
==== Front
Heliyon
Heliyon
Heliyon
2405-8440
Elsevier

S2405-8440(24)12638-2
10.1016/j.heliyon.2024.e36607
e36607
Research Article
Prevalence of ascending aortic atheromatous plaques and risk factors in Thai cardiac surgery patients: A prospective cohort study
Khamtuikrua Chaowanan a
Chaikittisilpa Nophanan a
Suksompong Sirilak a
Slisatkorn Worawong b
Raykateeraroj Nattaya nattaya.ray@mahidol.ac.th
a⁎
a Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
b Division of Cardio-Thoracic Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
⁎ Corresponding author. Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand. nattaya.ray@mahidol.ac.th
21 8 2024
30 8 2024
21 8 2024
10 16 e3660718 2 2024
30 7 2024
19 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
Cerebral embolism, a serious complication in cardiac surgery, is significantly impacted by atheromatous plaques in the ascending aorta and aortic arch. However, data on the prevalence of these plaques in Asian populations are sparse. This study aimed to evaluate the prevalence of atheromatous plaques in the ascending aorta among Thai cardiac surgery patients, thereby facilitating risk stratification and improving preoperative management. We conducted intraoperative epiaortic ultrasound examinations on 239 cardiac surgery patients. Clinically significant atheromatous plaques were defined as those exceeding 3.0 mm in thickness. The collected demographic and clinical data included sex, age, body weight, height, American Society of Anesthesiologists physical status classification, smoking status, alcohol consumption, and comorbidities. Atheromatous plaques were found in 33.5 % of the ascending aortas and 41.4 % of the aortic arches. The primary risk factors were advanced age (over 80 years; relative risk (RR) 1.444, 95 % confidence interval (CI) 1.113–1.874, P = 0.006) and carotid stenosis (RR 1.247, 95 % CI 1.04–1.495, P = 0.017). The prevalence of atheromatous plaques in Thai cardiac surgery patients was significant, with older age and carotid stenosis being major risk factors. Preoperative aortic imaging, such as computed tomography angiography or epiaortic ultrasound, should be applied to cardiac surgery candidates. In resource-limited settings, prioritizing patients of advanced age or those with carotid stenosis for imaging is advised.

Highlights

• 33.5 % of Thai cardiac patients show high prevalence of ascending aortic plaques.

• Advanced age, carotid stenosis key risks for significant ascending aortic plaques.

• CT angiography/epiaortic ultrasound in cardiac surgery might reduce post-op stroke.

Clinical trial registration: The clinical trial described in this paper was registered with ClinicalTrials.gov (registration number: NCT03381222) on December 18, 2017.

Keywords

Advanced age and carotid stenosis
Ascending aorta atheromatous plaques
Epiaortic ultrasound in cardiac surgery
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pmc1 Introduction

Cerebral embolism, which affects 2.61 %–5.2 % of cardiac surgery patients [1,2], markedly increases disability and mortality rates [2,3]. Previous research has identified atheromatous plaques in the ascending aorta [4,5] and the aortic arch [6] as pivotal contributors to perioperative stroke in these patients. During cardiopulmonary bypass, arterial cannula flow can dislodge these plaques from the aortic wall. This occurrence is particularly pronounced in the ascending aorta, the main region for arterial cannulation and aortic cross-clamping, as well as in the aortic arch.

To minimize such postoperative complications, preoperative detection of atheromatous plaques in the thoracic aorta via computed tomography angiography (CTA) is advised. Nevertheless, constraints prevent all patients from undergoing this imaging technique before cardiac surgery. Transesophageal echocardiography (TEE) is an alternative diagnostic tool but has proven less effective for the ascending aorta because of acoustic shadowing from the trachea. Consequently, intraoperative epiaortic ultrasound (EAU) is often employed for the immediate identification of aortic plaques.

Several studies have highlighted that the prevalence of atheromatous plaques in the ascending aorta varies significantly across different racial groups. In a United States-based study, Dávila-Román et al. [4] reported a 19.3 % incidence of these plaques in cardiac surgery patients. Conversely, Mills et al. [7], examining populations in England and the Netherlands, reported a substantially lower incidence of approximately 8.8 %. Gupta et al. [8] found that despite higher rates of hypertension, diabetes, coronary artery disease, and carotid artery disease, individuals of African ancestry present a lower incidence of atherosclerosis than those of European origin.

