Value of transesophageal echocardiography in the diagnosis of acute aortic dissection]

We describe our experience of six patients with clinical suspicion of acute aortic dissection (AAD) who were studied consecutively by transesophageal echocardiography (TEE) from April to July of 1991. All of them were previously submitted to transthoracic echocardiogram. The diagnosis was correctly established by TEE in five cases, confirmed by aortography and/or surgery (four cases), or by autopsy (one case). In one patient the diagnosis of AAD was excluded by TEE, and posteriorly by nuclear magnetic resonance. Four patients had a Stanford type A, and one patient a type B dissection. The site of entry was identified in three cases; the intimal entry tear of the type B dissection, not observed by TEE, was localized in the aortic arch by aortography. In three of the four type A dissection cases, a thrombus in the false lumen and an aortic regurgitation were found. No other noninvasive methods were used after the diagnosis of AAD by TEE. The surgical repair was successful in three cases, one of which, without previous necessity of aortography. In our experience, TEE increased extraordinarily the diagnosis efficacy of AAD, making possible an earlier therapeutic approach, and probably contributing to the improvement of the prognosis of this pathology.     

Usefulness of transesophageal echocardiography in assessment of aortic dissection

BACKGROUND. The value of transesophageal echocardiography in the assessment of patients with aortic dissection was studied. METHODS AND RESULTS. Group 1 (34 patients) represented all patients studied at our institution with this technique in whom aortic dissection was proven by aortography, surgery, or autopsy. Group 2 (27 patients) represented all patients studied with this technique at our institution in whom aortic dissection was excluded by aortography. Transesophageal echocardiography made a correct diagnosis of aortic dissection in 33 of 34 patients (sensitivity, 97%; specificity, 100%). It also correctly demonstrated the type of dissection in all 29 patients with aortographic or surgical proof. On the other hand, computed tomography scanning, performed in 24 of 34 patients in group 1, made a correct diagnosis in only 67% of patients and misclassified the type of dissection in 33%. Transesophageal echocardiography correctly identified involvement of the coronary arteries by aortic dissection in six of seven patients as well as absence of both left and right coronary artery involvement in 10 patients with aortic dissection. This technique was also useful in detecting communications between the true and false lumens, presence of thrombi in the false lumen, and, in two patients, localized dissection rupture with formation of a false aneurysm. In both groups 1 and 2, transesophageal echocardiography correctly identified patients with moderate to severe aortic regurgitation. CONCLUSIONS. Transesophageal echocardiography is very useful in the assessment of aortic dissection.     

多平面经食管超声心动图技术对主动脉夹层的诊断价值

目的 探讨多平面经食管超声心动图(TEE)技术对主动脉夹层(AD)的诊断价值。方法 对19例疑诊AD患者进行了多平面TEE检查。结果 19例患者均由多平面TEE明确诊断，其中14例经CT或MRI证实，5例由手术证实，准确性和特异性均为100％。DeBakey分型Ⅰ型夹层患者4例，Ⅱ型3例，破口均位于升主动脉；Ⅲ型12例中，9例破口位于降主动脉近心端，3例未探及内膜破口。结论 多平面TEE技术为AD无创性诊断开辟了新途径。     

Emergency surgical repair of acute aortic arch dissection. Apropos of 14 cases

Among 70 patients operated upon for acute dissection of the ascending aorta between 1977 and 1984, 14 (age range 40-72 years) benefited from emergency aortic arch repair motivated by the presence in, or extension to, this segment of the portal of entry, or by lesions of the supra-aortic main vessels. The operation was performed under cardiopulmonary bypass in all cases. Cerebral protection was ensured in 9 patients by deep hypothermia alone or with circulatory arrest for a mean period of 5 minutes (7 cases), and in 5 patients by continuous brain perfusion (carotid blood flow 4 ml/kg/min; perfusion pressure 70 mmHg). Repair consisted of ascending aorta replacement combined with gluing of the arch whenever possible, or bevelled resection in the concavity of the arch, or complete aortic arch replacement with reimplantation of the cervico-cerebral vessels when necessary. In every case the gelatin-resorcin-formalin glue was used to reinforce the aortic wall or the areas with sutures. Operative mortality was nil. Hospital mortality was 28.5%. In patients operated upon under deep hypothermia alone or associated with circulatory arrest the main complications were neurological (4 cases) and respiratory (3 cases) disorders; these were responsible for the death of 3 patients. A fourth patient died of mediastinitis. No neurological or respiratory complication occurred in patients who had brain perfusion. The mean follow-up period was 37 months (range 7-84 months). Late mortality was nil. All but one patient (sequelae of paraplegia) are in excellent clinical condition. Post-operative angiography alone or combined with computerized tomography showed satisfactory blood distribution in all cases and no aneurysm formation on the dissected aorta despite a persistent false lumen.     

