1. Cath Conference
Cardiology
Echo Conference
Aortic Diseases

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

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4. 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 ), moderately in adults younger than 40 years of age (r = 0.71, p less than ) and weakly in older adults (r = 0.40, p less than ). 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.

5. 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).

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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

7. 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.

8. 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– Guidelines on Thoracic Aortic Disease
Thoracoabdominal aneurysm (TAA): aneurysm involving
the thoracic and abdominal aorta (see Section ).
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).

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

10. 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.

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Aortic Dissection

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Aortic Dissection

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17. 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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23. 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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28. 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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32. Aortic Diseases Marfan and Pregnancy Strict BP control
Monthly or bimonthly echo
Avoid CTs
Delivery with CT surg available

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35. Questions

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