Diseases of the Aorta. Oh’s The Echo Manual Aortic aneurysm Aneurysm of the sinus of Valsalva...
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Transcript of Diseases of the Aorta. Oh’s The Echo Manual Aortic aneurysm Aneurysm of the sinus of Valsalva...
Diseases of the Aorta
Oh’s The Echo Manual
• Aortic aneurysm
• Aneurysm of the sinus of Valsalva
• Atherosclerosis & aortic debris
• Aortic dissection & intramural hematoma
• Aortitis
• Coarctation of the aorta
Feigenbaum’s Echocardiography
• Aortic dilatation & aneurysm
• Valsalva sinus aneurysm
• Aortic dissection
• Aortic atheroma
• Miscellaneous conditions
Thoracic Aorta
• Anatomy– Ascending aorta
• Aortic root & sinuses of Valsalva
– Aortic arch• Great vessels: brachiocephalic, left common
carotid, & left subclavian arteries
– Descending aorta• Intercostal arteries• Anterior spinal artery
– Abdominal aorta begins below diaphragm
Thoracic Aorta
• Histology– Intima– Media– Adventitia
• Physiology– Systole elastic stretch potential energy– Diastole elastic recoil kinetic energy
Aortic Aneurysm
• Pathologic dilatation > 1.5 times the normal diameter– Fusiform = symmetric dilatation– Saccular = asymmetric outpoutching– False = contained rupture
• Thoracic much less common than abdominal– AAA = 36.5 per 100,000 person-years– TAA = 5.9 per 100,000 person-years
Etiology
• Marfan syndrome– AA & arch
• Ehlers-Danlos syndrome– AA & arch
• Cystic medial degeneration– AA & arch
• Atherosclerosis– DA
• Traumatic– Proximal DA
• Inflammatory– Variable
• Infectious– AA (syphilis)– Variable (mycotic)
• Poststenotic– AA (aortic stenosis)– DA (coarctation)
• Postsurgical– AA (s/p AVR)
Clinical Course
• Natural history & progression of TAA not as well defined as AAA– Onset of symptoms heralds a more rapid
course
• Dichotomous growth rate– TAAs < 5.0 cm grow 0.17 cm/year– TAAs ≥ 5.0 cm grow 0.79 cm/year
• 5-year survival = 20-50%– Rupture is most common cause of death
Clinical Presentation
• Vascular complications– AR, CHF, ischemia from compression of coronary
artery, sinus of Valsalva rupture into RA or RV with LR shunt, thromboembolism
• Compression of external structures– SVC syndrome, dysphagia, hoarseness, respiratory
complaints, chest or back pain
• Rupture– Sudden, severe, sharp chest or back pain– Left pleural space > pericardium > esophagus
Physical Exam
• Diastolic murmur of AR
• Signs of CHF
• Pulsatile mass in suprasternal notch
• Differential pulses in extremities
• Signs of SVC syndrome
• Decreased air movement or stridor
Diagnosis
• CXR – shows widened mediastinum
• CT – defines size & extent
• MRA – also defines size & extent
• TTE – limited use
• TEE – role is under evaluation
• Aortography – reserved for pre-op eval
Therapy
• Medical– β-blockers decrease dP/dT (sheer stress)
• Percutaneous– Stent graft for DA distal to left subclavian a.
• Surgical– Recommended when maximal diameter is
greater than 6 cm• 7 cm for high-risk patients• 5.5 cm for Marfan patients
Surgery
• Dacron tube graft• Bentall procedure = valve + graft• Survival
– Perioperative mortality = 5-10%– 1-year survival ≥ 70%– 5-year survival = 50-60%
• Complications– MI (7.2%), CVA (4.8%), ARF (2.4%),
hemorrhage (7.2%), & paraplegia (6.0%)
Krinsky G et al. N Engl J Med 1997;337:1475-1476
Gadolinium-enhanced, three-dimensional MRA showing an aneurysm of the aortic arch (arrow) as well as a concomitant atherosclerotic ulcer (arrowhead)
Kawasaki S and Kawasaki T. N Engl J Med 2007;356:1251
An 84-year-old man with a history of gastric cancer and hypertension was admitted to the emergency department in shock after loss of consciousness
Aneurysm of Sinus of Valsalva
• Results from absence of media
• Typically does not cause symptoms
• Can compress adjacent structures
• Can rupture into adjacent structures– Most commonly into RA or RV– Ventricular septum
• Surgical repair typically recommended– Even in asymptomatic patients
Atherosclerosis
• Common finding in elderly patients
• Aortic plaques are more common in descending aorta > aortic arch > ascending aorta
• Typically are irregularly-shaped & frequently are mobile
• Can be flow-limiting or hemodynamically-compromising
Atherosclerosis
• Independent predictor of long-term neurologic morbitity & mortality
• In one study, ulcerated plaque present in 26% of patients with CVA but only 5% of patients without CVA
• Plaques > 4 mm thick are more likely to cause an embolic event
Kouchoukos N and Dougenis D. N Engl J Med 1997;336:1876-1889
Transverse epiaortic ultrasonographic image of the ascending aortain a patient with severe atherosclerosis of the ascending aorta
Aortic Dissection
• Incidence = 2,000 cases per year in US
• 2-to-1 male-to-female ratio
• Peak incidence in 6th & 7th decade of life
• 65% occur in AA, 20% in DA, 10% in arch, & 5% in abdominal aorta
• Mortality (75-80%) is greatest during acute phase (< 2 weeks)
Nienaber CA, Eagle KA. Circulation 2003; 108: 628-625.
