diseases of the aorta - american society of echocardiography › wp-content › uploads › 2016 ›...
TRANSCRIPT
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Diseases of the Aorta
Natesa G. Pandian
No disclosures
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A 69 year old woman with h/o HTN, hyperlipidemia and CAD
presented to the ED with 3 days of back pain. Other than a BP
of 168/96 mm Hg her physical exam was unremarkable. EKG
revealed LVH and strain. CXR and TTE were normal. A TEE
was performed to exclude dissection. Ascending aorta and
arch were normal.
TEE shows:
1) Normal aorta
2) Intramural hematoma
3) Penetrating aortic ulcer
4) Clotted dissection
Pre-Lecture Question 1
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This pulsed Doppler recording of distal
thoracic aorta is seen in:
1) Normal aorta
2) Intramural hematoma
3) Penetrating aortic ulcer
4) Clotted dissection
Pre-Lecture Question 2
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Pre-Lecture Question 2
The most likely
interpretation is:
1) Artefact
2) Dissection flap
3) Linear thrombus
4) A catheter in the aorta
Movie
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Aortic Dissection
Aortic Aneurysm
Penetrating Ulcer
Aortic Trauma
Aortic Atheroma
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Imaging ofthe Aorta
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Suprasternal
View
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Aorticannulus
Upper limit Mean+/-SD
3.12.6+/-0.3
1.61.3+/-0.1
2.62.3+/-O.2
1.61.3+/-0.1
Sinus of Valsalva
Upper limit Mean+/-SD
43.4+/-0.3
2.11.7+/-0.2
3.63.0+/-0.3
2.11.8+/-0.2
Supra-aortic ridge
Upper limit Mean+/-SD
3.62.9+/-0.3
1.91.5+/-0.2
3.22.6+/-0.3
1.91.5+/-0.2
Prox Asc Ao Upper limit Mean+/-SD
3.7-3.83.0+/-0.4 1.5+/-0.2
3.7-3.82.7+/-0.4 1.6+/-0.3
Absolute cm
Index cm/m2
Absolute cm
Index cm/m2
MEN WOMEN
Roman MJ et al Am J Cardiol 1989; 64:507-512; and Erbel R et al.European Heart Journal 2001; 22: 1542-1681
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Case
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? Aortic Dissection
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Case
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?
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Case
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Aortic Dissection
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If
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If aortic dissection is not diagnosed
and treated promptly
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If aortic dissection is not diagnosed
and treated promptly
The mortalityescalates every hr
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Aortic DissectionMortality Rates
21% within 24 hrs
49% at four days
74% at two weeks
93% at one year
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Aortic Dissection
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Acute Aortic Dissection
• 2000 new cases reported
in US per year
• True incidence possibly
10,000 per year
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Clinical History
Sudden severe pain: 74-90% cases
May propagate or be localized
90% with antr pain only: Asc. Aorta
90% with intrascap pain: Desc. aorta
Other symptoms:
Branches compromised
Rupture/Leakage
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Aortic DissectionTransthoracic Echo
Acoustic window not optimal
in all pts.
Sensitivity: 59 - 85%
Specificity: 63 - 96%
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Aortic Dissection
TEE
Investigator Pts Sen % Sp %
Erbel ‘89 164 99 98
Nienabar ‘93 110 94 87*
Keren ‘96 112 100 100
Sommer ‘96 49 96 96
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Aortic Dissection
“All I need to know is
the diagnosis and location”
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TEE in Aortic Dissection
• Intimal flap, True/False lumen• Entry sites, Prox extent, Type• Patency or clot in false lumen• Aortic regurgitation• Coronary involvement• LV wall motion, LV function• Pericardial effusion• Aortic ring sizing for surgery• Assessment of surgery
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Case
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Case
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Case
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Cor Angio: Normal coronaries
Back pain in the cath lab
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Cor Angio: Normal coronaries
Back pain in the cath lab
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*
Aortic Dissection
Yes
No
Not sure
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Case
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Intramural Hematoma
About 6 - 20% of aortic dissection
are intramural hematoma cases(106/553 from pooled data)
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Intramural Hematoma
• Thickening of aortic wall (>0.7 cm) with
central displacement of intimal layer
• Displaced intimal calcium
• Absence of flap/fenestration
• May be echolucent but no flow
• Increased external aortic diameter
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Intramural Hematoma
Treat like dissection
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Diagnosis of Intramural Hematoma
Intramural Atheroma
Hematoma Plaque
Intralum surface Usually smooth Usually irregular
Echodensity Hypoechoic Hyperechoic
Involvement Usually localized Usually diffuse
Peric effusion May be present --
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Aortic DissectionFollow-Up
• Upto 29% of late deaths after surgery
due to rupture of dissecting aneurysm
or dissection at remote site
• Incidence of subsequent aneurysm at
remote site is 17 - 25%
• In the majority, subsequent dissection
develops within 2 years
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Ao
LV Ao
Ao
LV
Ao
LA
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Aortic Aneurysm
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Case
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Bicuspid Aortic ValveAortic Root Enlargement
LV
LA
Aorta
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Aortic Surgery in Dilated AortaAHA/ACC/ESC Guidelines
What diameter ?
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Aortic Surgery in Dilated AortaAHA/ACC/ESC Guidelines
What diameter ?
