New ASE Guidelines: What you must know Federico M Asch MD, FASE, FACC Chair, ASE Guidelines and Standards Committee Medstar Washington Hospital Center Medstar Health Research Institute Georgetown University Washington, DC Costa Rica, August 2015
DISCLOSURE I, Federico Asch, have no relevant financial relationships with pharmaceutical, devices companies or the Educational Committee related to this activity.
ASE Guidelines 2014 Expert Consensus for Multimodality Imaging Evaluation of Adult Patients during and after Cancer Therapy: A Report from the ASE and EACVI, JASE, September 2014 Guidelines for the Cardiac Sonographer in the Performance of Contrast Echocardiography: A Focused Update from the ASE, JASE, August 2014 Radiation Safety for the Cardiac Sonographer: Recommendations of the Radiation Safety Writing Group for the Council on Cardiovascular Sonography of the ASE, JASE, August 2014 Multimodality Imaging Guidelines for Patients with Repaired Tetralogy of Fallot: A Report from the ASE, JASE, February 2014
ASE Guidelines 2015 Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and the EACVI, JASE, January 2015 Guidelines for the Use of Echocardiography as a Monitor for Therapeutic Intervention in Adults: A Report from the ASE, JASE, January 2015 Multimodality Imaging of Diseases of the Thoracic Aorta in Adults: From the ASE and the EACVI. JASE, February 2015 Use of Echo in Adult Hypertension: From EACVI and ASE. JASE July 2015 Guidelines for the Evaluation of ASD and PFO: ASE and SCA. JASE August 2015 Guidelines for the use echo in the management of patients with Left Ventricular Assist Device. JASE, August 2015
Update from the 2005 ASE Chamber Quantification document (Lang et al) Most referenced article in JASE history (>5500) Need for update given newer technologies newer techniques wealth of normative data available
What is new in the Updated CQ document Chamber dimension and function encompass many parameters, including strain and 3D echo. Describes all four chambers, and it is done in a way to avoid discrepancies with other guidelines. (2005 was only LV and LA) The writing group created the data from five databases representing > 3,000 patients. (2005 was expert opinion) The new document only indicates normal/abnormal. It will be left to the individual institutions to determine what they consider mild/moderate/severe.
Multiple modalities described M-mode 2D linear 2D Volumes
Multiple modalities described 2D Contrast 3D Strain
LV Normal ranges
Sources for the normative values
RV Function
The document by R Lang et al has been published in the Jan 2015 issue of JASE.
GUIDELINES AND STANDARDS J Am Soc Echocardiogr 2015;28:119-82 www.asecho.org Guidelines
Chest X-ray Imaging Techniques Echo (TTE, TEE, 3D-echo, epiaortic) Intravascular echo (IVUS) Intracardiac echo (ICE) CT/MDCT Magnetic resonance imaging Aortography
Diseases of the Thoracic Aorta Acute aortic syndromes - Aortic dissection - Intramural hematoma - Penetrating aortic ulcer - Ruptured aortic aneurysm Thoracic aortic aneurysms - Bicuspid aortic valve-related aortopathy - Marfan syndrome - Other genetic diseases (Ehlers-Danlos; Loeys-Dietz, Turner syndrome,etc) continued...
Diseases of the Thoracic Aorta Traumatic injury of thoracic aorta Aortic coarctation Atherosclerosis Aortitis - Noninfectious - Infectious
Measuring the Aorta
Measure perpendicular to the long-axis of the aorta
Measurement Options Inner edge-inner edge - CT Outer-outer Leading edge-leading edge- Echo
Recommended time to measure the aortic root A. End-systole B. End-diastole - Greater reproducibility (Ao pressure more stable in late diastole) - End-diastole easy to ID by QRS
TTE TEE CT and MRI
Thoracic Aortic Aneurysms
What to look for? Normal Aortic size in the adult: Ao root < 40 mm Ascending Ao < 37 mm Descending Aorta < 28 mm These values are, however, very variable.
Aortic size to be adjusted by body size and age < 20 yo 20-40 yo >40 yo Roman M et al. Am J Cardiol 1989;64:507
Complications and Asc Ao size Importance of accurate measurements Elefteriades, JACC 2010;55:841
Asc Aortic size at time of Type A Dissection 60% < 5.5 cm 40% <5 cm Pape et al for IRAD. Circulation 2007;116:1120
You want to explore the ENTIRE Aorta, AT LEAST ONCE
Marfan - Ao Root aneurysm
Marfan with prior graft in Asc Aorta Oct 2012 Dec 2012 Need to look at entire Aorta!! Dissections post graft! Mostly in arch/desc! Asch FM, Weinsaft J et al. Manuscript Under Review
Marfan MVP RPA aneurysm
Marfan Syndrome - Role of imaging Monitoring aortic enlargement Monitoring every 6/12 months (same method, side by side) Surgical Indication: Aortic diameter > 5cm Rapid progression (2-4 mm/year) Aortic dissection Family Hx of early dissection
BAV Aortopathy RL fusion type Most Common 33-60 % Normals Aortic root: 1-25 % Asc Aorta: 32-35% Arch: 10 % Kang JW et al. J Am Coll Cardiol Img 2013; 6:150 Schaefer BM et al. Heart 2008;94:1634.
RN fusion type (or RL distribution) RN fusion type 19-32 % Normals Aortic root: 1-15 % Asc Aorta: 26-54 % Arch: 41 % Kang JW et al. J Am Coll Cardiol Img 2013; 6:150 Schaefer BM et al. Heart 2008;94:1634.
BAV Asc Ao/Arch aneurysm
Acute Aortic Syndromes
Acute Aortic Syndromes Aortic dissection Intramural hematoma Penetrating aortic ulcer Ruptured aortic aneurysm
Aortic Dissection - Imaging Identify entry site Primary Objectives Determine type A vs B Involvement of coronary arteries? Identify complications: Presence, severity, mechanism of AR Pericardial or pleural effusion Rupture? Branch ischemia
Suspected Aortic Dissection Sensitivity of Imaging Modalities Meta-Analysis of 1,139 Patients Fig 23. Goldstein J Am Soc Echocardiogr 2015;28(2):119-82
Suspected Aortic Dissection Specificity of Imaging Modalities Meta-Analysis of 1,139 Patients Fig 24. Goldstein J Am Soc Echocardiogr 2015;28(2):119-82
. Aortic Dissection 2D-Echo Findings Hallmark: dissection flap Dilated aorta Widening of aortic walls Aortic insufficiency Pericardial and/or pleural effusion
Descending Thoracic Aorta TEE CT-scan
Aortic Arch CT-scan TEE
Hemopericardium
Flow in right coronary artery
Left coronary artery
Left Subclavian Artery
Mechanisms of Aortic Regurgitation B C
Atypical" Aortic Dissection (Intramural Hematoma) TL FL Typical "Atypical" = Dissection flap and false lumen = No dissection flap; Medial hematoma
"Atypical" Aortic Dissection (Intramural Hematoma) Prevalence 10-20% in CT/MRI/TEE studies Type III more common Normal size lumen False negative aortograms
Penetrating Aortic Ulcer adventitia media intima An ulceration of an atheromatous plaque that disrupts the internal elastic lamina and burrows deeply into the media
Ulcerated Aortic Plaque
Summary ASE takes Guidelines and Standards as a key component of its mission Newer roles of echocardiography trigger new guidelines: LV Assist devices Interventional Echocardiography ASD/PFO Older problems still need to be addressed; Updates are needed Valvular regurgitation and Stenosis Stress testing beyond CAD CSOE STAY TUNED FOR FURTHER GUIDELINES TO COME
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