Diagnosis of thoracic aortic dissection. Magnetic resonance imaging versus transesophageal echocardiography.

BACKGROUND. Aortic dissection requires prompt and reliable diagnosis to reduce the high mortality. The purpose of this study was to assess the reliability of both ECG-triggered magnetic resonance imaging (MRI) and transesophageal two-dimensional echocardiography combined with color-coded Doppler flow imaging (TEE) for the diagnosis of thoracic aortic dissection and associated epiphenomena. METHODS AND RESULTS. Fifty-three consecutive patients with clinically suspected aortic dissection were subjected to a dual noninvasive imaging protocol in random order; imaging results were compared and validated against the independent morphological "gold standard" of intraoperative findings (n = 27), necropsy (n = 7), and/or contrast angiography (n = 53). No serious side effects were encountered with either imaging method. In contrast to a precursory screening transthoracic echogram, the sensitivities of both MRI and TEE were 100% for detecting a dissection of the thoracic aorta irrespective of its location. The specificity of TEE, however, was lower than the specificity of MRI for a dissection (TEE, 68.2% versus MRI, 100%; p less than 0.005), which resulted mainly from false-positive TEE findings confined to the ascending segment of the aorta (TEE, 78.8% versus MRI, 100%; p less than 0.01). In addition, MRI proved to be more sensitive than TEE in detecting the formation of thrombus in the false lumen of both the aortic arch (p less than 0.01) and the descending segment of the aorta (p less than 0.05). There were no discrepancies between the two imaging techniques in detecting the site of entry to a dissection, aortic regurgitation, or pericardial effusion. CONCLUSIONS. Both MRI and TEE are atraumatic, safe, and highly sensitive methods to identify and classify acute and subacute dissections of the entire thoracic aorta. TEE, however, is associated with lower specificity for lesions in the ascending aorta. These results may still favor TEE as a semi-invasive diagnostic procedure after a precursory screening transthoracic echogram in suspected aortic dissection, but they establish MRI as an excellent method to avoid false-positive findings. Anatomic mapping by MRI may emerge as the most comprehensive approach and morphological standard to guide surgical interventions.     

Diagnosis of aortic dissection: The value and limitations of transesophageal echocardiography

Aortic dissection requires prompt and reliable diagnosis. The purpose of this study was to assess the accuracy and limitations of transesophageal echocardiography (TEE) for the diagnosis of aortic dissection. Twenty seven patients with clinically suspected aortic dissection were investigated by means of TEE. TEE results were compared to intraoperative findings (n=18), necropsy (n=4), and magnetic resonance imaging (n=5). The DeBakey classification was used for differentiation of dissection type. Twenty-three patients (85%) were correctly identified as having aortic dissection. Four false-positive TEE findings (15%) were confined to the nondissecting aneurysm of the ascending aorta in elderly patients. Retrospectively we found that protruding atherosclerotic plaques were recognized as small intimal flaps. Type of dissection was correctly diagnosed in all 23 patients, the primary entry site was identified in 15 patients (65%), aortic regurgitation was found in 55.5% of patients, and pericardial effusion was detected in 33.3%. We conclude that TEE allows accurate diagnosis and classification of aortic dissection. However, some cases could be overdiagnosed in lesions of the ascending aorta, especially in nondissecting aneurysms. Another limitation of TEE is the inability to define the primary entry site in some cases. Still, overall results may favor TEE as the primary bedside diagnostic procedure to identify patients requiring urgent surgical intervention.Presented at the 35th World Congress, International College of Angiology, Copenhagen, Denmark, July 1993     

Anomalous inferior vena cava mimicking aortic dissection on transesophageal echocardiography

Transesophageal echocardiography (TEE) is considered an excellent method for the diagnosis of aortic dissection, especially that involving the descending aorta. It has also proved useful in the evaluation of conditions mimicking aortic dissection, usually disclosing in these situations other types of severe aortic disease. We are not aware of any report dealing with venous abnormalities which presented diagnostic problems in a patient evaluated with TEE because of a suspected aortic dissection. Left ventricular (LV) free wall rupture complicated with acute myocardial infarction (AMI) usually occurs in the early phase of AMI. True aneurysm of the LV is sometimes a complication of AMI but rarely ruptures. In our patient, a 72-year-old woman, the LV free wall ruptured on Day 49 after the onset of AMI and the ruptured site was the thinnest wall of large true aneurysm of the LV. The large aneurysmal formation probably was due to corticosteroids used for pericarditis. More attention should be paid to late cardiac rupture and the use of corticosteroids.     