In an Asian population study, Nohara et al. [9] observed a 29 % incidence of clinically significant atheromatous plaques in cardiac surgery patients in Japan. These plaques were identified via transesophageal echocardiography and characterized by intimal thickening exceeding 3.0 mm and/or mobile plaques in the aortic arch. However, studies specifically addressing the presence of plaques in the ascending aorta among Asians are scarce. Given the racial differences in the occurrence of aortic atherosclerosis, it is plausible that the risk factors for ascending aortic atheromatous plaque also vary among racial groups.

This study aimed to elucidate the prevalence and risk factors for ascending aortic atheromatous plaque in Thai cardiac surgery patients and to compare these findings with those from other racial groups. We hypothesized that the prevalence patterns and associated risk factors for atheromatous plaques in the Thai population are unique. Consequently, the study objectives were to determine the prevalence of this condition and to identify its specific risk factors in the Thai context. Ultimately, this research seeks to raise awareness about atheromatous plaques, identify at-risk patients, and contribute to reducing postoperative complications.

2 Materials and methods

This prospective cohort study included 239 patients aged ≥50 years who underwent cardiac surgery via median sternotomy. Data collection spanned from July 2018 to December 2019. The exclusion criteria comprised the presence of pericarditis and specific aortic abnormalities, such as aneurysms and dissections. The research protocol was authorized by the Siriraj Institutional Review Board (approval number: Si 151/2018), and the study was registered at ClinicalTrials.gov (ID: NCT03381222). Written informed consent was obtained from all patients before participation.

2.1 Intervention

After the induction of general anesthesia in the operating suite, a median sternotomy and pericardiotomy were performed. An EAU examination of the ascending aorta and the aortic arch was then conducted using a Philips L15-7io linear array ultrasound probe (Philips Medical Systems, Bothell, WA, USA) enclosed in a sterile sleeve. Five standard views were recorded according to the Guidelines 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 [10]. These views included the proximal, middle, and distal portions of the ascending aorta in the short axis, and the ascending aorta and aortic arch in the long axis.

The EAU images were interpreted by two cardiac anesthesiologists certified in advanced perioperative transesophageal echocardiography. These anesthesiologists were not present in the operating room during the procedures and were blinded to the patients' clinical histories and all other variables. Prior to the study, the anesthesiologists jointly reviewed the aforementioned guidelines [10] and Katz et al.’s grading protocol for atheroma interpretation [6]. However, the two anesthesiologists independently conducted initial interpretations and were blinded to each other's assessments. Discrepancies in the classifications of aortic atheromatous plaques were reconciled through joint reevaluations based on Katz et al.’s protocol [6]. During these reappraisals, the anesthesiologists collaboratively reviewed the images, discussed their interpretations, and reached a consensus to ensure accurate and consistent final classification.

Aortic atherosclerosis was evaluated via the Katz et al. protocol [6], which employs a five-grade scale. Grade I indicates a normal-appearing aorta; grade II signifies extensive intimal thickening; grade III describes a sessile atheroma protruding less than 5.0 mm into the aortic lumen; grade IV represents an atheroma protruding more than 5.0 mm; and grade V denotes a mobile atheroma.

Additionally, the protocol developed by Dávila-Román et al. [5] was utilized to assess the clinical significance of atheromatous plaque thickness. According to their protocol, a normal aorta exhibits no intimal thickening. Mild atherosclerosis is characterized by ≤ 3.0 mm thickening without irregularities, whereas moderate atherosclerosis involves >3.0 mm thickening with irregularities or calcifications. Severe atherosclerosis is defined as > 5.0 mm of thickening accompanied by features such as protruding atheroma, thrombus, extensive calcification, or ulcerated plaques. Each aortic segment was graded based on the most severe finding identified.

Patients were classified into two groups according to the severity of their atherosclerosis. The first group included individuals with clinically nonsignificant atherosclerosis, defined as Katz grades I and II and/or meeting the Dávila-Román criteria for a normal aorta and mild atherosclerosis. The second group comprised patients with clinically significant atherosclerosis, identified as Katz grades III to V and/or adhering to the Dávila-Román protocols for moderate and severe atherosclerosis.

