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
Advantages:

test for suspected AAS

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?

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

Examples of IMH

Pics from Evangelista, et al. Eur J Echocardiogr 2010, Flachskampf, FA. Seminars in Cardiothoracic and Vascular

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.