Aortic dissection echocardiography

Aortic dissection Microchapters
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Case #1

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

In the management of the acute patient with suspected aortic dissection, a transesophageal echo performed acutely in the emergency room is the preferred approach. If the patient is hemodynamically unstable, then a transesophageal echo can be performed in the operating room as the patient after the patient has been induced and is being prepared for surgery.

Echocardiography

• The transesophageal echocardiogram (TEE) is a relatively good test in the diagnosis of aortic dissection, with a sensitivity of up to 98% and a specificity of up to 97%. It is a relatively non-invasive test, requiring the individual to swallow the echocardiography probe. It is especially good in the evaluation of AI in the setting of ascending aortic dissection, and to determine whether the ostia (origins) of the coronary arteries are involved.
• While many institutions give sedation during transesophageal echocardiography for added patient-comfort, it can be performed in cooperative individuals without the use of sedation.
• Disadvantages of the TEE include the inability to visualize the distal ascending aorta (the beginning of the aortic arch), and the descending abdominal aorta that lies bellow the stomach. A TEE may be technically difficult to perform in individuals with esophageal strictures or varices.
• Transthoracic (TTE) unfortunately does not provide good images of the distal ascending, transverse and descending aorta in a small number of patients. Its use is limited to assess cardiac complications of dissection including AI, tamponade and LV function.
• Transesophageal (TEE), however, is a portable technique that can be brought to the emergency department and establish a diagnosis in < 5 minutes of starting the test. It can identify true and false lumens, the intimal flap, thrombosis in the false lumen, pericardial effusion, AI, and the proximal coronaries.
• Although monoplane TEE has a sensitivity of 98%, its specificity is only 77%. This can be increased to a sensitivity and specificity of 99% and 98% respectively with combined use of TTE and TEE. Biplane and multiplane imagine however have been shown to be 98% sensitive and 95% specific for aortic dissection.
• In general, it is recommended to perform bedside multiplane TEE in patients with acute symptoms or clinically unstable, and MRI in patients with a more chronic presentation if they are hemodynamically stable.
• CT angio is reserved for patients whom TEE or MRI is unavailable or contraindicated. Aortography is required if the tests listed above are non-diagnostic.

Echocardiography Images

Echocardiogram of an aortic dissection

Echocardiogram of an aortic dissection

Aortic Dissection

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Aortic Dissection Type A

Example 1	{{#ev:googlevideo|-1580944144837691434}}	Example 2	{{#ev:googlevideo|-3610218405615821421}}
Example 3	{{#ev:googlevideo|-8461290621229660122}}	Example 4	{{#ev:googlevideo|-8561147882050584609}}
Example 5	{{#ev:googlevideo|2157100999251300976}}	Example 6	{{#ev:googlevideo|698950344523479477}}

Aortic Dissection Type B

Example 1	{{#ev:googlevideo|3238725821918795498}}	Example 2	{{#ev:googlevideo|197658671308723787}}

2010 ACC/ AHA Guideline Recommendations: Evaluation and Management of Acute Thoracic Aortic Disease (DO NOT EDIT)

Screening Tests for Aortic Dissection (DO NOT EDIT)

Class I

"1. Urgent and definitive imaging of the aorta using transesophageal echocardiogram, computed tomographic imaging, or magnetic resonance imaging is recommended to identify or exclude thoracic aortic dissection in patients at high risk for the disease by initial screening (Level of Evidence: B)"

Determining the Presence and Progression of Thoracic Aortic Disease (DO NOT EDIT)

Class I

"1. Measurements of aortic diameter should be taken at reproducible anatomic landmarks, perpendicular to the axis of blood flow, and reported in a clear and consistent format. (Level of Evidence: C) "

"2. For measurements taken by echocardiography, the internal diameter should be measured perpendicular to the axis of blood flow. For aortic root measurements, the widest diameter, typically at the mid sinus level, should be used. (Level of Evidence: C)"

"3. Abnormalities of aortic morphology should be recognized and reported separately even when aortic diameters are within normal limits. (Level of Evidence: C)"