Demographic and clinical data were collected for each participant. These data included sex, age, body weight, height, American Society of Anesthesiologists physical status classification, smoking status, alcohol consumption, and a detailed comorbidity profile. The comorbidity profile encompassed hypertension, stroke, coronary artery disease, peripheral arterial disease, chronic obstructive pulmonary disease, renal insufficiency, and carotid artery disease. This comprehensive dataset was crucial for identifying potential risk factors contributing to the development of atheromatous plaques in the ascending aorta.

2.2 Study outcomes

The primary objective was to determine the prevalence of atheromatous plaques in the ascending aorta and the aortic arch in patients undergoing cardiac surgery. Secondary outcomes focused on identifying risk factors for the development of atheromatous plaques in these aortic regions.

2.3 Statistical analysis

On the basis of a previously reported 19.3 % incidence rate of ascending aorta atheromatous plaque [4], the initial sample size was calculated as 239 participants to achieve 95 % confidence with a 5 % margin of error. To account for a potential 5 % dropout rate, the sample size was adjusted to 250 participants, ensuring sufficient statistical power to meet the study's objectives.

The data were analyzed using IBM SPSS Statistics, version 21.0 (IBM Corp., Armonk, NY, USA). Continuous variables are presented as means ± standard deviations for normally distributed data and as medians with ranges for nonnormally distributed datasets. Group comparisons were performed via t-tests for continuous variables and chi-square tests or Fisher's exact tests for categorical variables. Multivariate stepwise (conditional) logistic regression was employed to identify key independent predictors of the presence of atheromatous plaques. Crude relative risks (RRs) and adjusted RRs were calculated using STATA. Relative risks (RRs) with 95 % confidence intervals (CIs) were calculated, with P values < 0.05 indicating statistical significance.

3 Results

EAU was successfully performed on all 239 patients, allowing detailed assessments of atherosclerosis in the ascending aorta and the aortic arch (Fig. 1). The mean age of the patients was 66.91 years (standard deviation: 8.9), with males comprising 60 % of the cohort (Table 1). The predominant surgical procedure was coronary artery bypass grafting, which was performed on 57.3 % of the patients. Notably, 36.4 % (87) of the participants had a history of smoking, whereas 6.3 % (15) reported chronic alcohol use. High prevalence rates of comorbidities were observed, with hypertension and ischemic heart disease being the most common (73.6 % and 71.5 %, respectively).Fig. 1 CONSORT diagram.

Fig. 1

Table 1 Demographic and clinical characteristics of the study population.

Table 1Parameters	Total (n = 239)	
Age, y (mean ± SD)	66.91 ± 8.9	
Sex		
 Male	144 (60)	
 Female	95 (40)	
ASA physical status classification		
 ASA III	210 (87.9)	
 ASA IV	29 (12.1)	
Body mass index, (kg/m2)		
 <18.5 kg/m2 (underweight)	17 (7.1)	
 18.5–23 kg/m2 (normal)	89 (37.2)	
 23.1–27.5 kg/m2 (overweight)	86 (36)	
 >27.5 kg/m2 (obese)	47 (19.7)	
History of alcohol consumption	15 (6.3)	
History of cigarette smoking	87 (36.4)	
Comorbidities		
 Ischemic heart disease	171 (71.5)	
 Hypertension	176 (73.6)	
 Cerebrovascular accident	35 (14.6)	
 Peripheral arterial disease	17 (7.1)	
 Carotid stenosis	5 (2.1)	
 Chronic obstructive pulmonary disease	10 (4.2)	
 Diabetes mellitus	104 (43.5)	
 Renal function		
 GFR ≥40 mg/dl	194 (81.2)	
 GFR <40 mg/dl	45 (18.8)	
Operation		
 CABG	137 (57.3)	
 CABG with other procedures	32 (13.4)	
Valvular	67 (28)	
Others	3 (1.3)	
ASA: American Society of Anesthesiologists; CABG: coronary artery bypass graft surgery; GFR: glomerular filtration rate.

The values are reported as numbers (%) or as means ± standard deviations.