Diagnostic goals in aortic dissection. Value of transthoracic and transesophageal echocardiography]

The combination of different ultrasound techniques like transthoracic, suprasternal, subcostal and transesophageal echocardiography have a high sensitivity and specificity in the diagnosis of aortic dissection. The limitation of this combined ultrasound technique is related to the visualization of the ascending part of the aortic arch which, cause of the interposition of the trachea, can not be visualized completely. The beginning or the end of a dissection in this part of the aorta may be misinterpreted. False negative results are rare. False positive results due to artefacts resulting from reverberations in an ectatic ascending aorta have to be taken into account. The most important diagnostic aims in acute or chronic aortic dissection can be described: 1. confirmation of the diagnosis by visualization of the intima membrane, 2. the differentiation of the true and false lumen depending on visualization of spontaneous echocardiographic contrast thrombus formation, slow or reduced reversed flow, systolic diameter reduction and signs of entry jet into the false lumen, 3. detection of intimal tear, demonstrating communication by two-dimensional or color Doppler echocardiography, 4. determination of the extent of the dissection with classification according to DeBakey type I, II and III or Stanford A and B with differentiation to communicating or non-communicating dissection, antegrade or retrograde dissection limited to the descending aorta or expanding to the ascending aorta, 5. detection of wall motion abnormalities as a sign of preexisting coronary artery disease or myocardial ischemia due to ostium occlusion by an intimal flap, coronary artery rupture or collapse of the true lumen during diastole, 6. detection and grading of aortic insufficiency, 7. detection of side branch involvement by suprasternal, subcostal and abdominal sonography, which will gain the information which side can be chosen for cannulation or catheterization at the femoral artery, 8. detection of pericardial pleural effusion and mediastinal hematoma as a sign of emergency as rupture can occur within minutes. Without surgical intervention have be performed. Based on these informations, surgery can be performed in all acute situations in type A dissection without further investigations. This decision is particularly important in patients with signs of emergency like pericardial or pleural effusion or mediastinal hematoma.     

Diagnosis of acute aortic dissection by echocardiography

Until recently, the diagnosis of aortic dissection rested on aortography. The purpose of this study was to evaluate the diagnostic value of echocardiography in that disease and its ability to inform on the extent of the dissection and on the presence of associated lesions. Twenty-six patients (mean age 64 +/- 10 years) admitted for suspected aortic dissection were explored by echocardiography and the results were compared with those of angiography and/or anatomical findings. Echocardiography provided the diagnosis in 14 of the 16 patients with aortic dissection and excluded it in the remaining 10 patients. The sensitivity and specificity of the method were 87.5 p. 100 and 100 p. 100 respectively. The type of dissection was correctly determined in 90 p. 100 of the patients whose aorta had been totally explored by echocardiography. Aortic regurgitation and pericardial effusion were detected in 81 p. 100 and 50 p. 100 respectively of patients with aortic dissection. These results confirm the diagnostic value of echocardiography in dissection of the aorta. The extent of the lesion can only be evaluated when the whole of the aorta is visualized. The echocardiographic diagnosis is easier when the ascending aorta is involved (type I), while in type III aortic dissection there is a risk of missing a retrograde lesion of the aorta and confusing this type with type I. In this study two kinds of intimal flap motion were observed: in the first one the motion was independent of that of the aorta, while the second one resembled a division of the aortic, wall the motion of which is parallel to that of the aorta.     

Usefulness of transesophageal echocardiography in the diagnosis of conditions mimicking aortic dissection

Between September 1987 and April 1989, forty patients suspected to have aortic dissection were evaluated by transesophageal echocardiography. Aortic dissection was identified in 18 patients. This study evaluated the ability of transesophageal echocardiography in the assessment of the 22 patients in whom aortic dissection was not found. A range of pathologic conditions was diagnosed in these patients. Five patients had ischemic heart disease when they were initially seen. Among the remaining 17 only one patient had a normal aorta. Aortic disease was present in the other 16 patients with aortic dilatation in 10. Atheromas were detected in seven patients with concomitant aortic dilatation in five of them. An extrinsic aortic mass was present in two patients. Transesophageal echocardiography correctly identified an anastomotic leak at the site of left coronary artery implantation in a patient with a recent Bentall procedure, and a large mobile clot within the proximal descending aorta in a patient with blunt chest trauma. These findings obviated the need for other tests in 15 patients and led to surgery in four with no ancillary tests performed in three of them. Thus transesophageal echocardiography has an important role in assessing patients with suspected dissection. Aortic disease is common even in patients in whom aortic dissection is excluded, and some of the conditions can be just as life-threatening as dissection. Transesophageal echocardiography not only reliably identifies dissection but can also detect luminal and extraluminal diseases not adequately visualized by other modalities.     

