echocardiographic evaluation of acute aortic syndromes kyle stribling, md echo conference 4/20/11
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Echocardiographic Echocardiographic Evaluation of Acute Aortic Evaluation of Acute Aortic Syndromes Syndromes
Kyle Stribling, MDEcho Conference 4/20/11
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Acute Aortic SyndromeAcute Aortic SyndromeDefinition:
◦ 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
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Aortic DissectionAortic 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
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Intramural HematomaIntramural HematomaRupture of vasa vasorum or plaque collection of blood in media w/o intimal tear May extend toward lumen and lead to dissectionHigh rate of ruptureAscending aorta IMHs are surgical
Pics from google images
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Penetrating atherosclerotic Penetrating atherosclerotic ulcerulcerErosion of intimal plaque into
mediaMay lead to IMH, dissection,
aneurysm, or rupture
Pics from google images
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Echo AlgorithmEcho Algorithm
Meredith EL and Masani ND. Eur J Echocardiogr 2009.
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Role of TTERole of TTEReasonable acute test for suspected AASAdvantages:
◦ 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?
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TTE ViewsTTE Views
Additional viewsModified PS and apical 2c views to see descending aoRight or high left parasternal views to eval ascending ao
Evangelista, et al. Eur J Echocardiogr 2010.
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Role of TEERole of TEEAdvantages: 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
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TEE ViewsTEE Views
Evangelista, et al. Eur J Echocardiogr 2010.
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Examples of AD by TTEExamples of AD by TTE
Evangelista, et al. Eur J Echocardiogr 2010.
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Examples of AD by TEEExamples of AD by TEE
Meredith EL and Masani ND. Eur J Echocardiogr 2009.
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Examples of AD by TEEExamples of AD by TEE
Flachskampf, FA. Seminars in Cardiothoracic and Vascular Anesthesia 2006.
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True vs. False LumenTrue vs. False Lumen
Evangelista, et al. Eur J Echocardiogr 2010.
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True vs. False LumenTrue vs. False Lumen
Flachskampf, FA. Seminars in Cardiothoracic and Vascular Anesthesia 2006.
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Examples of IMHExamples 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
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Examples of IMHExamples of IMH
Pics from google images
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Examples of PAUExamples of PAU
Pics from Meredith EL and Masani ND. Eur J Echocardiogr 2009 and Evangelista, et al. Eur J Echocardiogr 2010.
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Cases
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Mr. BWMr. BW47 yo male presents with inferior
STEMI. Unable to engage RCA in cath lab
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Ms. FSMs. FS81 yo WF transferred to ICU for
possible Ao dissection on CT at OSH
c/o abd pain, N/V, diarrhea
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Ms. GCMs. GC53 yo female with cath
complication when attempting RCA intervention
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Ms. JEMs. JE49 yo female with evidence of
Type B dissection on CTEcho ordered to eval for effusion
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Mr. KBMr. KB34 yo male s/p Ao root repair
presents with severe CPMRI showed mediastinal
hematoma
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Mr. MKMr. MK71 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
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Ms. PHMs. PH35 yo female with Hx traumatic
Ao dissection of descending Ao presented w/ sudden onset CP after cocaine use
PE unremarkableCXR widened mediastinum
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Mr. XDMr. XD58 yo male s/p cardiac arrestLM dissection in cath lab after LM
PCIEcho ordered to eval for
retrograde extension of dissection into proximal aorta
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ReferencesReferencesKayser, 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.