Discrepancies in plaque classification occurred in 21.8 % (52/239) of the patients, with some showing inconsistent ultrasound interpretations across multiple views. Nineteen discrepancies were related to the aortic arch, 12 to the distal ascending aorta, 11 to the middle ascending aorta, 10 to the proximal ascending aorta, and 10 to the long axis view of the ascending aorta. Most classification discrepancies involved Katz grades II and III; the other Katz grades were generally consistent. All discrepancies were resolved through joint reevaluations by the anesthesiologists.

The distribution of aortic atherosclerosis varied across locations, with the highest prevalence in the aortic arch (41.4 %; Table 2). The prevalence was identical in the proximal and distal ascending aorta (33.5 %) and lower in the mid-ascending aorta (25.1 %).Table 2 Prevalence of clinically significant aortic atherosclerosis.

Table 2Aortic atherosclerosis	Incidence of clinically significant aortic atherosclerosis (%)	
 Proximal ascending aortic SAX view	80 (33.5)	
 Mid ascending aortic SAX view	60 (25.1)	
 Distal ascending aortic SAX view	80 (33.5)	
 Ascending aortic LAX view	55 (23)	
 Aortic arch LAX view	99 (41.4)	
LAX: long axis; SAX: short axis.

The values are reported as numbers (%).

Clinically nonsignificant plaque = Katz grades I and II and/or the Dávila-Román protocols for normal aorta and mild atherosclerosis. Clinically significant plaque = Katz grades III–V and/or Dávila-Román protocols for moderate and severe atherosclerosis.

Univariate analysis revealed several factors significantly associated with aortic plaque formation: age (65–80 years and >80 years), ischemic heart disease, hypertension, and carotid stenosis (Table 3). These variables, along with cerebrovascular accidents, were subjected to multiple logistic regression analyses. Advanced age (>80 years; RR 1.444, 95 % CI 1.113–1.874; P = 0.006) and carotid stenosis (RR 1.247, 95 % CI 1.04–1.495; P = 0.017) remained significant predictors of aortic plaque formation.Table 3 Correlation between the incidence of aortic atherosclerosis and associated risk factors.

Table 3Factors	Atheromatous plaque	Crude RR (95 % CI)	P	Adjusted RR (95 % CI)	P	
No (n = 88)	Yes (n = 151)	
Age (y)	
 50–64	45 (45.9)	53 (54.1)					
 65–80	41 (33.3)	82 (66.7)	1.232 (0.987–1.538)	0.064*	1.139 (0.909–1.427)	0.256	
 >80	2 (11.1)	16 (88.9)	1.643 (1.285–2.100)	0*	1.444 (1.113–1.874)	0.006*	
Sex	
 Male	51 (35.4)	93 (64.6)					
 Female	37 (38.9)	58 (61.1)	0.945 (0.772–1.156)	0.584			
Body mass index, (kg/m2)	
 <18.5 kg/m2 (underweight)	7 (41.2)	10 (58.8)					
 18.5–23 kg/m2 (normal)	34 (38.2)	55 (61.8)	0.951 (0.618–1.464)	0.822			
 23.1–27.5 kg/m2 (overweight)	34 (39.5)	52 (60.5)	0.978 (0.772–1.239)	0.857			
 >27.5 kg/m2 (obese)	13 (27.7)	34 (72.3)	1.170 (0.919–1.489)	0.201			
Smoking	30 (34.5)	57 (65.5)	1.059 (0.869–1.290)	0.567			
Alcohol consumption	4 (26.7)	11 (73.3)	1.173 (0.850–1.619)	0.331			
Heart disease	
 Ischemic heart disease	53 (31)	118 (69)	1.421 (1.090–1.853)	0.009*	1.283 (0.976–1.686)	0.074	
 Other heart disease	35 (51.5)	33 (48.5)					
Hypertension	57 (32.4)	119 (67.6)	1.331 (1.022–1.733)	0.034*	1.181 (0.9–1.55)	0.229	
Cerebrovascular accident	9 (25.7)	26 (74.3)	1.212 (0.969–1.516)	0.092	1.15 (0.923–1.432)	0.211	
Peripheral arterial disease	8 (47.1)	9 (52.9)	0.827 (0.522–1.310)	0.420			
Carotid stenosis	0	5 (100)	1.602 (1.450–1.770)	0*	1.247 (1.04–1.495)	0.017*	
Diabetes mellitus	33 (31.7)	71 (68.3)	1.152 (0.950–1.395)	0.149			
CI: confidence interval; RR: relative risk.

