could be of supplementary benefit in the occasional aortic isthmus in which a “bump” to the ductus arteriosus cannot be distinguished from an aortic rupture.
1 ReferencesDouglas C. Smith, M.D.
Ramesh C. Bansal, M.D.
Loma Linda University Medical Center, Loma Linda, CA 923541
Bansal RC ,Chandrasekaran K ,Ayala K ,Smith DC . Frequency and explanation of false negative diagnosis of aortic dissection by aortography and transesophageal echocardiography. J Am Coll Cardiol 1995;25:1393-1401
CrossRef | Web of Science | Medline
To the Editor:
Smith et al. attribute a positive predictive value of 99 percent to transesophageal echocardiography in the diagnosis of aortic rupture. The positive predictive value of a test is the percentage of true positive results among all positive results. On the basis of the results presented, Table 1Table 1
Results of Transesophageal Echocardiography Used to Detect Aortic Rupture. can be constructed. Using the following formula, one can calculate the positive predictive value of the test:Positive predictive value = true positives/(true positives + false positives) = 10/(10 + 1) = 10/11 = 90.9 percent.
It is not my intention to underestimate the value of this method and the conclusions presented. My concern is that the concept of the positive predictive value is very basic, and the value should not be calculated incorrectly.
José Eduardo R. Azevedo, M.D.
Hospital São Paulo, São Paulo, BrazilAuthor/Editor Response
The authors reply:
To the Editor: We wish to acknowledge substantial redundancy of patients in our 1995 Journal study1 of 93 patients with suspected aortic injury. Seventy-six of these patients, 8 of whom had positive results on transesophageal echocardiography, had been included in a study of 160 patients with the same condition published in the Journal of Trauma in 1994.2 The 1994 study also included many patients described one year earlier in our initial report of the successful use of transesophageal echocardiography to diagnose thoracic aortic injury.3 Although we cited the 1993 report in our article in the Journal, we neglected to cite the larger 1994 study2 and failed to inform you that that study had been accepted for publication. We sincerely apologize for any confusion about the total number of patients studied and any duplication of data.
In response to Drs. Smith and Bansal, we have reviewed our four-year experience with injuries to arch vessels. Of 6158 patients admitted because of blunt trauma, 251 had suspected aortic injuries, 172 underwent angiography, and none had injuries to the arch vessels. We have evaluated three injuries to the subclavian artery, which involved a pulse deficit in one case, a brachial plexopathy in the second, and both conditions in the third. We have not seen any patients with blunt trauma who had injuries to the innominate or proximal carotid arteries.
The available studies support our conclusions. In an autopsy series of 275 patients4 and a clinical study of 73 patients with blunt thoracic injury,5 there was only 1 patient with an injury to an arch vessel, and that injury was contiguous with an aortic injury. A collective review6 showed that with the exception of the brachiocephalic trunk, other clinical and radiographic signs usually accompany injuries to the arch vessels. Thus, our experience and those reported confirm that injuries to these vessels are “rare and usually apparent clinically.”
As pointed out by Dr. Azevedo, the positive predictive value of transesophageal echocardiography was incorrectly reported in our paper. The value is the number of true positive results divided by the number of all positive results7 and is 10/11 or 90.9 percent. Notably, the one patient with a “false positive” result of transesophageal echocardiography did not undergo surgery and may actually have had a false negative angiographic study. Since a patient with negative bedside transesophageal echocardiography could avoid aortography, the most relevant statistic is the negative predictive value: 82 true negative results divided by a total of 82 negative results, or 100 percent.
7 ReferencesMikel D. Smith, M.D.
Paul A. Kearney, M.D.
University of Kentucky College of Medicine, Lexington, KY 40536-00841
Smith MD ,Cassidy JM ,Souther S , et al. Transesophageal echocardiography in the diagnosis of traumatic rupture of the aorta. N Engl J Med 1995;332:356-362
Full Text | Web of Science | Medline2
Buckmaster MJ ,Kearney PA ,Johnson SB ,Smith MD ,Sapin PM . Further experience with transesophageal echocardiography in the evaluation of thoracic aortic injury. J Trauma 1994;37:989-995
CrossRef | Web of Science | Medline3
Kearney PA ,Smith DW ,Johnson SB ,Barker DE ,Smith MD ,Sapin PM . Use of transesophageal echocardiography in the evaluation of traumatic aortic injury. J Trauma 1993;34:696-703
CrossRef | Web of Science | Medline4
Parmley LF ,Mattingly TW ,Manion WC ,Jahnke EJ Jr . Nonpenetrating traumatic injury of the aorta. Circulation 1958;17:1086-1101
Web of Science | Medline5
Kieny R ,Charpentier A . Traumatic lesions of the thoracic aorta: a report of 73 cases. J Cardiovasc Surg (Torino) 1991;32:613-619
Web of Science | Medline6
Poole GV . Fracture of the upper ribs and injury to the great vessels. Surg Gynecol Obstet 1989;169:275-282
Web of Science | Medline7
The interpretation of diagnostic data. In: Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology: a basic science for clinical medicine. 2nd ed. Boston: Little, Brown, 1991:85-7.
- Citing Articles (4)
Citing Articles
1
Anna Holdgate, Sarah Dunlop. (2005) Review of branch aortic injuries in blunt chest trauma. Emergency Medicine Australasia 17:1, 49-56
CrossRef2
Yoram Ben-Menachem. (1997) Assessment of Blunt Aortic-brachiocephalic Trauma. The Journal of Trauma: Injury, Infection, and Critical Care 42:5, 969-972
CrossRef3
R. Prétre, M. Chilcott, N. Mürith, A. Panos. (1997) Blunt injury to the supra-aortic arteries. British Journal of Surgery 84:5, 603-609
CrossRef4
Prêtre, René, Chilcott, Michael, . (1997) Blunt Trauma to the Heart and Great Vessels. New England Journal of Medicine 336:9, 626-632
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