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Echocardiographic Evaluation of Acute Aortic Syndromes

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Echocardiographic Evaluation of Acute Aortic Syndromes ... aneurysm, or rupture Pics from ... Cases Mr. BW 47 yo male presents with inferior STEMI. – PowerPoint PPT presentation

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Title: Echocardiographic Evaluation of Acute Aortic Syndromes


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

2
Acute Aortic Syndrome
  • Definition
  • 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

3
Aortic 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
4
Intramural Hematoma
  • Rupture of vasa
  • vasorum or
  • plaque ?
  • collection of blood
  • in media w/o
  • intimal tear
  • May extend toward
  • lumen and lead to dissection
  • High rate of rupture
  • Ascending aorta IMHs are surgical

Pics from google images
5
Penetrating atherosclerotic ulcer
  • Erosion of intimal plaque into media
  • May lead to IMH, dissection, aneurysm, or rupture

Pics from google images
6
Echo Algorithm
Meredith EL and Masani ND. Eur J Echocardiogr
2009.
7
Role of TTE
  • Reasonable acute test for suspected AAS
  • Advantages
  • 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?

8
TTE Views
Additional views Modified PS and apical 2c views
to see descending ao Right or high left
parasternal views to eval ascending ao
Evangelista, et al. Eur J Echocardiogr 2010.
9
Role of TEE
  • Advantages 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

10
TEE Views
Evangelista, et al. Eur J Echocardiogr 2010.
11
Examples of AD by TTE
Evangelista, et al. Eur J Echocardiogr 2010.
12
Examples of AD by TEE
Meredith EL and Masani ND. Eur J Echocardiogr
2009.
13
Examples of AD by TEE
Flachskampf, FA. Seminars in Cardiothoracic and
Vascular Anesthesia 2006.
14
True vs. False Lumen
Evangelista, et al. Eur J Echocardiogr 2010.
15
True vs. False Lumen
Flachskampf, FA. Seminars in Cardiothoracic and
Vascular Anesthesia 2006.
16
Examples 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
17
Examples of IMH
Pics from google images
18
Examples of PAU
Pics from Meredith EL and Masani ND. Eur J
Echocardiogr 2009 and Evangelista, et al. Eur J
Echocardiogr 2010.
19
  • Cases

20
Mr. BW
  • 47 yo male presents with inferior STEMI. Unable
    to engage RCA in cath lab

21
Ms. FS
  • 81 yo WF transferred to ICU for possible Ao
    dissection on CT at OSH
  • c/o abd pain, N/V, diarrhea

22
Ms. GC
  • 53 yo female with cath complication when
    attempting RCA intervention

23
Ms. JE
  • 49 yo female with evidence of Type B dissection
    on CT
  • Echo ordered to eval for effusion

24
Mr. KB
  • 34 yo male s/p Ao root repair presents with
    severe CP
  • MRI showed mediastinal hematoma

25
Mr. MK
  • 71 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

26
Ms. PH
  • 35 yo female with Hx traumatic Ao dissection of
    descending Ao presented w/ sudden onset CP after
    cocaine use
  • PE unremarkable
  • CXR widened mediastinum

27
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28
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29
Mr. XD
  • 58 yo male s/p cardiac arrest
  • LM dissection in cath lab after LM PCI
  • Echo ordered to eval for retrograde extension of
    dissection into proximal aorta

30
References
  • Kayser, et al. Circumferential Involvement of an
    Acute Type B Aortic Dissection. J Am Soc
    Echocardiogr 2007201416.e7-1416.e11.
  • Flachskampf, FA. Assessment of Aortic Dissection
    and Hematoma. Seminars in Cardiothoracic and
    Vascular Anesthesia 200610(1)83-88
  • Meredith EL and Masani ND. Echocardiography in
    the emergency assessment of acute aortic
    syndromes. Eur J Echocardiogr 200910i31-i39.
  • Evangelista, et al. Echocardiography in aortic
    diseases EAE recommendations for clinical
    practice. Eur J Echocardiogr 201011645-658.
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