The values are reported as numbers (%). *P < 0.05 indicates statistical significance.

Table 4 stratifies postoperative outcomes for cardiac surgery patients on the basis of the presence of clinically significant aortic atheromatous plaques. The perioperative stroke incidence was 2 % in the significant plaque group and 0 % in the nonsignificant plaque group (P = 0.301). At 28 days after surgery, the stroke incidence was 0.7 % in the significant plaque group and 0 % in the nonsignificant plaque group (P = 1.0). The mortality rates at 28 days were 2.8 % for the significant plaque group and 2.3 % for the nonsignificant plaque group, with no statistically significant difference (P = 1.0). Although there was a trend suggesting a potential link between clinically significant plaques and perioperative stroke, this association lacked statistical significance. No significant correlations emerged for 28-day postoperative stroke or mortality.Table 4 Outcomes following cardiac surgery procedures.

Table 4Postoperative outcome	Clinically significant aortic atherosclerosis	P	
No	Yes	
Perioperative stroke	0	3 (2)	0.301	
28-day stroke	0	1 (0.7)	1	
28-day mortality	2 (2.3)	4 (2.8)	1	
The values are reported as numbers (%).

Clinically nonsignificant plaque = Katz grades I and II and/or the Dávila-Román protocols for normal aorta and mild atherosclerosis. Clinically significant plaque = Katz grades III–V and/or Dávila-Román protocols for moderate and severe atherosclerosis.

4 Discussion

Aortic atherosclerosis markedly increases morbidity and mortality in cardiopulmonary bypass patients because of the risk of plaque dislodgement during surgical procedures. The ascending aorta and aortic arch are particularly susceptible to plaque dislodgement arising from interventions such as aortic cross-clamping and aortic cannulation, as well as from the flow dynamics of the aortic cannula.

Our study revealed a 33.5 % prevalence of clinically significant atheromatous plaques in the ascending aorta and a 41.4 % prevalence in the aortic arch. Ascending aortic atheroma prevalence varies by diagnostic method and population. Western countries report lower rates: 8.8 % by preoperative angiogram [7], 11.1%–14.7 % by intraoperative transesophageal echocardiography [8], and 9.7%–19.3 % by EAU [4,11]. Asian populations have a relatively high incidence: 29 % in transesophageal echocardiography studies [9] and 33.5 % in our study. This elevated prevalence may be attributed to racial differences, as noted by Nohara et al. [9].

The higher prevalence of clinically significant atheromatous plaques observed in our study may also have resulted from the use of EAU rather than transesophageal echocardiography. EAU provides a more direct and unobstructed view of the ascending aorta, thus reducing the chance of missing atheroma due to anatomical constraints such as the position of the trachea [12,13]. A comparison of our findings with those of previous EAU studies [4,11] further supports the influence of racial differences. The comparative data suggest that people of Asian ancestry have higher atherosclerosis rates than individuals of European or African ancestry, regardless of the diagnostic method used.

This study identified advanced age and carotid stenosis as predictors of clinically significant atheromatous plaques. Hypertension and ischemic heart disease were associated with aortic atherosclerosis, but these associations were not significant in our multivariate analysis. Sex, body mass index, smoking behavior, alcohol consumption, and peripheral artery disease did not significantly correlate with ascending aortic plaque. In contrast to previous studies [[14], [15], [16]], cerebrovascular accidents lacked a statistically significant association with aortic plaque.

4.1 Advanced age

Advanced age is a significant risk factor for aortic plaque development [[17], [18], [19], [20], [21], [22]]. This association is attributed to increased cellular inflammation, heightened apoptosis, and diminished cellular function and proliferation in older individuals [17]. Moreover, the prevalence of comorbidities such as diabetes mellitus, hypertension, and dyslipidemia rises with age [18], further exacerbating plaque formation. Studies have revealed subclinical aortic plaque in nearly half of older subjects, with the incidence increasing proportionally with age [19,20]. Thus, a strong correlation exists between advancing age and the extent of atherosclerosis.

