Acute Aortic Disease.. - Index of

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Imaging of Aneurysms and Dissections 45 TTE has significant added value in patients in whom the aortic pathology also involves the aortic valve. The degree of aortic regurgitation is a major determinant of the surgical planning, as degree of aortic insufficiency enters into the equation, in addition to the goal of preventing rupture and/or dissection. Aortic aneurysms and pseudoaneurysms in more distal segments of the aorta may be harder to diagnose, due to limited visibility. Even when the diagnosis can be made by TTE, additional imaging is usually required to define the exact aortic anatomy, to obtain a more precise diameter measurement, and to visualize adequately the length of the abnormality. For the reasons described, mainly the incomplete vessel visualization and large distance from the transducer, TTE is not highly accurate for diagnosis of thoracic aortic dissection. Sensitivity of TTE for detection of aortic dissection is best in the ascending aorta, with reported values 78% to 100% and corresponding specificities 87% to 96%. Accuracy is substantially lower in cases with type B dissections, with much lower sensitivities (7–9). Even when detected, TTE is rarely able to fully describe the length of the dissection, and to clarify the entry and exit points. The proposed echocardiographic criteria for diagnosis of aortic dissection are listed in Table 2. These criteria are applicable for both TTE and TEE. Specificity of TTE for detection of acute aortic dissection is better than the corresponding sensitivity but also suboptimal (7–9). False positive findings are frequently the result of echo reverberations, occurring usually when the ultrasound beam is directed perpendicularly to an interface of tissues with greatly different acoustic impedance (10). Therefore, a positive TTE study may not automatically establish the diagnosis, and confirmation may be sought with a more definitive imaging modality. Similarly, when there is a strong clinical suspicion for dissection, failure of echocardiography to detect the abnormality should not be interpreted as absence of the disease. Instead, additional imaging should be obtained, so that the entire aorta can be adequately imaged. TTE can be particularly helpful in assessing patients with acute aortic dissection when the dissection involves the aortic valve with subsequent aortic regurgitation. This may occur in as many as 50% of patients with ascending aortic dissection (11). In cases where hemopericardium develops from rupture of the aorta into the pericardial sac, TTE can demonstrate the pathology, although the acuity of this condition rarely allows for elective or very detailed assessment. Table 2 Proposed Echocardiographic Criteria for Aortic Dissection Aortic root dilation (type A dissections) Widening of the aortic wall Identification of the dissection flap Detection of two separate flows in the aorta (true and false lumens) Visualization of complications of dissection (aortic regurgitation, left pleural effusion, and hemopericardium)
46 Danias TEE is highly sensitive for detection of acute aortic pathology. Compared to TTE, TEE has the advantage of unobscured images, courtesy of the immediate proximity of the esophagus to the heart and the aorta. The descending thoracic aorta lies immediately behind the esophagus and therefore the entire descending aorta can be visualized in transverse, longitudinal, and oblique planes from the upper and lower esophagus. Imaging of the ascending aorta can be obtained from the upper esophagus, along with a thorough evaluation of the aortic valve. Finally, as the probe is pulled further back, a good view of the aortic arch and the takeoff of the large arch vessels can be obtained. Aortic aneurysms can be thoroughly imaged and precise measurements can be obtained in all directions. The thickness and texture of the aortic wall can also provide information regarding the underlying pathology. For example, in patients with atherosclerotic aneurysms, the presence of calcium, plaque, and intramural thrombus can be easily detected. Regarding assessment of aortic dissection, the sensitivity of TEE is much higher than TTE, and almost the entire thoracic aorta can be adequately imaged. The same diagnostic criteria as those previously described for TTE (Table 2) are used for detection of aortic dissection. The typical diagnostic finding is the identification of the intimal flap inside the aortic lumen (Fig. 4). Blood flow is usually slower in the false lumen compared to the true lumen, and thrombosis of the false lumen is not uncommon. The lumen diameter may be increased in patients with dissecting aneurysm and, in cases with aortic valve involvement, aortic insufficiency can be clearly visualized. TEE can usually identify the entry and exit points (12) but identification of multiple entry and exit sites may be challenging. Compared to TTE, TEE has enhanced sensitivity due to improved visualization. However, the incremental increase in specificity is not similar. Reverberation and linear artifacts are a common source of erroneous interpretation in TEE (13). These artifacts in the ascending aorta occur in as many as one-quarter of patients. Linear artifacts are less common in the descending thoracic aorta and account for
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Acute Aortic Disease
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15. Heart Failure: Basic Science an
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52. Clinical, Interventional, and I
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Informa Healthcare USA, Inc. 270 Ma
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Introduction Informa Healthcare has
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Foreword There is no disease more c
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Preface Over 100 years ago, the gre
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Preface xi Some distinguishing feat
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xiv Acknowledgments Above all, than
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Page 59 and 60: 30 Isselbacher SYMPTOMS Pain Experi
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Page 69 and 70: 40 Danias spinal arteries) and the
Page 71 and 72: 42 Danias Figure 2 Anteroposterior
Page 73: 44 Danias However, due to the dista
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Page 79 and 80: 50 Danias Figure 6 Transverse slice
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Page 91 and 92: 62 Danias DISCUSSION AND COMMENTARY
Page 93 and 94: 64 Danias tomography, among others.
