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CHAPTER 23: Disorders of the Aorta

GUIDELINES Sources

  • Boodhwani M, Andelfinger G, Leipsic J. Canadian Cardiovascular Society position statement on the management of thoracic aortic disease. Can J Cardiol. 2014;30:577–589.

  • Erbel R, Aboyans V, Boileau C. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014;35:2873–2926.

  • Extensive document with mention of rare disorders.

  • Genetic diseases that affect the aorta.

  • Coral reef aorta.

  • Aortic tumors.

Source

  • Goldstein SA, Evangelista A, Abbara S, et al. Multimodality imaging of diseases of the thoracic aorta in adults. J Am Soc Echocardiogr. 2015;28:119–182.

  • Normal dimensions of the aorta.

  • Echo measurement of the proximal ascending aorta.

  • Images of dissection.

  • Aortic regurgitation in dissection.

  • Imaging of intramural hematomas and penetrating aortic ulcers.

  • Imaging in coarctation.

Source

  • Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 guidelines for the diagnosis and management of patients with thoracic aortic disease. J Am Coll Cardiol. 2010;55:e27–e129.

AORTIC DISSECTION

  • Diagnosis of dissection:

    • - The availability of CT scanning in emergency departments has now made CT a more common initial imaging mode than TEE.

    • - TEE is still used to rapidly diagnose dissection in critically ill patients who are too unstable to be placed in a CT scanner.

    • - TEE is used instead of CT in patients where renal dysfunction prohibits the use of contrast for the CT images.

    • - Local physician expertise also may influence the use of CT versus TEE for initial diagnosis.

    • - When the diagnosis is made on CT, TEE will still be subsequently used in patients intraoperatively during the repair.

    • - Transthoracic echo is useful only for initial diagnosis in those rare instances when an intimal flap is clearly visualized.

  • Both TTE and TEE can detect and evaluate the consequences of dissection:

    • - Pericardial effusion. (The mode of death in this lethal disorder is most commonly cardiac tamponade.)

    • - Aortic regurgitation. (It may be possible to save the aortic valve by resuspending it during repair of the dissection.)

    • - If the dissection extends to a coronary ostium, the dissection can cause myocardial infarction. In that case, there may be left ventricular wall motion abnormalities on echo associated with ECG abnormalities of infarction.

Imaging

  • Numerous artifacts can be present in the proximal ascending aorta, making the confident diagnosis of a dissection flap difficult on PLAX TTE (Fig 23-1).

  • Common pitfall: The suprasternal view of the normal aortic arch and the adjacent brachiocephalic/innominate vein may fool an inexperienced observer. Saline contrast injection in a left arm vein, and systolic–diastolic venous color flow, will help identify the vein.

FIGURE 23-1

Annuloaortic ectasia in Marfan syndrome. There is pear-shaped aneurysmal dilatation of the proximal ascending aorta. There is no narrowing of the aorta at the junction between the sinus of Valsalva and the ascending aorta (sinotubular junction).

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