Imaging of the ascending aorta by transthoracic echocardiography: would adding medial sliding with clockwise rotation of the transducer to the recommended aortic view increases the visualized segment
Authors: Farouk H , El Chilali K , Schoene D , Witt C , Kloppe A 
Published: January 2025

Abstract

Background
Assessment of the ascending aorta beyond the sinotubular junction using transthoracic echocardiography (TTE) is challenging. It is recommended to move the transducer to upper intercostal spaces from the left parasternal long-axis view (PLAX) to get a better visualization of the ascending aorta. During our daily practice, we noticed that adding both medial sliding as well as clockwise rotation to the upwards recommended movement of the transducer would increase the length of the imaged ascending aorta.

Methods
The length of the visualized ascending aorta was measured using two techniques. The first is the EACVI recommended view and the second is our suggested modification of this view. We start by getting the standard left PLAX then we slide the transducer 2 cm medially followed by 2 to 3 cm upwards sliding with a 20 to 30° clockwise rotation. All these maneuvers should be made without losing the contact between the transducer and the patient’s skin while keeping a slight caudal tilting of the probe (towards the patient’s right hip). This maneuver is like moving the probe in an inverted comma (˛) pathway starting from the standard left PLAX view. In some patients, we started with 20 to 30° clockwise rotation (knob pointing at 11 O’clock) and then sliding the probe about 2 cm medially. This slight clockwise rotation while moving medially corrects the heart-aorta-angle and keeps the long-axis of the ascending aorta in the focus of TTE field. Three hundred patients with good echocardiographic images were examined using both techniques. We measured the length between two points, the proximal which is the coaptation point between the right and acoronary cusp of the aortic valve during diastole to the most distally visualized point in the ascending aorta.

Results
Patients’ age was 65±15 years, 48% were females. Sixty-eight percent of these patients were hypertensive while coronary artery disease was diagnosed in about 55% of them. We could visualize 62.6±9.4 mm of the ascending aorta using the suggested view compared to 45.2±5.0 mm using the EACVI recommended one (P &lt; 0.001). The measured diameter of the distal ascending aorta using both methods was similar. Ascending aortic dilatation starting beyond the sinutubular junction could be detected by both views but not using the standard left PLAX (Figure 1). The continuity of aortic root and the ascending aorta is more obvious in the modified aortic view (Figure 2).

Conclusion
Compared to the recommended left PLAX with upward movement of the transducer for assessing the ascending aorta, a longer segment could be imaged with an upwards and medial sliding combined with a slight clockwise rotation of the transducer. Using either of these two methods could identify distal pathologies more efficiently compared to the standard left PLAX and should be always included in the standard echocardiographic assessment.