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ab c
>s
d
Fig. 20 Postcontrast CT images demonstrate an 8mm thick type A IMH in a 54-year old man with
chest pain (a-c) that is found to have resolved at 3month follow up (d, e) with medical management only. AA Ascending aorta; LV Left ventricle
e
Fig. 21 Axial CT images with contrast demonstrate a type B IMH (arrows) in a middle-aged
woman (a) that resolved on follow-up imaging 8months later (b)
Imaging ofIntramural Hematoma andPenetrating Atherosclerotic Ulcer byCT andMRI
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selected subgroups. Conversely, type B lesions are typically treated medically or
with endovascular stenting with surgery being reserved for those patients in which
serious complications are identied. Outcomes are favorable for those patients that
are appropriately managed, and identifying harbingers for potential complications
are crucial in the successful management of IMH.
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https://doi.
Echocardiography fortheDiagnosis
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andManagement ofAcute Aortic
Syndromes
SumbalJanjua, AndrewD.Maslow, andAthenaPoppas
Introduction: Denitions
The aorta consists of ve main anatomic segments: the aortic root, the tubular portion of the ascending aorta (the proximal ascending aorta), the aortic arch, the
descending thoracic aorta, and the abdominal aorta. The aortic root includes the
aortic valve annulus, aortic valve cusps, coronary ostia, and sinuses of Valsalva. The
aortic root joins the proximal ascending aorta at the sinotubular junction (STJ). The
proximal portion of the ascending aorta extends from the STJ to the origin of the
brachiocephalic artery. The aortic arch extends from the brachiocephalic artery to
the left subclavian artery. The descending thoracic aorta consists of the proximal
part (from the left subclavian artery to the level of the pulmonary artery) and the
distal part (from the level of the pulmonary artery to the diaphragm). The abdominal
aorta consists of the proximal part, which extends from the diaphragm to the ostia
of the renal arteries; and the distal part, which extends from the renal arteries to the
iliac bifurcation.
S. Janjua
Department of Cardiology, MedStar Washington Hospital Center, Georgetown University,
Washington, DC, USA
e-mail: sumbal.a.janjua@medstar.net
A. Poppas (
Division of Cardiology, Lifespan Cardiovascular Institute, Brown University Warren Alpert
School of Medicine, Providence, RI, USA
e-mail: apoppas@lifespan.org
A. D. Maslow
Department of Anesthesiology, Rhode Island Hospital, Brown University Warren Alpert
School of Medicine, Providence, RI, USA
e-mail: amaslow@rcn.org
J. S. Coselli et al. (eds.), Aortic Dissection and Acute Aortic Syndromes,
https://doi.org/10.1007/978-3-030-66668-2_12
*)
175© Springer Nature Switzerland AG 2021
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S. Janjua et al.
Transthoracic Approach
Echocardiographic Imaging
The aortic root is best visualized in the parasternal long-axis view by TTE [1–8]
(Fig.1). Measurement of the aortic root diameter should be made perpendicular to
the axis of the proximal aorta. The standard measurement is taken as the largest
diameter from the right coronary sinus of Valsalva to the posterior (usually noncoronary) sinus. Most studies report aortic root diameter measurements at end-diastole
using the leading edge–to–leading edge technique [2, 7, 9, 10]. The aortic annulus
is generally elliptical in older adults and, hence, most reliably measured with 3D
echocardiography. The proximal ascending aorta is best seen in parasternal long and
short-axis views or right upper sternal border. Once again, the measurements are
made from leading edge to leading edge. The aortic arch is imaged from a suprasternal notch or supraclavicular approach. Only a short segment of the ascending aorta
is visible from the suprasternal notch, in most adults (Fig.2). The descending thoracic aorta is seen in cross section posterior to the left atrium in the parasternal
long- axis view. From the subcostal view, the distal thoracic and proximal abdominal
aorta is seen as it traverses the diaphragm.
Doppler Flows
Color Doppler interrogation of the ascending aorta from the parasternal approach
allows evaluation of the ow pattern in the proximal aorta and assessment of any
concomitant aortic regurgitation and grading of severity. Pulsed- wave (PW) or
continuous-wave (CW) Doppler recordings of descending aortic ow from the
suprasternal notch show systolic ow away from the transducer. Normal ow in the
descending aorta shows brief, low-velocity, early diastolic ow reversal,
Fig. 1 Normal aortic root
morphology and
dimensions on
transthoracic imaging
parasternal long axis view.
Yellow line is proper root
measurement in mid sinus
of Valsalva
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177
Fig. 2 Normal Transesophageal images of aortic root, valve and ascending aorta. Upper panel is
short axis view of the aortic valve in systole and diastole. NCC-noncornary cusp, LCC-left coronary cusp, RCC-right coronary cusp. Lower panel is long axis view of the aorta showing the relationship of the ascending aorta (AscAo) to the left ventricular outow tract (LVOT) and the
coronary cusps
low-velocity antegrade ow in mid-diastole, low-velocity ow reversal at enddiastole. Flow patterns in the proximal abdominal aorta are similar to those seen in
the descending thoracic aorta.
Limitations ofTransthoracic Imaging
The major limitations of TTE evaluation of the aorta are acoustic access and image
quality. Acoustic access maybe suboptimal from one or more of the windows needed
for full evaluation of the aorta. Image quality maybe poor due to beam width at the
depth of the aorta. Beam-width artifact, noise, and poor lateral resolution make differentiation of intraluminal defects from artifacts difcult. Evaluation by TEE is
more sensitive and specic for diagnosing pathology, and hence, is the appropriate
modality in most patients with acute aortic disease.