Accuracy of biplane and multiplane transesophageal echocardiography in diagnosis of typical acute aortic dissection and intramural hematoma

Objectives. The purpose of this study was to evaluate the diagnostic accuracy of biplane and multiplane transesophageal echocardiography in patients with suspected aortic dissection, including intramural hematoma.Background. Transesophageal echocardiography is a useful technique for rapid bedside evaluation of patients with suspected acute aortic dissection. The sensitivity of transesophageal echocardiography is high, but the diagnostic accuracy of biplane and multiplane transesophageal echocardiography for dissection and intramural hematoma is less well defined.Methods. We studied 112 consecutive patients at a major referral center who had undergone biplane or multiplane transesophageal echocardiography to identify aortic dissection. The presence, absence and type of aortic dissection (type A or B, typical dissection or intramural hematoma) were confirmed by operation or autopsy in 60 patients and by other imaging techniques in all. The accuracy of transesophageal echocardiography for ancillary findings of aortic dissection (intimal flap, fenestration and thrombosis) was assessed in the 60 patients with available surgical data.Results. Of the 112 patients, aortic dissection was present in 49 (44%); 10 of these had intramural hematom (5 with and 5 without involvement of the ascending aorta). Of the remaining 63 patients without dissection, 33 (29%) had aortic aneurysm and 30 (27%) had neither dissection nor aneurysm. The overall sensitivity and specificity of transesophageal echocardiography for the presence of dissection were 98% and 95%, respectively. The specificity for type A and type B dissection was 97% and 99%, respectively. The sensitivity and specificity for intramural hematoma was 90% and 99%, respectively. The accuracy of transesophageal echocardiography for diagnosis of acute significant aortic regurgitation and pericardial tamponade was 100%.Conclusions. Biplane and multiplane transesophageal echocardiography are highly accurate for prospective identification of the presence and site of aortic dissection, its ancillary findings and major complications in a large series of patients with varied aortic pathology, Intramural hematoma carries a high complication rate and should be treated identically with aortic dissection.     

Follow-up of patients undergoing surgery for aortic dissection: evaluation with transesophageal echocardiography]

BACKGROUND. Transesophageal echocardiography (TEE) is a useful means in the diagnosis of acute aortic dissection (AD), owing to its very high sensibility and specificity. In this study, TEE was performed to assess post-surgical evolution. PATIENTS. Between 1982 and 1991, 119 pts. were operated on in our institution for AD (De Bakey I and II type): 87 pts. underwent replacement of the ascending aorta with a composite tubular graft bearing a mechanical valve; 26 had a simple tubular graft and 6 had aortic reconstruction. Sixty-eight of 72 discharged pts. were followed for up to 9.5 years (mean 4.5 +/- 2.6). Nine years after surgery actuarial survival of discharged pts. was 75%. Seven pts. died after a mean period of 3.4 years from surgery: only one died from postoperative complication (dehiscence of proximal anastomosis), none for aortic rupture distal to the graft. TEE was performed in 32 of these pts. and in other two operated on elsewhere, after 4.4 +/- 2.7 years from surgery; before the operation, type I AD was diagnosed in 23 pts. and type II in 11 pts. RESULTS. In 10/11 pts. with type II AD the aortic arch and the descending aorta looked normal; in one patient a localized intimal flap was found up to the arch. The descending aorta diameter was somewhat higher than in normal subjects (25.2 +/- 2.8 vs 21.9 +/- 3.7 mm), but in only one case was it beyond 2DS (32 mm). In all type I pts. an intimal flap persisted distal to the graft, along the whole thoracic aorta. Within the false lumen a flow was detected by color-Doppler in 14/23 pts. (61%), and spontaneous echo-contrast was noted in 14 pts. (61%). A thrombus was observed in 7 pts. (30%) and it was generally localized; in only one case it was extensive with total obliteration of the false lumen. In 16 pts. (70%) communications between the two lumina were found. The descending aorta diameter ranged from 25 to 53 mm, and mean value was higher than in normal subjects (34.2 +/- 6.2 vs 21.9 +/- 3.7 mm). CONCLUSIONS. In most pts. with type II AD, surgery can be a definitive treatment, as the remaining aorta keeps to normal size and appearance. In type I AD, operation is only palliative, as the dissection persists: the false lumen is often perfused through one or more communications with the true lumen and seldom its obliteration is noted. The persistence of dissection does not necessarily seem to be an ominous finding, as the survival of the study population was high and no patient died from aortic rupture. Nevertheless, long-term prognosis can be affected by aorta dilation that often (but not always) follows the persistence of wall dissection. For its high reliability, easy feasibility and low cost TEE is a very useful method for following up patients operated on for AD and for detecting those who are at higher risk of aortic rupture because of lumen dilation.     

