1 / 66

Diseases of the Aorta

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

liseli
Download Presentation

Diseases of the Aorta

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Diseases of the Aorta

  2. 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

  3. Feigenbaum’s Echocardiography • Aortic dilatation & aneurysm • Valsalva sinus aneurysm • Aortic dissection • Aortic atheroma • Miscellaneous conditions

  4. 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

  5. Thoracic Aorta • Histology • Intima • Media • Adventitia • Physiology • Systole  elastic stretch  potential energy • Diastole  elastic recoil  kinetic energy

  6. 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

  7. 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) Etiology

  8. 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

  9. Clinical Presentation • Vascular complications • AR, CHF, ischemia from compression of coronary artery, sinus of Valsalva rupture into RA or RV with LR 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

  10. 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

  11. 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

  12. 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

  13. 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%)

  14. Gadolinium-enhanced, three-dimensional MRA showing an aneurysm of the aortic arch (arrow) as well as a concomitant atherosclerotic ulcer (arrowhead) Krinsky G et al. N Engl J Med 1997;337:1475-1476

  15. 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 Kawasaki S and Kawasaki T. N Engl J Med 2007;356:1251

  16. 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

  17. 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

  18. 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

  19. Transverse epiaortic ultrasonographic image of the ascending aorta in a patient with severe atherosclerosis of the ascending aorta Kouchoukos N and Dougenis D. N Engl J Med 1997;336:1876-1889

  20. 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)

  21. Nienaber CA, Eagle KA. Circulation 2003; 108: 628-625.

  22. Nienaber CA, Eagle KA. Circulation 2003; 108: 628-625.

  23. Nienaber CA, Eagle KA. Circulation 2003; 108: 628-625.

  24. 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

  25. Physical Exam • Hypertension • Hypotension • Pseudohypotension • Diastolic murmur of AR • Signs of CHF • Pulse deficits • Neurologic deficits

  26. 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%

  27. 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

  28. CT Scan Showing Localized Dissection of the Aortic Arch with an Intimal Tear (Arrows) Pasic M et al. N Engl J Med 1999;341:1775

  29. MRI of type B aortic dissection Kouchoukos N and Dougenis D. N Engl J Med 1997;336:1876-1889

  30. A 68-year-old woman was admitted to the emergency room with sudden left hemiparesis Pineiro D and Bellido C. N Engl J Med 1999;340:1553

  31. TEE of type A aortic dissection O'Gara P et al. N Engl J Med 2004;350:1666-1674

  32. Nienaber CA, Eagle KA. Circulation 2003; 108: 772-778.

  33. Nienaber CA, Eagle KA. Circulation 2003; 108: 628-625.

  34. Mehta RH, et al. Circulation 2002: 105: 200-206.

  35. Mehta RH, et al. Circulation 2002: 105: 200-206.

More Related