Echocardiographic Evaluation of Acute Aortic Syndromes

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Echocardiographic Evaluation of Acute Aortic
Syndromes

• Kyle Stribling, MD
• Echo Conference 4/20/11

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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

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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
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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
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Penetrating atherosclerotic ulcer

• Erosion of intimal plaque into media
• May lead to IMH, dissection, aneurysm, or rupture

Pics from google images
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Echo Algorithm
Meredith EL and Masani ND. Eur J Echocardiogr
2009.
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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 (63-93), particularly for Type B
  dissection (31-55)
• Distinguish etiology and extent?

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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.
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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

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TEE Views
Evangelista, et al. Eur J Echocardiogr 2010.
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Examples of AD by TTE
Evangelista, et al. Eur J Echocardiogr 2010.
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Examples of AD by TEE
Meredith EL and Masani ND. Eur J Echocardiogr
2009.
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Examples of AD by TEE
Flachskampf, FA. Seminars in Cardiothoracic and
Vascular Anesthesia 2006.
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True vs. False Lumen
Evangelista, et al. Eur J Echocardiogr 2010.
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True vs. False Lumen
Flachskampf, FA. Seminars in Cardiothoracic and
Vascular Anesthesia 2006.
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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
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Examples of IMH
Pics from google images
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Examples of PAU
Pics from Meredith EL and Masani ND. Eur J
Echocardiogr 2009 and Evangelista, et al. Eur J
Echocardiogr 2010.
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• Cases

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Mr. BW

• 47 yo male presents with inferior STEMI. Unable
  to engage RCA in cath lab

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Ms. FS

• 81 yo WF transferred to ICU for possible Ao
  dissection on CT at OSH
• c/o abd pain, N/V, diarrhea

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Ms. GC

• 53 yo female with cath complication when
  attempting RCA intervention

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Ms. JE

• 49 yo female with evidence of Type B dissection
  on CT
• Echo ordered to eval for effusion

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Mr. KB

• 34 yo male s/p Ao root repair presents with
  severe CP
• MRI showed mediastinal hematoma

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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

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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

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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

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References

• Kayser, et al. Circumferential Involvement of an
  Acute Type B Aortic Dissection. J Am Soc
  Echocardiogr 2007201416.e7-1416.e11.
• Flachskampf, FA. Assessment of Aortic Dissection
  and Hematoma. Seminars in Cardiothoracic and
  Vascular Anesthesia 200610(1)83-88
• Meredith EL and Masani ND. Echocardiography in
  the emergency assessment of acute aortic
  syndromes. Eur J Echocardiogr 200910i31-i39.
• Evangelista, et al. Echocardiography in aortic
  diseases EAE recommendations for clinical
  practice. Eur J Echocardiogr 201011645-658.