4.2 Carotid stenosis

Carotid stenosis significantly correlates with ascending aortic plaque [23], likely due to shared pathogenesis and risk factors. Kallikazaros et al. [24] reported a high prevalence of aortic and carotid plaques in cardiac patients without clinical atherosclerotic cardiovascular disease. Regression analysis identified carotid plaque as a strong predictor of aortic plaque. Additionally, carotid stenosis is associated with coronary artery plaque development [[25], [26], [27]]. Consequently, current evidence strongly links carotid stenosis with aortic plaque formation.

4.3 Ischemic heart disease

Postmortem studies by Vihert et al. [28] and McGill et al. [29] established a link between ischemic heart disease and aortic atherosclerosis. Several clinical studies have also correlated thoracic aortic atherosclerosis with coronary artery disease in transesophageal echocardiography patients [[30], [31], [32], [33], [34]]. However, our multivariate analysis of the Thai cardiac surgery cohort revealed no significant correlation between ischemic heart disease and ascending aortic plaque. This finding supports our focus on the ascending aorta and aligns with previous research indicating a weak link between ascending aortic plaque and coronary artery disease [35,36]. This discrepancy with studies that examined the entire thoracic aorta warrants further investigation.

4.4 Hypertension

Consistent with findings by Fukuda et al. [27], our multivariate analysis revealed no significant association between hypertension and ascending aortic atherosclerosis. In contrast, several studies have identified hypertension as an independent risk factor for atherosclerosis [[20], [21], [22],36]. This discrepancy may stem from the broader examination of the thoracic aorta in those studies [20,21,36], which often revealed a high plaque incidence in the descending aorta. Our study focused on the ascending aorta, highlighting the importance of anatomical specificity in evaluating the prevalence and distribution of aortic plaques.

4.5 Cerebrovascular accidents

Ascending aortic atherosclerosis is widely recognized as an independent risk factor for cerebrovascular events [4,5,20,37], indicating its role as an embolic source and a contributor to systemic atherosclerosis. However, neither univariate nor multivariate analyses in our study revealed significant associations between cerebrovascular accidents and significant ascending aortic plaque. This finding aligns with a prior study reporting only weak associations [35]. Cerebrovascular accidents have diverse etiologies beyond embolism, which may complicate the establishment of a clear association between stroke and ascending aortic plaque.

4.6 Smoking behavior

Cigarette smoking is a well-established risk factor for adverse cardiovascular outcomes [21,29,35,[38], [39], [40]]. It exacerbates oxidative stress, vascular inflammation, platelet activation, and dyslipidemia, all of which promote atherosclerosis. However, our study revealed no significant association between cigarette smoking and thoracic aortic atherosclerosis. This result may be attributed to the inclusion of both current and former smokers in our analysis, as smoking cessation was associated with a significantly lower risk of cardiovascular disease [41]. Our findings align with those of another study [36] reporting no significant connection between smoking and aortic atherosclerosis. Our results also support a prior hypothesis that atherosclerotic changes may persist for at least a decade after smoking cessation [39]. The complex relationship between smoking and atherosclerosis warrants further investigation.

4.7 Other factors

Consistent with previous research, our study revealed no significant correlations between aortic atherosclerosis and sex [19,21,22], alcohol consumption [42,43], diabetes mellitus [21,28,35,36], or body mass index [21,36,44]. Although we also observed no significant association between ascending aortic plaque and peripheral arterial disease, this lack of correlation may be attributed to the potential underdiagnosis of peripheral arterial disease in our study [45,46]. This is because our cohort primarily consisted of symptomatic patients receiving treatment. Therefore, further investigations are needed to definitively assess the potential role of peripheral arterial disease as a risk factor for ascending aortic plaque.

Our study revealed a relatively low perioperative stroke incidence of 1.25 % (3 out of 239 cardiac surgery patients), compared with the typical range of 2.61%–5.2 % [1,2]. This lower incidence may be attributable to the proactive identification of ascending aortic plaque through EAU, enabling surgeons to adjust the aortic cannula insertion points and minimize plaque disruption.