Nienaber CA, Eagle KA. Circulation 2003; 108: 628-625.
Nienaber CA, Eagle KA. Circulation 2003; 108: 628-625.
Clinical Presentation
• Sudden, severe chest and/or back pain– Tearing, stabbing, or ripping
• Less common presentations– CHF (due to AR)– Syncope (due to tamponade)– CVA– Paraplegia– Cardiac arrest
Physical Exam
• Hypertension– Hypotension– Pseudohypotension
• Diastolic murmur of AR
• Signs of CHF
• Pulse deficits
• Neurologic deficits
Diagnosis
• CXR– Widened aortic silhouette– Calcium sign = displacement of intimal calcium > 1
cm from outer aortic soft tissue
• CTA– Sensitivity = 83-94%– Specificity = 87-100%
• MRA– Gold standard– Sensitivity & specificity ~ 98%
Diagnosis
• TTE– Better for AA than DA – Sensitivity = 59-85%– Speficificty = 63-96%
• TEE– Sensitivity = 98-99%– Specificity = 77-97%– Depends on experience of operator
Pasic M et al. N Engl J Med 1999;341:1775
CT Scan Showing Localized Dissection of the Aortic Arch with an Intimal Tear (Arrows)
Kouchoukos N and Dougenis D. N Engl J Med 1997;336:1876-1889
MRI of type B aortic dissection
Pineiro D and Bellido C. N Engl J Med 1999;340:1553
A 68-year-old woman was admitted to the emergency room with sudden left hemiparesis
O'Gara P et al. N Engl J Med 2004;350:1666-1674
TEE of type A aortic dissection
Nienaber CA, Eagle KA. Circulation 2003; 108: 772-778.
Nienaber CA, Eagle KA. Circulation 2003; 108: 628-625.
Mehta RH, et al. Circulation 2002: 105: 200-206.
Mehta RH, et al. Circulation 2002: 105: 200-206.
Mehta RH, et al. Circulation 2002: 105: 200-206.
Equation for predicting mortality
Mehta RH, et al. Circulation 2002: 105: 200-206.
Intramural Hematoma
• Thrombus between intima & adventitia
• Typically occurs in elderly patients with hypertension
• Precursor for aortic dissection– 15-20% of dissections present with hematoma– 12-45% of hematomas progress to dissection
• Managed similarly to aortic dissection
Kouchoukos N and Dougenis D. N Engl J Med 1997;336:1876-1889
Computed Tomographic Scan of an Intramural Hematoma (Arrows) of the Ascending Aorta
Schmidli J and Carrel T. N Engl J Med 2003;348:1776
A 68-year-old man presented with acute thoracic, abdominal, & back pain & progressive shock
Harris K and Rosenbloom M. N Engl J Med 1997;336:1875
A 77-year-old woman with a history of hypertension and an abdominal aortic aneurysm presented with acute upper back discomfort
Aortitis
• Inflammation of aortic wall
• Etiologies include– Infectious
• Syphilitic & mycotic
– Vasculitis• Giant cell arteritis & Takayasu’s disease
– Connective-tissue disease• Ankylosing spondylitis & rheumatoid arthritis
Pugh P and Grech E. N Engl J Med 2002;346:676
Examination of a 74-year-old man with a one-year history of mild, stable angina revealed a murmur consistent with the presence of aortic regurgitation
Coarctation of the Aorta
• Potential cause of secondary hypertension
• Narrowing of descending thoracic aorta– Typically distal to left subclavian artery
• Associated with bicuspid aortic valve, PDA, VSD, aneurysm of circle of Willis, & Turner syndrome
Bruce C and Breen J. N Engl J Med 2000;342:249
A 30-year-old farmer was referred for evaluation of a bicuspid aortic valve
References
• Oh’s The Echo Manual
• Topol’s Manual of Cardiovascular Medicine