Echocardiographic Evaluation of Acute Aortic Syndromes

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Echocardiographic Evaluation of
Acute Aortic Syndromes
Kyle Stribling, MD
Echo Conference 4/20/11
Acute Aortic Syndrome

Definition:
◦ Describes a collection of life-threatening acute injuries to
aorta

Types:
◦
◦
◦
◦

Aortic dissection (AD)
Intramural hematoma (IMH)
Penetrating atherosclerotic ulcer (PAU)
Traumatic transection
Consequences:
◦ Death caused by Ao rupture or associated mechanical
complications
◦ Type A AD mortality increases 1-2%/hr for first 48 hrs after
presentation
◦ Other AAS have increased mortality also
Aortic Dissection


pressures at
intima cause
tearing  false +
lumen that may
propagate
Locations:
◦ 65% occur w/in
3 cm coronary
ostia
◦ 10% occur in
arch
◦ 10% occur in descending thoracic Ao

Classifications:
◦ Type A: ascending Ao (surgical)
◦ Type B: not involving ascending Ao (nonsurgical)
Pics from google images
Intramural Hematoma




Rupture of vasa
vasorum or
plaque 
collection of blood
in media w/o
intimal tear
May extend toward
lumen and lead to dissection
High rate of rupture
Ascending aorta IMHs are surgical
Pics from google images
Penetrating atherosclerotic ulcer
Erosion of intimal plaque into media
 May lead to IMH, dissection, aneurysm, or
rupture

Pics from google images
Echo Algorithm
Meredith EL and Masani ND. Eur J Echocardiogr 2009.
Role of TTE


Reasonable acute test for suspected AAS
Advantages:
◦ Rapid and noninvasive
◦ May be diagnostic (78-100% sensitive for Type A)
◦ Clues to AAS







Bicuspid Ao valve
Acute AI
Dilated Ao root
Pericardial effusion
WMA
May rule in or out other diff diagnoses
Disadvantages
◦ Relatively poor sensitivity (59-83%) and specificity (6393%), particularly for Type B dissection (31-55%)
◦ Distinguish etiology and extent?
TTE Views
Additional views
Modified PS and apical 2c views to see descending ao
Right or high left parasternal views to eval ascending ao
Evangelista, et al. Eur J Echocardiogr 2010.
Role of TEE

Advantages: Ideal Dx test for AAS
◦
◦
◦
◦
Safe
Fast
Bedside exam or in OR w/o transport
Identifies extent and etiology of injury and associated
complications
◦ Sensitive (94-100%) and specific (77-100%)
◦ Meta analysis by Shiga, et al 2006
 TEE, Helical CT, and MRI had 100% sensitivity and specificity

Disadvantages:
◦ Invasive
◦ Sedation
◦ TEE “blindspot” -- trachea between esophagus and upper
ascending aorta
TEE Views
Evangelista, et al. Eur J Echocardiogr 2010.
Examples of AD by TTE
Evangelista, et al. Eur J Echocardiogr 2010.
Examples of AD by TEE
Meredith EL and Masani ND. Eur J Echocardiogr 2009.
Examples of AD by TEE
Flachskampf, FA. Seminars in Cardiothoracic and Vascular Anesthesia 2006.
True vs. False Lumen
Evangelista, et al. Eur J Echocardiogr 2010.
True vs. False Lumen
Flachskampf, FA. Seminars in Cardiothoracic and Vascular Anesthesia 2006.
Examples of IMH
Pics from Evangelista, et al. Eur J Echocardiogr 2010, Flachskampf, FA. Seminars in Cardiothoracic and Vascular Anesthesia 2006, and Meredith EL
and Masani ND. Eur J Echocardiogr 2009
Examples of IMH
Pics from google images
Examples of PAU
Pics from Meredith EL and Masani ND. Eur J Echocardiogr 2009 and Evangelista, et al. Eur J Echocardiogr 2010.
Cases
Mr. BW

47 yo male presents with inferior STEMI.
Unable to engage RCA in cath lab
Ms. FS
81 yo WF transferred to ICU for possible
Ao dissection on CT at OSH
 c/o abd pain, N/V, diarrhea

Ms. GC

53 yo female with cath complication when
attempting RCA intervention
Ms. JE
49 yo female with evidence of Type B
dissection on CT
 Echo ordered to eval for effusion

Mr. KB
34 yo male s/p Ao root repair presents
with severe CP
 MRI showed mediastinal hematoma

Mr. MK
71 yo male with Hx Type A dissection s/p
Ao root replacement, mechanical AVR,
and arch repair with bacteremia
 Echo ordered to r/o endocarditis

Ms. PH
35 yo female with Hx traumatic Ao
dissection of descending Ao presented w/
sudden onset CP after cocaine use
 PE unremarkable
 CXR widened mediastinum

Mr. XD
58 yo male s/p cardiac arrest
 LM dissection in cath lab after LM PCI
 Echo ordered to eval for retrograde
extension of dissection into proximal
aorta

References
Kayser, et al. Circumferential Involvement of an Acute
Type B Aortic Dissection. J Am Soc Echocardiogr
2007;20:1416.e7-1416.e11.
 Flachskampf, FA. Assessment of Aortic Dissection and
Hematoma. Seminars in Cardiothoracic and Vascular
Anesthesia 2006;10(1):83-88
 Meredith EL and Masani ND. Echocardiography in the
emergency assessment of acute aortic syndromes.
Eur J Echocardiogr 2009;10:i31-i39.
 Evangelista, et al. Echocardiography in aortic diseases:
EAE recommendations for clinical practice. Eur J
Echocardiogr 2010;11:645-658.

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