The early detection of atherosclerotic plaques via techniques such as EAU and CTA is crucial for enhancing clinical decision-making and disease management. By enabling accurate patient stratification and the tailoring of surgical approaches, these imaging modalities can minimize plaque embolization and reduce the risk of perioperative stroke.

While the REGROUP trial by Shapeton et al. [47] found no significant difference in stroke rates with the use of EAU, it underscored the importance of EAU in guiding surgical decision-making. By identifying heavily diseased aortic segments, EAU enables surgeons to avoid unnecessary manipulation and potential plaque disruption. Similarly, Hangler et al. [48] demonstrated that modifying surgical techniques on the basis of EAU findings, such as the use of single cross-clamping or no-touch techniques, can mitigate stroke risk in high-risk patients.

Advanced imaging modalities such as EAU and CTA substantially impact perioperative outcomes. For example, CTA has proven effective in detecting thoracic aortic plaques, which are associated with increased long-term mortality following cardiothoracic surgery [49,50]. High-pitch CTA offers a non-invasive means of assessing atherosclerotic plaques in the ascending aorta, facilitating risk stratification and surgical planning to reduce perioperative stroke rates [51]. Integrating advanced imaging techniques into clinical practice enhances surgical planning, risk assessment, and patient outcomes by reducing perioperative complications and promoting smoother recovery.

5 Limitations of the study

This study's small sample size and short follow-up duration limit the ability to definitively determine the long-term prognostic value of aortic atherosclerosis for predicting stroke or mortality. Additionally, differences in sensitivity between EAU and CTA may limit the generalizability of our findings. Potential confounding factors and variability in ultrasound interpretation could also have influenced the results.

Future research with larger, multicenter cohorts and longer follow-up periods is necessary to validate our findings and fully elucidate the prognostic significance of aortic atherosclerosis in cardiac surgery patients. Such investigations should evaluate whether clinically significant aortic plaques can predict stroke or mortality, thereby informing routine preoperative imaging recommendations.

6 Conclusions

Our study underscores the prevalence of atheromatous plaques in the ascending aorta and aortic arch among Thai cardiac surgery patients, identifying advanced age and carotid stenosis as significant risk factors. Consequently, preoperative aortic imaging, such as CTA or EAU, should be applied to cardiac surgery candidates. When imaging resources are limited, prioritizing their use in elderly patients or those with carotid stenosis is advisable. While the statistical significance of the observed differences in stroke rates may be debatable, the early detection of aortic atheromatous plaques through advanced imaging techniques has a crucial practical impact. These methods facilitate surgical planning and execution, ultimately improving patient outcomes. Future research should explore the impact of aortic atheromatous plaque in diverse patient populations and refine strategies for minimizing perioperative complications.

Ethics approval statement

The study protocol was authorized by the Siriraj Institutional Review Board (approval number: Si 151/2018; approval date: March 13, 2018). All patients provided written informed consent.

Funding

The study was supported by the Siriraj Research Development Fund (IO: R016132029), 10.13039/501100013238 Faculty of Medicine Siriraj Hospital, Mahidol University , Bangkok, Thailand. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data availability statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

CRediT authorship contribution statement

Chaowanan Khamtuikrua: Conceptualization, Methodology, Formal analysis, Project administration, Data curation, Writing – original draft, Writing – review & editing. Nophanan Chaikittisilpa: Data curation. Sirilak Suksompong: Conceptualization, Methodology, Project administration, Writing – review & editing. Worawong Slisatkorn: Data curation. Nattaya Raykateeraroj: Conceptualization, Methodology, Formal analysis, Project administration, Data curation, Writing – original draft, Writing – review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

We extend our gratitude to Assistant Professor Chulaluk Komoltri, statistician at the Division of Clinical Epidemiology, Faculty of Medicine Siriraj Hospital, Mahidol University, for her expert assistance with the data analysis and insightful advice on data interpretation. We also thank Ms. Chusana Rungjindamaifor, a research assistant in the Department of Anesthesiology, and Ms. Chayanan Thanakiattiwibun, a research assistant in the Integrated Perioperative Geriatric Excellence Research Center, Faculty of Medicine Siriraj Hospital, Mahidol University, for their invaluable administrative contributions. Further appreciation is extended to the surgeons in the Division of Cardio-Thoracic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, for their significant contributions to this research.
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