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Transesophageal Approach
Echocardiographic Imaging
The aortic valve and sinuses of Valsalva are best seen in short-axis with the image
plane rotated to approximately 45°. The aortic valve, sinuses of Valsalva, and
ascending aorta are then obtained in the long axis by rotating the image plane to
approximately 120° (Fig. 3a and b). The aortic arch is best imaged from a high
esophageal transducer position. Presence of the trachea/left bronchus impedes complete visualization of the distal ascending aorta and proximal aortic arch. Posterior
rotation of the probe provides excellent images of the descending thoracic aorta and
the proximal abdominal aorta in either a cross-sectional plane at 0° or long-axis
plane at 90° to 120°. From a transgastric position, the proximal abdominal aorta is
seen posterior to the stomach. The entire length of the aorta can be examined in
cross-sectional views as the probe is slowly withdrawn from the stomach into the
esophagus, with imaging of the aortic arch just prior to removal of the probe.
X-plane or biplane feature can allow simultaneous images in the long and short axis
views. Three-dimensional (3D) TEE provides additional information in dening the
anatomy and extent of abnormalities such as a dissection ap or identifying the
a
Fig. 3 2D and 3D TEE imaging of Aortic Dissection. (a) 2D SAX view of dissection ap prolapsing across the aortic valve (AoV). Surrounding structures: LA-left atrium, RA-right atrium,
RV-right ventricle. (b) 3D LAX view of the dissection ap in the ascending aorta (AscAo) (c) 3D
SAX view of the dissection ap prolapsing across the trileaet aortic valve. (d) 2D LAX view of
the circumferential dissection ap with insertion at the sinotubular junction. (e) Color Doppler of
LAX showing differential ow in large false and small true lumen
b c
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location and size of the entry site. The origins and course of the coronary arteries are
visible in both short- and long-axis views on some TTE and all TEE images.
179
Doppler Flows
TEE color ow imaging of the aorta shows the normal antegrade ow pattern in the
ascending aorta, arch, and descending aorta and is essential in the evaluation of
abnormal blood ow patterns in the presence of aortic dissection. Color Doppler
evaluation of the aortic valve is essential since aortic valve regurgitation can result
from commissural involvement by aortic dissection resulting in inadequate support
of the leaets or a ail aortic leaet due to extension of a dissection ap into the
valve tissue.
Acute Aortic Syndromes
Acute aortic syndromes (AAS) include a spectrum of life-threatening aortic
conditions.
The term AAS includes classic aortic dissection, intramural hematoma (IMH),
penetrating aortic ulcer (PAU), aortic aneurysm rupture (contained or not contained)
[11]. Aortic pseudoaneurysm, traumatic aortic disease and sinus of valsalva aneurysm will also be briey discussed given their clinical relevance and the need to
differentiate pathological processes.
Aortic Dissection
Transthoracic Imaging
Advances in echocardiography have improved the sensitivity of TTE for diagnosis
of aortic dissection to approximately 85 percent or more [12, 13]. The echocardiographic diagnosis of aortic dissection is highly secure when there is a dilated aortic
lumen, a linear, mobile echogenic structure with a pattern of motion different than
the aortic wall and different color Doppler ow patterns in the true and false lumen.
The role of TTE in suspected aortic dissection also includes diagnosis of cardiac
complications of dissection, including aortic insufciency, pericardial effusion/tamponade and regional left ventricular systolic function. Importantly, TTE remains
less sensitive for detection of aortic dissection than TEE, CT, and MRI. Thus,
absence of a dissection ap on TTE should not be used to exclude aortic dissection
but prompt further assessment.
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S. Janjua et al.
Transesophageal Imaging
TEE is highly accurate for establishing the diagnosis of both type A and type
B acute.
aortic dissection. Several studies have demonstrated the high accuracy of TEE,
with sensitivity approaching 100% [14–16]. TEE images of the aorta are superior to
TTE images because of the shorter distance between the transducer and the aorta,
the use of a higher-frequency transducer, and better ultrasound tissue penetration
(Fig.4). Features of aortic dissection seen on TEE imaging include a dissection ap
that appears as a thin, linear, echogenic structure in the aortic lumen with undulating
motion different than the normal systolic pulsations, Color Doppler evidence of
blood ow in both the true (bounded by endothelium) lumen and the false (bounded
by media) lumen, the entry site into the false lumen, other communications between
the two channels, thrombosis of the false lumen or a hematoma in the wall of the
aorta (Table1). TEE imaging of the integrity of the aortic valve apparatus can help
guide the surgeon of the potential for aortic valve-sparing operations as well
(Table2).
a
bc
fgh
Fig. 4 Aortic Dissection compared with Intramural Hematoma on TEE imaging. The top panel is
a SAX of aortic dissection. (a and b). Diastole and systole showing the thin intimal ap with a
larger false lumen (FL). (c and d). Diastole and systole with color ow revealing ow in true lumen
(TL). (e). Color ow with circle highlighting the entry tear with ow from true to false lumen. The
lower panel is a different patient with an intramural hematoma (IMH) seen as echo density contained within the media (with permission from Maslow et al. Journal of Cardiothoracic and
Vascular Anesthesia, Vol. 32, Issue 3, p1341–1362)
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