echocardiographic evaluation of acute aortic syndromes kyle stribling, md echo conference 4/20/11

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Echocardiographic Echocardiographic Evaluation of Acute Evaluation of Acute Aortic Syndromes Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

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Page 1: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

Echocardiographic Echocardiographic Evaluation of Acute Aortic Evaluation of Acute Aortic Syndromes Syndromes

Kyle Stribling, MDEcho Conference 4/20/11

Page 2: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo 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

Page 3: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

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

Page 4: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

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

Page 5: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

Penetrating atherosclerotic Penetrating atherosclerotic ulcerulcerErosion of intimal plaque into

mediaMay lead to IMH, dissection,

aneurysm, or rupture

Pics from google images

Page 6: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

Echo AlgorithmEcho Algorithm

Meredith EL and Masani ND. Eur J Echocardiogr 2009.

Page 7: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

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?

Page 8: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

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.

Page 9: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

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

Page 10: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

TEE ViewsTEE Views

Evangelista, et al. Eur J Echocardiogr 2010.

Page 11: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

Examples of AD by TTEExamples of AD by TTE

Evangelista, et al. Eur J Echocardiogr 2010.

Page 12: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

Examples of AD by TEEExamples of AD by TEE

Meredith EL and Masani ND. Eur J Echocardiogr 2009.

Page 13: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

Examples of AD by TEEExamples of AD by TEE

Flachskampf, FA. Seminars in Cardiothoracic and Vascular Anesthesia 2006.

Page 14: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

True vs. False LumenTrue vs. False Lumen

Evangelista, et al. Eur J Echocardiogr 2010.

Page 15: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

True vs. False LumenTrue vs. False Lumen

Flachskampf, FA. Seminars in Cardiothoracic and Vascular Anesthesia 2006.

Page 16: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

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

Page 17: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

Examples of IMHExamples of IMH

Pics from google images

Page 18: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

Examples of PAUExamples of PAU

Pics from Meredith EL and Masani ND. Eur J Echocardiogr 2009 and Evangelista, et al. Eur J Echocardiogr 2010.

Page 19: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

Cases

Page 20: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

Mr. BWMr. BW47 yo male presents with inferior

STEMI. Unable to engage RCA in cath lab

Page 21: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

Ms. FSMs. FS81 yo WF transferred to ICU for

possible Ao dissection on CT at OSH

c/o abd pain, N/V, diarrhea

Page 22: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

Ms. GCMs. GC53 yo female with cath

complication when attempting RCA intervention

Page 23: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

Ms. JEMs. JE49 yo female with evidence of

Type B dissection on CTEcho ordered to eval for effusion

Page 24: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

Mr. KBMr. KB34 yo male s/p Ao root repair

presents with severe CPMRI showed mediastinal

hematoma

Page 25: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

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

Page 26: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

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

Page 27: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11
Page 28: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11
Page 29: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

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

Page 30: Echocardiographic Evaluation of Acute Aortic Syndromes Kyle Stribling, MD Echo Conference 4/20/11

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.