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Echocardiographic Evaluation of Acute Aortic Syndromes

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)

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Echocardiographic Evaluation of Acute Aortic Syndromes

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

  2. 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

  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 • 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

  27. 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

  28. 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.

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