> 55 mm
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Surgery to repair the aortic root or replace the
ascending aorta is indicated in patients with bicuspid
aortic valves if the diameter of the aortic root or
ascending aorta is > 5.0 cm* or if the rate
of increase in diameter is 0.5 cm/yr or more
(Level of Evidence: C)
In patients with bicuspid valves undergoing AVR
because of severe AS or AR, repair of the aortic root or
replacement of the ascending aorta is indicated if the
diameter of the aortic root or ascending aorta is greater
than 4.5 cm
(Level of Evidence: C)
Aortic Surgery in Pts with BAVAHA/ACC Guidelines
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CLASS I
Operative intervention to repair the aortic
sinuses or replace the ascending aorta is
indicated in patients with a bicuspid aortic
valve if the diameter of the aortic sinuses or
ascending aorta is > 5.5 cm
Level of evidence: B
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CLASS IIa
Operative intervention to repair the aortic sinuses or replace the ascending aorta is reasonable in patients with bicuspid aortic valves if the diameter of the aortic sinuses or ascending aorta is greater than 5.0 cm and a risk factor for dissection is present (family history of aortic dissection or if therate of increase in diameter is > 0.5 cm per year).
Level of evidence: C
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CLASS IIa
Replacement of the ascending aorta is reasonable in patients with a bicuspid aortic valve who are undergoing aortic valve surgery because of severe AS/AR if the ascending aorta diameter is > 4.5 cm.Level of evidence: C
Replacement of the sinuses of Valsalva is not necessary in all cases and should be individualized
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Disorders associatedwith Aortic Aneurysms
• Marfan Syndrome
• Ehlers-Danlos Syndrome
• Ankylosing Spondylitis
• Behcet disease
• Reiter Syndrome
• Williams Syndrome
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Case
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Aneurysm
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Case
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Penetrating Aortic Ulcer
Courtesy: Mankad, MD
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PenetratingAortic Ulcer
Courtesy: Mankad, MD
![Page 83: Diseases of the Aorta - American Society of Echocardiography › wp-content › uploads › 2016 › 04 › 4.19...ascending aorta is > 5.0 cm* or if the rate of increase in diameter](https://reader030.vdocuments.site/reader030/viewer/2022041023/5ed576f4d9145e0f8900b46b/html5/thumbnails/83.jpg)
Penetrating Aortic Ulcer
- Atherosclerotic disease superficial
ulceration of plaque confined to intima
- Ulcer may penetrate into internal elastic
lamina and into media
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Penetrating Aortic Ulcer - Sequele
• Benign
• Deep ulcer (true saccular aneurysm)
• Medial hematoma
• Pseudoaneurysm
• Transmural rupture
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Penetrating Aortic Ulcer
- More common in descending aorta
- Elderly, hypertensive patients
- Symptoms: chest pain, back pain
- Symptomatic involvement of ascending aorta or
arch has high risk for rupturesurgery
- Surgery for descending P.A.U. if:
Hemodynamic instability
Pseudoaneurysm
Pericardial effusion
Bloody pleural effusion
Expanding intramural hematoma
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Aortic Masses
• Atheromas
• Thrombotic masses
• Tumors (sarcoma,
histiocytoma, angiosarcoma)
• Mysteriomas
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Case
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AorticAtheroma
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Aortic Atheroma
• Association with systemic embolic events
• > 3 or >4 mm atheroma: a higher risk
• Besides Rx of dyslipidemia, other forms
of therapy unproven/controversial
• Has intraoperative implications in
patients undergoing aortic cannulation
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Case
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Case
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What next ?
1. Thrombus - Anticoagulate
2. Thrombus - Surgery
3. Tumor – Do more work-up
4. Tumor - Operate
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What next ?
1. Thrombus - Anticoagulate
2. Thrombus - Surgery
3. Tumor – Do more work-up
4. Tumor - Operate
5. Just talk
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Case
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Aortic Trauma
- High Mortality (20% survival to hospital)
- Horizonal deceleration injury (MVA)
- Vertical decel injury (falling from height)
- Most common sites:
Aortic isthmus tethered by ligamentum
arteriosum
Ascending aorta above sinus of valsalva
Origin of the innominate artery
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Diagnosis of Aortic Trauma
Angiography—transport of patient, risk of worsening vascular trauma
CT—requires transport of patient
TEE
Cannot be performed in severe facial injury or cervical spine injury
May not see distal ascending aorta or great vessels
![Page 104: Diseases of the Aorta - American Society of Echocardiography › wp-content › uploads › 2016 › 04 › 4.19...ascending aorta is > 5.0 cm* or if the rate of increase in diameter](https://reader030.vdocuments.site/reader030/viewer/2022041023/5ed576f4d9145e0f8900b46b/html5/thumbnails/104.jpg)
Echo Findings in Aortic Trauma
- “thick stripe” due to deep laceration
- Pseudoaneurysm
- Fusiform dilation
- Intramural hematoma
- Intraluminal thrombi
- Mediastinal hematoma
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Case
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Coarctation of the Aorta
• Pre-ductal, Ductal or Post-ductal
• If hypertensive/symptomatic,Angioplasty/stent or surgery
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Kimura-Hayama E T et al. Radiographics 2010;30:79-98
Pseudo-coarctation of the Aorta
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Thank You