Cath Conference Cardiology Echo Conference Aortic Diseases

Aortic Diseases Introduction ASE – Chamber Quanification Guidelines ACC/AHA/ATS – Diagnosis and Management Guidelines

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Aortic Diseases blank Abstract Two-dimensional echocardiography is increasingly used to measure aortic root dimensions, which provide prognostic information in aortic regurgitation and the Marfan syndrome. Aortic root dilatation is currently detected by nomograms based on M-mode echocardiographic data. Aortic root diameters measured by 2-dimensional echocardiography at the anulus, sinuses of Valsalva, supra-aortic ridge and proximal ascending aorta in 135 normal adults and 52 normal children were compared with age, gender, body habitus, blood pressure and stroke volume, and with M-mode findings and normal limits. Two-dimensional measurements at the sinuses of Valsalva were larger than M-mode aortic root values (p less than 0.001), and use of 2-dimensional values with M-mode nomograms falsely diagnosed aortic dilatation in 40% of normal children and 19% of normal adults. Two-dimensional measurements at the sinuses closely correlated with body surface area in children (r = 0.93, p less than 0.0005), moderately in adults younger than 40 years of age (r = 0.71, p less than 0.0005) and weakly in older adults (r = 0.40, p less than 0.0005). In adults, gender influenced aortic root size at all levels (p less than 0.001), but dimensions were similar when indexed for body surface area. Age strongly influenced supraaortic ridge and ascending aortic diameters; blood pressure and stroke volume had no independent effect on aortic size. In conclusion, (1) 2-dimensional echocardiographic aortic root dimensions are influenced by age and body size but not by blood pressure; (2) aortic root dilatation is overdiagnosed when aortic diameter at the sinuses of Valsalva is compared with M-mode nomograms; (3) nomograms comparing aortic diameter with body surface area should be used in children; and (4) although use of nomograms based on body size in adults should maximize sensitivity for aortic dilatation, 98% specificity is attained by use of an upper normal limit of 2.1 cm/m2 for aortic diameter at the sinuses of Valsalva in both men and women.

Aortic Diseases Ao diameter PSLAX 2D v M-mode @ Sinus of Vals Perpendicular RPSV in RLD SSN Recordings should be made from the parasternal long-axis acoustic window to visualize the aortic root and proximal ascending aorta. Two-dimensional images should be used to visualize the LV outflow tract and the aortic root should be recorded in different views in varying intercostal spaces and at different distances from the left sternal border. Right parasternal views, recorded with the patient in a right lateral decubitus position, are also useful. Measurements are usually taken at: (1) aortic valve annulus (hinge point of aortic leaflets); (2) the maximal diameter in the sinuses of Valsalva; and (3) sinotubular junction (transition between the sinuses of Valsalva and the tubular portion of the ascending aorta).

Aortic Diseases Some experts favor inner edge to inner edge techniques to match those used by other methods of imaging the aorta, such as MRI and computed tomography scanning. However, the normative data for echocardiography were obtained using the leading edge technique

Aortic Diseases TEE Ascending 130 ME-LA 45 ME-SA Descending 0-SA 90-LA Blind spot Upper AsAo trachea The thoracic aorta can be better imaged using TEE than TTE, as most of it is in the near field of the Journal of the American Society of Echocardiography Volume 18 Number 12 Lang et al 1457 transducer. The ascending aorta can be seen in long axis using the midesophageal aortic valve long-axis view at about 130 degrees and the midesophageal ascending aorta long-axis view. The short-axis view of the ascending aorta is obtained using the midesophageal views at about 45 degrees. For measurements of the descending aorta, short-axis views at about 0 degrees, and long-axis views at about 90 degrees, can be recorded from the level of the diaphragm up to the aortic arch (Figure 19). The arch itself and origins of two of the great vessels can be seen in most patients. There is a blind spot in the upper ascending aorta and the proximal arch that is not seen by TEE because of the interposed tracheal bifurcation.

Aortic Diseases Definitions Aneurysm >50% increase in diameter vs normal Ectasia dilation less than 150% Aortic Dissection disruption of media layer with bleeding Aneurysm (or true aneurysm): a permanent localized dilatation of an artery, having at least a 50% increase in diameter compared with the expected normal diameter of the artery in question. Although all 3 layers (intima, media, and adventitia) may be present, the intima and media in large aneurysms may be so attenuated that in some sections of the wall they are undetectable. Pseudoaneurysm (or false aneurysm): contains blood resulting from disruption of the arterial wall with extravasation of blood contained by periarterial connective tissue and not by the arterial wall layers (see Section 8.4). Such an extravascular hematoma that freely communicates with the intravascular space is also known as a pulsating hematoma (8–10). Ectasia: arterial dilatation less than 150% of normal arterial diameter. Arteriomegaly: diffuse arterial dilatation involving several arterial segments with an increase in diameter greater than 50% by comparison to the expected normal arterial JACC Vol. 55, No. 14, 2010 Hiratzka et al. e35 April 6, 2010:e27–129 2010 Guidelines on Thoracic Aortic Disease Thoracoabdominal aneurysm (TAA): aneurysm involving the thoracic and abdominal aorta (see Section 9.2.2.3). Abdominal aortic aneurysm (AAA): aneurysm involving the infradiaphragmatic abdominal aorta. Aortic dissection (AoD): disruption of the media layer of the aorta with bleeding within and along the wall of the aorta. Dissection may, and often does, occur without an aneurysm being present. An aneurysm may, and often does, occur without dissection. The term “dissecting aortic aneurysm” is often used incorrectly and should be reserved only for those cases where a dissection occurs in an aneurysmal aorta (see Section 8.1).

Aortic Diseases Ao Image Recs class I Same landmaks CT/MRI external diameter Echo internal diameter Abnl immediate referral Minimize radiation

Aortic Diseases Echo Ascending Ao Nomogram Thoracic Ao absolute In general, TEE is superior to TTE for assessment of the thoracic aorta. Through the use of multiplane image acquisition, 3-dimensional Doppler TEE is safe and can be performed at the bedside, with a low risk of complications (less than 1% overall, less than 0.03% for esophageal perforation), most of which are related to conscious sedation (69,70). Reconstruction of the aorta can be performed.

Aortic Diseases Aortic Dissection

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Aortic Diseases DeBakey Stanford I – originates in ascending Ao to arch II – confined to ascending Ao IIIa – descending Ao IIIb – descending Ao w/ extension below diaphragm Stanford A – Ascending Ao B – No Ascending Ao involvement

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Aortic Diseases Penetrating Atherosclerotic Ulcer Penetrates the internal elastic lamina Allows hematoma formation within the media Ao wall Mushroom-like outpouching Elderly >65 y/o, HTN, chest or back pain

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Aortic Diseases Methods. Specialized statistical methods were applied to the prospectively accumulated database of 1600 patients with thoracic aneurysm and dissection, which includes 3000 serial imaging studies and 3000 patient years of follow-up.

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Aortic Diseases Marfan and Pregnancy Strict BP control Monthly or bimonthly echo Avoid CTs Delivery with CT surg available

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