Download Aortic Disease

The Aorta
Pitfalls and Difficult Cases
in Evaluating the Aorta by Echo
Raphael Rosenhek
Department of Cardiology
Medical University of Vienna
Euroecho 2011
Budapest, December 8th 2011
Aortic Disease
Anatomy of the Ascending Aorta
Time (months)
Nataf, P et al. Heart 2006;92:1345-52
Aortic Disease
Measurement of Aortic Root Diameters
Internal diameter:
1. Aortic annulus
External diameter
(leading edge to leading edge)
2. Sinus of Valsalva
3. Sinotubular junction
4. Ascending aorta
Time (months)
Nataf, P et al. Heart 2006;92:1345-52
Aortic Root Dilatation
Causes
Congenital
• Bicuspid Aortic Valve, Marfan, Ehlers Danlos Type IV, Aortic Coarctation,
Turner, Familial aortic aneurysm, Tuberous sclerosis, Fabry, Polycystic kidney
disease, Osterogenesis imperfecta, Homocystinuria, Noonan syndrome
Degenerative
• Atherosclerosis, Hypertension, Annuloaortic ectasia
Mechanical/Hemodynamic
• Trauma, Post-stenotic dilation, Aortic Dissection, Catheter induced injury
Inflammatory Aortitis
• Takayasu arteritis, Giant cell arteritis, Ankylosing spondilitis, Reiter’s syndrome,
Acute anterior uveitis, Psoriatic arthritis, Juvenile Rheumatoid arthritis,
Kawasakis, Wiskott-Aldrich syndrome, Behcet’s syndrome, Relapsing
polychondritis, Idiopathic aortitis, Sarcoidosis
Infectious Aortitis
• Syphilis, Tuberculosis, HIV, Salmonella, Aspergillus, Staphylococcus aureus,
Pneumococcus
Adapted from Boyer et al, Curr Op Cardiol. 2004;19:563-569
Aortic Regurgitation and the Aortic Root
Causes of AR in Pts having AVR Surgery
Valve n=122 (46%)
Congenital malformation
Bicuspid
59 (22%)
Quadricuspid
2 (1%)
Tricuspid
5 (2%)
Infective Endocarditis
46 (17%)
Rheumatic?
8 (3%)
Miscellaneous
2 (1%)
Nonvalve n=146 (54%)
Aortic dissection
28 (10%)
Marfan of frome fruste
15 (6%)
Aortitis
12 (4%)
Cause unclear
91 (31%)
Roberts WC et al, Circulation. 2006;114:422-429
Aortic Root Disease
Mechanisms of Functional Aortic Regurgitation
Normal Aortic Valve Anatomy
• Full diastolic coaptation
Sinotubular Junction Dilation
• dilation of the sinotubular junction relative to
the anulus
• leaflet tethering
Aortic Leaflet Prolapse
• Dissection extending into the aortic root
• Disruption of normal leaflet attachment
Dissection Flap Prolapse
• Redundant Dissection flap prolapsing through
intrinsically normal leaflets
Movsowitz et al, J Am Coll Cardiol. 2000;36:884-90
Aortic Dissection - TTE
Aortic Dissection
Aortic Dissection - TEE
Aortic Dissection With a Cusp Prolapse
Aortic Regurgitation
Aortic Dissection With a Prolapsing Intimal Flap
Chow et al, J Cardiothor Vasc Anesth. 2007;21:85-87
Aortic Regurgitation
Aortic Root Dilation - Takayasu Aortitis
Aortic Root Dilation
Diastolic Regurgitant Orifice
Brady et al, Echocardiography. 2006;23:495-498
Bicuspid Aortic Valve
Aortic Regurgitation
Bicuspid Aortic Valve
Aortic Root Dilation
Bicuspid Aortic Valve
Aortic Root Dilation
type 1, "fusion" between right and left coronary cusp
type 2, "fusion" between right and non-coronary cusp
type 3, "fusion" between left and non-coronary cusp
Normal Shape
Ascending Distension
Effaced
Schaefer B et al, Heart. 2008;94:1634-38
Bicuspid Aortic Valve
Aortic Dilation
Aortic dilatation by bicuspid aortic valve type and aortic shape. Incidence of ascending aortic
dilatation, as determined by an aortic diameter greater than 3.6 cm (black bars) or an indexed
diameter greater than 2.1 cm/m2 (grey bars) for various combinations of BAV (1 and 2) phenotype
and aortic shape (A, E and N).
Schaefer B et al, Heart. 2008;94:1634-38
Aortic Root Dilation and BAV
Predictors of Progression
Thanassoulis G et al, Nat Clin Pract Cardiovasc Med. 2008;5:821-8
Aortic Disease
Clinical Risk Factors for Acute Aortic Syndromes
Meredith E L , Masani N D Eur J Echocardiogr 2009;10:i31-i39
Aortic Disease
Normal Size of Thoracic Aortic Segments
Echocardiography in Aortic Diseases: EAE Recommendations
Evangelista A et al. Eur J Echocardiogr 2010;11:645-658
Aortic Disease
Echocardiographic Views of the Aorta
Echocardiography in Aortic Diseases: EAE Recommendations
Evangelista A et al. Eur J Echocardiogr 2010;11:645-658
Aortic Dissection
Contrast Echocardiography
• Visualization of an intimal flap
• True and false lumen in the aortic arch
Evangelista A et al. Eur Heart J 2010;31:472-479
Aortic Dissection
Contrast Echocardiography
• Identification of the entry tear
Evangelista A et al. Eur Heart J 2010;31:472-479
Aortic Disease
Intramural Hematoma
• Thickened aortic wall
• Intima characterized by focal brightness (distinction from thrombus)
• Echo free rim around the aorta
Meredith E L , Masani N D Eur J Echocardiogr 2009;10:i31-i39
Aortic Disease
Normal Size of Thoracic Aortic Segments
• Atheroma of the descending aorta
• Bulge associated with plaque rupture
Meredith E L , Masani N D Eur J Echocardiogr 2009;10:i31-i39
Aortic Disease
Visualization of Coronary Origin
• Visualization of the left coronary artery origin
• Flow visualization by color Doppler
Meredith E L , Masani N D Eur J Echocardiogr 2009;10:i31-i39
Aortic Disease
Visualization of Head and Neck Vessels
• Visualization of head and neck vessels
• Origin of left common carotid and subclavian arteries arising from
the true lumen
• Color Doppler showing unobstructed blood flow
Meredith E L , Masani N D Eur J Echocardiogr 2009;10:i31-i39
Aortic Disease
Reverberation Artefact
• Apparent linear echo in the aorta mirroring the posterior aortic wall
• Twice the distance from the probe with twice movement amplitude
Meredith E L , Masani N D Eur J Echocardiogr 2009;10:i31-i39
Aortic Disease
Aortic Diseases Evaluation Pathway
2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the
Diagnosis and Management of Patients with Thoracic Aortic Disease
Anesth Analg 2010;111:279-315
Aortic Disease
Aortic Diseases Evaluation Pathway
2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the
Diagnosis and Management of Patients with Thoracic Aortic Disease
Anesth Analg 2010;111:279-315
Aortic Disease
Aortic Diseases Evaluation Pathway
2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the
Diagnosis and Management of Patients with Thoracic Aortic Disease
Anesth Analg 2010;111:279-315
Acute Aortic Syndrome
Algorithm for the use of Echocardiography
Meredith E L , Masani N D Eur J Echocardiogr 2009;10:i31-i39
Aortic Diseases
Summary
• Echocardiography is the method of choice for the assessment of the
aortic root and the aortic valve
• Role of contrast echocardiography in acute aortic syndromes,
• Complementarity of TTE and TEE
• Other imaging modalities (MR, CT) may be required to assess the
ascending aorta
The Aorta
Elements of the Imaging Report
1. The location at which the aorta is abnormal
2. The maximum diameter of any dilatation, measured from the external wall of the aorta,
perpendicular to the axis of flow, and the length of the aorta that is abnormal
3. For patients with presumed or documented genetic syndromes at risk for aortic root
disease measurements of aortic valve, sinuses of Valsalva, sinotubular junction, and
ascending aorta
4. The presence of internal filling defects consistent with thrombus or atheroma
5. The presence of intramural hematoma, aortic ulcera, and calcification
6. Extension of aortic abnormality into branch vessels, including dissection and aneurysm,
and secondary evidence of end-organ injury (eg, renal or bowel hypoperfusion)
7. Evidence of aortic rupture, including periaortic and mediastinal hematoma, pericardial
and pleural fluid, and contrast extravasation from the aortic lumen
8. When a prior examination is available, direct image to image comparison to determine if
there has been any increase in diameter
2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the
Diagnosis and Management of Patients with Thoracic Aortic Disease.
Anesth Analg 2010;111:279-315
The Aorta
Early Studies
Da Vinci, 15th century