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==Overview==
==Overview==
In the management of the [[acute]] patient with suspected [[aortic]] dissection, a [[TEE|transesophageal echo]] performed [[acute]]ly in the emergency room is the preferred approach. If the patient is [[hemodynamic]]ally unstable, then a [[TEE|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 ==
== Echocardiography ==
 
===Transthoracic 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 (medical)|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 aorta|ascending aortic]] dissection, and to determine whether the [[ostium|ostia]] (origins) of the [[coronary artery|coronary arteries]] are involved.
The echocardiographic changes diagnostic of aortic dissection include:
*While many institutions give [[sedation]] during [[TEE|transesophageal echocardiography]] for added patient-comfort, it can be performed in cooperative individuals without the use of [[sedation]].
* Intimal flaps in the aorta
*Disadvantages of the [[TEE]] include the inability to visualize the [[distal]] [[ascending aorta]] (the beginning of the [[aortic arch]]), and the [[descending aorta|descending abdominal aorta]] that lies bellow the [[stomach]]. A [[TEE]] may be technically difficult to perform in individuals with [[esophageal stricture]]s or [[varices]].
* Obstruction of a false lumen
*[[TTE|Transthoracic (TTE)]] unfortunately does not provide good images of the [[distal]] [[ascending aorta|ascending]], transverse and [[descending aorta]] in a small number of patients. Its use is limited to assess [[cardiac]] [[complication]]s of dissection including [[AI]], [[tamponade]] and [[LV function]].
* Intimal calcification displacement toward the center of the lumen
*[[TEE|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 lumen]]s, the [[intima]]l flap, [[thrombosis]] in the [[false lumen]], [[pericardial effusion]], [[AI]], and the [[proximal]] [[coronary artery|coronaries]].
* Separation of intimal layers from the thrombus
*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% [[sensitivity|sensitive]] and 95% [[specificity|specific]] for [[aortic]] dissection.
* Shearing of different wall layers during aortic pulsation
*In general, it is recommended to perform bedside multiplane [[TEE]] in patients with [[acute]] [[symptom]]s or clinically unstable, and [[MRI]] in patients with a more [[chronic]] presentation if they are [[hemodynamic]]ally stable.
The sensitivity and specificity of transthoracic echocardiography vary based on the type of dissection and are usually lower for the diagnosis of distally located aortic dissection.<br>
*[[CT]] [[angiography]] is reserved for patients whom [[TEE]] or [[MRI]] is unavailable or contraindicated. [[Aortography]] is required if the tests listed above are non-diagnostic.
Echocardiography may also show pleural effusion, which may be suggestive of the development of cardiac tamponade.
 
===Transesophageal Echocardiography===
Transesophageal echocardiography may be useful in the diagnosis of aortic dissection in patients in whom transthoracic echocardiography has limited efficacy. Findings associated
*Sensitivity is usually higher (99%). However, it has limited usage in the diagnosis of dissections involving the distal portion of ascending aorta.  
==Echocardiography Examples of Aortic dissection==
==Echocardiography Examples of Aortic dissection==
{|align="center"
{|align="center"
|-
|-
|[[Image:Aortic dissection - Echocardiogram - Longitudinal view.jpg|420px|thumb|left|[[Echocardiogram]] of an [[aortic]] dissection]] || [[Image:Aortic dissection - Echocardiogram - Longitudinal view - Color.jpg|420px|thumb|left|[[Echocardiogram]] of an [[aortic]] dissection]]
|[[Image:Aortic dissection - Echocardiogram - Longitudinal view.jpg|420px|thumb|left|[[Echocardiogram]] of an [[aortic]] dissection]] || [[Image:Aortic dissection - Echocardiogram - Longitudinal view - Color.jpg|420px|thumb|left|[[Echocardiogram]] of an [[aortic]] dissection]]
|}
|}
===Aortic Dissection===
===Aortic Dissection===
{|align="center"
{|align="center"

Revision as of 17:37, 14 December 2019

Aortic dissection Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Aortic dissection from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Special Scenarios

Management during Pregnancy

Case Studies

Case #1


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] Sahar Memar Montazerin, M.D.[3]

Overview

Echocardiography

Transthoracic Echocardiography

The echocardiographic changes diagnostic of aortic dissection include:

  • Intimal flaps in the aorta
  • Obstruction of a false lumen
  • Intimal calcification displacement toward the center of the lumen
  • Separation of intimal layers from the thrombus
  • Shearing of different wall layers during aortic pulsation

The sensitivity and specificity of transthoracic echocardiography vary based on the type of dissection and are usually lower for the diagnosis of distally located aortic dissection.
Echocardiography may also show pleural effusion, which may be suggestive of the development of cardiac tamponade.

Transesophageal Echocardiography

Transesophageal echocardiography may be useful in the diagnosis of aortic dissection in patients in whom transthoracic echocardiography has limited efficacy. Findings associated

  • Sensitivity is usually higher (99%). However, it has limited usage in the diagnosis of dissections involving the distal portion of ascending aorta.

Echocardiography Examples of Aortic dissection

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}}

2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases (DO NOT EDIT)[1]

Diagnostic Value of Echocardiography in the Diagnosis of Aortic Dissection

Class I
"Initial recommended imaging study for the diagnosis of acute aortic syndrome is transthoracic echocardiography. (Level of Evidence: C)"
Class IIa
"In stable patients, transoesophageal echocardiography is the recommended imaging study. (Level of Evidence: C)"


2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease (DO NOT EDIT)[2]

Screening Tests (DO NOT EDIT)[2]

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)[2]

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)"

References

  1. ↑ Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ (November 2014). "2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC)". Eur. Heart J. 35 (41): 2873–926. doi:10.1093/eurheartj/ehu281. PMID 25173340.
  2. ↑ 2.0 2.1 2.2 Hiratzka LF, Bakris GL, Beckman JA; et al. (2010). "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine". Circulation. 121 (13): e266–369. doi:10.1161/CIR.0b013e3181d4739e. PMID 20233780. Unknown parameter |month= ignored (help)

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