Ambulatory follow-up of aortic dissection by transesophageal two-dimensional and color-coded Doppler echocardiography

Follow-up of 18 patients with aortic dissection (five with type I, one with type II, 11 with type III dissection according to DeBakey) by transesophageal, two-dimensional and color-coded Doppler echocardiography showed a persistence of the false lumen in five of seven patients (71%) after surgery and in nine of 11 patients (82%) after medical therapy. In two patients treated with surgery, the dissected part of the aorta had been resected, whereas in two patients treated medically, a progressive and complete obliteration of the false lumen was observed. In the false lumen, thrombus formation was absent in four, localized in four, and progressive in six patients. Flow within the false lumen could be registered in 14 patients, and two distinct flow patterns were differentiated (laminar biphasic flow or slowly circulating flow). Persisting intimal tears were visualized by two-dimensional echocardiography in four patients, whereas color-coded Doppler showed an additional one to three intimal tears in the descending aorta in 10 patients. Flow across these intimal tears was biphasic in 75% of patients; that is, systolic flow was directed from the true to the false lumen with diastolic flow reversal. Unidirectional flow was detected in 25% of the communications, directed in 20% from the true to the false lumen, serving as an entry only and in one (5%) as reentry only. Additional information concerning complications like extension of the dissection (one of 18 patients), localized dilatation of the regurgitation (three of 18 patients) were detected by this method. Concerning the morphologic findings and the detection of flow characteristics, the transesophageal approach was superior to conventional echocardiography especially in the descending thoracic aorta. Thus, transesophageal two-dimensional and color-coded Doppler echocardiography seems to be an ideal method not only for the easy detection of aortic dissection but also for follow-up.     

The role of transesophageal echocardiography in aortic valve preserving procedures

In selected cases of aortic regurgitation, aortic valve (AV) repair and AV sparing root reconstruction viable alternatives to aortic valve replacement. Repair and preservation of the native valve avoids the use of long-term anticoagulation, lowers the incidence of subsequent thromboembolic events and reduces the risk of endocarditis. Additionally repair has a low operative mortality with reasonable mid-term durability. The success and longer term durability of AVPP has improved with surgical experience. An understanding of the mechanism of the AR is integral to determining feasibility and success of an AVPP. Assessment of AV morphology, anatomy of the functional aortic annulus (FAA) and the aortic root with transesophageal echocardiography (TEE) improves the understanding of the mechanisms of AR. Pre- and intra-operative TEE plays a pivotal role in guiding case selection, surgical planning, and in evaluating procedural success. Post-operative transthoracic echocardiography is useful to determine long-term success and monitor for recurrence of AR.     

Intravascular ultrasound in patients with suspected aortic dissection: comparison with transesophageal echocardiography]

Thirteen patients with suspected aortic dissection (two women, 11 men, age 61 +/- 10.8 years) underwent transesophageal echocardiography (TEE), intravascular ultrasound (IVUS), angiography, and in part computed tomography (CT). TEE was performed using 3.5 or 3.75 MHz ultrasound transducers. IVUS examination was done using a 6F 20 MHz "rotational-tip" IVUS catheter (Boston Scientific) advanced over a guiding-wire positioned in the ascending aorta by the "side-saddle" technique. In two patients it was not possible to advance the catheter into the abdominal aorta. Of the remaining 11 patients, eight had aortic dissection (six Typ III, one Typ II, and one Typ I, de Bakey classification). Two patients had aortic aneurysms without dissection and one patient had a perforation of the ascending aorta. TEE, CT, and angiography led to the correct diagnosis in all patients, while IVUS failed to provide precise information within the ascending aorta and the aortic arch. Reasons were the limited scanfield of the 20 MHz transducer and the inability to steer and position the IVUS catheter. Contrary to the limited value in the ascending aorta, IVUS could successfully scan the entire descending aorta, including the dissection membrane and the originating vessels, if the max. diameter was less than 4 cm. No adverse effects occurred. Intravascular ultrasound allows to scan the entire aorta in patients with suspected aortic dissection. The current limitations can be solved only by the introduction of steerable and/or low frequency catheters.