1. Echocardiographic Evaluation of Acute Aortic Syndromes
Kyle Stribling, MD
Echo Conference 4/20/11

2. Acute Aortic Syndrome Definition: Types: Consequences:
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

3. 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

4. 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

5. Penetrating atherosclerotic ulcer
Erosion of intimal plaque into media
May lead to IMH, dissection, aneurysm, or rupture
Pics from google images

6. Echo Algorithm
Meredith EL and Masani ND. Eur J Echocardiogr 2009.

7. 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?

8. 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.

9. Role of TEE Advantages: Ideal Dx test for AAS Disadvantages: 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

10. TEE Views
Evangelista, et al. Eur J Echocardiogr 2010.

11. Examples of AD by TTE
Evangelista, et al. Eur J Echocardiogr 2010.

12. Examples of AD by TEE
Meredith EL and Masani ND. Eur J Echocardiogr 2009.

13. Examples of AD by TEE
Flachskampf, FA. Seminars in Cardiothoracic and Vascular Anesthesia 2006.

14. True vs. False Lumen
Evangelista, et al. Eur J Echocardiogr 2010.

15. True vs. False Lumen
Flachskampf, FA. Seminars in Cardiothoracic and Vascular Anesthesia 2006.

16. 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

17. Examples of IMH
Pics from google images

18. Examples of PAU
Pics from Meredith EL and Masani ND. Eur J Echocardiogr 2009 and Evangelista, et al. Eur J Echocardiogr 2010.

19. Cases

20. Mr. BW
47 yo male presents with inferior STEMI. Unable to engage RCA in cath lab

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

22. Ms. GC
53 yo female with cath complication when attempting RCA intervention

23. Ms. JE 49 yo female with evidence of Type B dissection on CT
Echo ordered to eval for effusion

24. Mr. KB 34 yo male s/p Ao root repair presents with severe CP
MRI showed mediastinal hematoma

25. 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

26. 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

29. 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

30. References
Kayser, et al. Circumferential Involvement of an Acute Type B Aortic Dissection. J Am Soc Echocardiogr 2007;20:1416.e 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: