Aortic pathology can present in many ways, including acute aortic syndromes, such as an aortic dissection, or chronically, as in cases with aortic aneurysmal disease or atherosclerotic disease. Echocardiography is especially valuable in the acute setting due to its rapid availability and portability, enabling its use in the emergency department (ED) and the operating room. While transthoracic echocardiography (TTE) is useful to evaluate the proximal aorta, the aortic valve, left ventricular function, and the presence of pericardial effusion, it is relatively insensitive for the diagnosis of acute pathology such as dissection. Transesophageal echocardiography is a more sensitive and specific modality to evaluate the aorta and is often used in the emergent setting or in the operating room. Computed tomographic angiography (CT angiography) is often even more readily available in the ED and in many institutions, including our own, has supplanted the use of TEE in the acute setting unless there are contraindications to its use. Magnetic resonance angiography (MRA) is an ideal imaging modality for the evaluation and follow-up of patients with aortic pathology; however, its role in the emergent situation, especially in hemodynamically unstable patients, is limited.
In this chapter, Drs. Sofowora and Ijioma will explore the use of echocardiography in a variety of clinical settings in patients with suspected or known aortic pathology, including patients with suspected acute aortic syndromes (aortic dissection, acute intramural hematoma), atheroembolic events due to aortic atherosclerosis, and chronic aortopathies in patients with connective tissue disease such as Marfan syndrome and bicuspid aortic valves.
SECTION 1: ACUTE AORTIC DISSECTION
CLINICAL CASE PRESENTATION
The patient is a 79-year-old woman with a longstanding history of hypertension and a 40 pack-year cigarette smoking history presented to the emergency department with severe chest pain that was described as tearing in nature and was followed by fainting. Her daughter-in-law saw her at the house and called emergency services. On arrival in the emergency department, she was diaphoretic and moaning in pain. An ECG demonstrated normal sinus rhythm with evidence of left ventricular hypertrophy and nonspecific ST-segment changes. On physical examination, her pulses were thready, her blood pressure was 90/30 mm Hg, her apex beat was thrusting, and she had a fourth heart sound with a loud A2. She had a mid-diastolic murmur that was best heard along the sternal border with her leaning forward in expiration. Her lungs were clear and she had no edema. She had a dialysis fistula in her left arm. A transthoracic echocardiogram showed a linear opacity in her ascending aorta and at least moderate aortic regurgitation (Figures 7-1-1 and 7-1-2). After an emergent CT scan confirmed a type A dissection, she was taken to the operating room (OR). Representative intraoperative TEE images are shown in Figures 7-1-3, 7-1-4, 7-1-5, 7-1-6, 7-1-7, 7-1-8. Her dissection was repaired, and the ascending aorta was replaced ...