Acute Aortic Syndromes

Acute Aortic Syndromes Vera H. Rigolin, MD, FASE, FACC, FAHA Professor of Medicine Northwestern University Feinberg School of Medicine Medical Director, Echocardiography Laboratory Northwestern Memorial Hospital Immediate Past-President, American Society of Echocardiography Disclosures Disclosures: None that pertain to this presentation. Acute Aortic Syndrome • Aortic dissection • Intramural hematoma • Atherosclerotic plaque rupture • Penetrating ulcer • Aneurysm rupture All have similar clinical presentations Sudden onset severe chest/back pain Aortic Dissection • Annual incidence is 10-30 per million • Usually occurs in pts with pre-existing aortic conditions – Aneurysms, Marfan’s, bicuspid AV, HTN • Intimal tear into media. Column of blood propagates prox and distal to tear. Types of Aortic Dissection Feigenbaum’s Echocardiography, 7th ed. 2010 Complications of Aortic Dissection • Pericardial effusion • Complete or partial aortic rupture • Compromise of branch vessels • Coronary artery compromise • Aortic pseudoaneurysm • Aortic insufficiency History • 52 yo M w/ HTN, HL presented with chest pressure and headache. • Chest pressure began after pt began after a migraine. • Describes chest sensation as constant "pressure" in substernal, as if "someone were pressing on my chest”. • Chest pressure was constant, lasted until pt received SLNG in ED. • In ED, noted new heart murmur. EKG was non-ischemic. CXR negative for acute process. Trop=0.02 • Echo with Doppler/stress echo ordered PLAX PLAX PLAX Suprasternal Notch Apical 5 Chamber Spectral Doppler Intra-op TEE Mechanisms of AR in Aortic Dissection Feigenbaum’s Echocardiography, 7th ed. 2010 65 yr old Asian Female Complaining of Chest Pain M-mode AV PLAX Accuracy of TEE for Diagnosis of Aortic Dissection Feigenbaum’s Echocardiography, 7th ed. 2010 Intramural Hematoma • Variant of aortic dissection • Hemorrhage into media without rupture into lumen • Defined as area of crescenteric thickening of wall of >7 mm. No communication to lumen • 60% located in descending aorta • Often associated with atherosclerosis • Ascending aorta IMHs are surgical Dissection vs Hematoma Feigenbaum’s Echocardiography, 7th ed. 2010 History • 79 yr old female with h/o HTN, COPD • Presented with hypertensive urgency and neck/face pain and headache Aortic Arch Descending Aorta Another Case 95 yr old with back pain who died from multiorgan failure a week later This was incidentally noted on a CT Slide Courtesy of Kameswari Maganti, MD Penterating Ulcer • Begins as ulceration of atherosclerotic plaque • Results in disruption of intima and media • Penetration through adventitia can result in aortic rupture • Typical imaging characteristics: Focal outpouching of aortic wall; often with atherosclerosis Penetrating Ulcer Feigenbaum’s Echocardiography, 7th ed. 2010 Penetrating Aortic Ulcer (2-8% of AAS) • Atherosclerotic lesion penetrates internal elastic lamina into media • Associated with variable degree of IMH • May lead to pseudoaneurysm, rupture or late aneurysm • Acute chest or back pain • More common in desc ao (61%), abdominal ao (30%), arch of aorta (7%) • 25% of PAUs are incidentally detected Slide Courtesy of Kameswari Maganti, MD Penetrating Ulcer J Am Coll Cardiol. 57(11):1327, 2011 Mar 15. Summary • Aortic dissection, intramural hematoma and penetrating ulcer known as acute aortic syndromes • Clinical presentations are similar • TEE is useful in defining diagnosis, location and associated complications Thank You.

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