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.