echocardiographic evaluation of acute aortic syndromes kyle stribling, md echo conference 4/20/11
TRANSCRIPT
Echocardiographic Echocardiographic Evaluation of Acute Aortic Evaluation of Acute Aortic Syndromes Syndromes
Kyle Stribling, MDEcho Conference 4/20/11
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
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
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
Penetrating atherosclerotic Penetrating atherosclerotic ulcerulcerErosion of intimal plaque into
mediaMay lead to IMH, dissection,
aneurysm, or rupture
Pics from google images
Echo AlgorithmEcho Algorithm
Meredith EL and Masani ND. Eur J Echocardiogr 2009.
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?
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.
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
TEE ViewsTEE Views
Evangelista, et al. Eur J Echocardiogr 2010.
Examples of AD by TTEExamples of AD by TTE
Evangelista, et al. Eur J Echocardiogr 2010.
Examples of AD by TEEExamples of AD by TEE
Meredith EL and Masani ND. Eur J Echocardiogr 2009.
Examples of AD by TEEExamples of AD by TEE
Flachskampf, FA. Seminars in Cardiothoracic and Vascular Anesthesia 2006.
True vs. False LumenTrue vs. False Lumen
Evangelista, et al. Eur J Echocardiogr 2010.
True vs. False LumenTrue vs. False Lumen
Flachskampf, FA. Seminars in Cardiothoracic and Vascular Anesthesia 2006.
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
Examples of IMHExamples of IMH
Pics from google images
Examples of PAUExamples of PAU
Pics from Meredith EL and Masani ND. Eur J Echocardiogr 2009 and Evangelista, et al. Eur J Echocardiogr 2010.
Cases
Mr. BWMr. BW47 yo male presents with inferior
STEMI. Unable to engage RCA in cath lab
Ms. FSMs. FS81 yo WF transferred to ICU for
possible Ao dissection on CT at OSH
c/o abd pain, N/V, diarrhea
Ms. GCMs. GC53 yo female with cath
complication when attempting RCA intervention
Ms. JEMs. JE49 yo female with evidence of
Type B dissection on CTEcho ordered to eval for effusion
Mr. KBMr. KB34 yo male s/p Ao root repair
presents with severe CPMRI showed mediastinal
hematoma
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
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
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
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.