Multimodality Imaging of the Thoracic Aorta
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1 Multimodality Imaging of the Thoracic Aorta Steven Goldstein MD, FACC Director Noninvasive Cardiology MedStar Heart and Vascular Institute Washington Hospital Center Saturday, October 8, 2016
2 DISCLOSURE I have N O relevant financial relationships
3 Sunset in Kentucky
4 GUIDELINES AND STANDARDS J Am Soc Echocardiogr 2015;28: www. asecho.org Guidelines
5 Imaging Modalities
6 Imaging Techniques Chest X-ray Echo (TTE, TEE, 3D-echo, epiaortic) Intravascular echo (IVUS) Intracardiac echo (ICE) CT/MDCT Magnetic resonance imaging Aortography
7 Imaging Techniques Chest X-ray Echo (TTE, TEE, 3D-echo, epiaortic) Intravascular echo (IVUS) Intracardiac echo (ICE) CT/MDCT Magnetic resonance imaging Aortography
8 Acute Aortic Syndromes
9 Heart 2001;85: Isidre Vilacosta and Jose Alberto San Roman
10 Acute Aortic Syndromes Heterogeneous group of conditions Disruption of the aortic wall Similar clinical picture - Chest and/or back pain ( aortic pain ) - Usually underlying hypertension Need for prompt diagnosis urgent care
11 Acute Aortic Syndromes Classic aortic dissection Intramural hematoma (variant of AD) Penetrating atherosclerotic aortic ulcer Ruptured/leaking aortic aneurysm Aortic trauma usually considered separately
12 Acute Aortic Syndromes Delay in recognition and treatment is associated with unacceptable increase in mortality Signs and symptoms may be subtle/atypical Diagnosis requires high index of suspicion
13 Acute Aortic Syndromes Imaging Modalities Rapid, accurate diagnosis essential CT-scan Echocardiography (TTE;TEE) Preferred in acute setting Magnetic resonance imaging
14 Aortic Dissection
15 Aortic Dissection Tear Adventitia Media Intima Tear False Lumen Blood True Lumen
16 Aortic Dissection - Imaging Primary Objectives Identify entry site Determine type A vs B Involvement of coronary arteries? Identify complications: Presence, severity, mechanism of AR Pericardial or pleural effusion Rupture? Branch ischemia
17 aortic dissection
18 Imaging Modalities for Aortic Dissection CT-Scan Initial test in >70% of patients (IRAD) Widely available, quickest diagnostic times Very high diagnostic accuracy Relatively operator independent Allows evaluation of entire aorta (including arch vessels, mesenteric vessels, and renal arteries)
19 CT-Scan for Aortic Dissection Disadvantages Ionizing radiation exposure Requires iodinated contrast material Pulsation artifact in ascending aorta (can be improved with ECG gating)
20 Imaging Modalities for Aortic Dissection Very high diagnostic accuracy Widely available, portable, convenient, fast Excellent for: TEE - Pericardial effusion - Presence, degree, mechanism of AR - L V function Can detect involvement of coronary arteries Safely performed on critically ill patients Optimal procedure for guidance in OR
21 Detection of Aortic Dissection Accuracy of TEE Author Year n With Diss'n Sens Spec Erbel Hashimoto Adachi Ballal Simon Nienaber % 100% 98% 97% 100% 98% 98% N/A N/A 100% 100% 77% Kang % 91% Totals % 94%
22 TEE for Aortic Dissection Disadvantages Depends on skill of operator Blind spot upper ascending aorta Not reliable for cerebral vessels, mesenteric vessels, renal arteries Semi-invasive Reverberation artifacts (rarely a problem)
23 Imaging Modalities for Aortic Dissection MRI Very high diagnostic accuracy 3D multiplanar and high resolution Does not require ionizing radiation or iodinated contrast material Appropriate for serial imaging over many years
24 MRI for Aortic Dissection Disadvantages Less widely available Difficult monitoring critically ill patients Longer examination time Not feasible in emergent of unstable clinical situations Caution with use of gadolinium in renal failure
25 Diagnosis of Aortic Dissection Comparative Study of Spiral CT, MRI, TEE 49 suspected aortic dissection 25 had dissection (18 type A; 7 type B) Spiral CT Sensitivity Specificity 100% 100% Time 28 min MRI 100% 94% 27 min TEE 100% 94% 45 min Sommer Radiology 199:347(1996)
26
27 . Aortic Dissection 2D-Echo Findings Hallmark: dissection flap Double-channel aorta (TL and FL) Dilated aorta (usual) Re-entry sites (ostia of intercostals) Cobwebs (false lumen) Aortic insufficiency Pericardial and/or pleural effusion
28
29 LA TL FL
30
31 Descending Thoracic Aorta TEE CT-scan
32 Aortic Arch CT-scan TEE
33 Aortic Regurgitation Mechanisms of Aortic Regurgitation Dilatation of aortic root leading to incomplete aortic leaflet copatation Cusp prolapse Disruption of aortic annular support resulting in flail leaflet Invagination of dissection flap through the aortic valve in diastole Pre-existing aortic valve disease (eg,bic AoV)
34 Mechanisms of Aortic Regurgitation A B C
35
36 Case 1
37 Case 2 RM - 46 year old man Known bicuspid aortic valve S/P coarct repair (remote) Sudden onset of severe chest pain Syncope
38 Intramural Hematoma
39 Atypical" Aortic Dissection (Intramural Hematoma) TL FL Typical "Atypical" = Dissection flap and false lumen = No dissection flap; Medial hematoma
40 "Atypical" Aortic Dissection (Intramural Hematoma) Prevalence 10-20% in CT/MRI/TEE studies Type III more common Normal size lumen False negative aortograms
41 Totals 289/1,687 17%
42 Intramural Hematoma Imaging Features Focal aortic wall thickening Preserved luminal shape with a smooth luminal border Absence of dissection flap and false lumen Echolucent regions may be present in the aortic wall Note: Often missed by aortogram which is a luminogram
43
44
45 Intramural Hematoma
46 Intramural Hematoma CT-scan
47 Intramural Hematoma MRI
48 Case 3
49 Case 4
50 Summary Advances in imaging techniques have greatly increased our understanding of thoracic aortic diseases Indications for specific modality depends on: - Accuracy for specific diseases - Availability - Cost/benefit ratio TTE used most often for aortic root assessment continued...
51 Summary CT-scan high resolution of entire aorta including arch, mesenteric, and renal vessels MRI greatest morphologic and dynamic information without radiation, but less widely available TEE optimal procedure for guidance in OR safely performed on critically ill patients, even those on ventilators
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