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Page 97 and 98: 68 Raghupathy and Eagle the inciden
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96 Elefteriades and Rizzo Table 3 C
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98 Elefteriades and Rizzo DISCUSSIO
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100 Milewicz et al. KNOWN GENETIC S
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102 Milewicz et al. Table 2 Quick G
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104 Milewicz et al. ascending aorti
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106 Milewicz et al. Turner syndrome
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108 Milewicz et al. dissection in t
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110 Milewicz et al. Figure 5 Haplot
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112 Milewicz et al. A genome wide s
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114 Milewicz et al. Structural anal
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116 Milewicz et al. assembly of a h
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118 Milewicz et al. in the nuclei o
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120 Milewicz et al. 22. Furlong J,
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122 Milewicz et al. DISCUSSION AND
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124 Milewicz et al. Figure A Distri
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126 Elefteriades and Koullias Figur
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128 Elefteriades and Koullias prope
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8 Matrix Metalloproteinases in Aort
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Matrix Metalloproteinases in Aortic
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INTRODUCTION 9 Inflammation and Rem
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Inflammation and Remodeling in the
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10 Weight Lifting and Aortic Dissec
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Weight Lifting and Aortic Dissectio
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11 Timing of Acute Aortic Events: H
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Timing of Acute Aortic Events 171 F
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SECTION IV: TREATMENT OF ACUTE AORT
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Natural History of Thoracic Aortic
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206 Shahriari and Farkas properties
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208 Shahriari and Farkas Figure 2 E
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210 Shahriari and Farkas Less than
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212 Shahriari and Farkas helpful if
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214 Shahriari and Farkas Figure 6 A
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216 Shahriari and Farkas (68). Many
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218 Shahriari and Farkas Figure 9 H
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220 Shahriari and Farkas fistula is
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222 Shahriari and Farkas MEGS is de
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224 Shahriari and Farkas 26. Svenss
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226 Shahriari and Farkas 63. Fehren
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14 Acute Aortic Dissection: Anti-im
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Acute Aortic Dissection 231 lamella
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Acute Aortic Dissection 233 P t is
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Acute Aortic Dissection 235 From th
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Acute Aortic Dissection 237 Figure
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Acute Aortic Dissection 239 concern
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Acute Aortic Dissection 241 Table 2
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Acute Aortic Dissection 243 dissect
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Acute Aortic Dissection 245 22. Bax
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Acute Aortic Dissection 247 62. Lin
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Acute Aortic Dissection 249 DISSCUS
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252 Elefteriades and Griepp ACUTE A
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254 Elefteriades and Griepp Figure
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256 Elefteriades and Griepp sometim
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262 Elefteriades and Griepp to a se
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264 Elefteriades and Griepp Natural
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266 Elefteriades and Griepp CONCLUS
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268 Elefteriades and Griepp DISCUSS
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270 Brinster et al. thoracic aneury
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272 Brinster et al. Figure 1 Retrop
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274 Brinster et al. artery. Z3 land
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276 Brinster et al. or ischemia of
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278 Brinster et al. registry arm (2
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280 Brinster et al. Table 3 Early P
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282 Brinster et al. According to th
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284 Brinster et al. ranged from 1 t
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Table 4 Meta-Analysis of Tevar for
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288 Brinster et al. conventional op
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290 Brinster et al. using no (or lo
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292 Brinster et al. Table 5 Risk Fa
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294 Brinster et al. wire manipulati
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296 Brinster et al. Thoracoabdomina
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298 Brinster et al. 25. Hagan PG, N
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300 Brinster et al. 60. Elefteriade
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302 Brinster et al. 98. Liu ZG, Sun
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304 Brinster et al. 131. Szeto WY,
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306 Brinster et al. 100% 90% 80% 70
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308 Brinster et al. ● “Long-ter
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310 Hackmann et al. treatment. New
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312 Hackmann et al. tissue than in
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314 Hackmann et al. Table 1 Pharmac
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316 Hackmann et al. Some anti-hyper
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318 Hackmann et al. inhibits NF-κB
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320 Hackmann et al. Patients with C
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322 Hackmann et al. ACKNOWLEDGMENTS
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324 Hackmann et al. 34. Thompson RW
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326 Hackmann et al. 70. LeMaire SA,
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328 Hackmann et al. 105. Marra DE,
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330 Hackmann et al. DISCUSSION AND
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332 Elefteriades Diseases of the th
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334 Elefteriades Table 1 Individual
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336 Elefteriades Table 1 Individual
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338 Elefteriades Failure to Diagnos
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340 Elefteriades of physicians on t
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342 Elefteriades Figure 3 Computed
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344 Elefteriades reviewed over the
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346 Elefteriades DISCUSSION AND COM
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348 Elefteriades Figure 1 (See colo
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350 Elefteriades that are the subje
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SECTION VII: SYNTHESIS 20 The Key L
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The Key Lessons of This Book—In a
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362 Index Aging, aortic aneurysms a
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364 Index Cytokines, aortic aneurys
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366 Index Pathoanatomy classificati
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368 Index [Thoracic aortic aneurysm
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Figure 1.C Note from schematic depi
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Figure 8.1 Dramatic clinical exampl
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Figure 11.2 Proposed schema for the
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Figure 19.1 Future prospects in car
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