European Journal of Echocardiography (2009) 10, i31–i39

doi:10.1093/ejechocard/jen251

Echocardiography in the emergency assessment

of acute aortic syndromes
E. Louise Meredith and Navroz D. Masani*
Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK

KEYWORDS Acute aortic syndrome (AAS) is a collective term for several life-threatening acute aortic conditions:
Acute aortic syndromes; aortic dissection, intramural haematoma (IMH), penetrating atherosclerotic ulcer, and traumatic tran-
Acute aortic dissection; section. Mortality from acute ascending aortic (type A) dissection increases rapidly immediately after
Intramural haematoma; presentation, reaching 1–2% per hour for the first 48 h. Early surgical intervention is recommended
Transthoracic for type A aortic dissection and has been shown to improve outcome. Transthoracic echocardiography
echocardiography; is an extremely valuable, often overlooked, clinical tool in diagnosing and assessing AAS in the emer-
Transoesophageal gency setting. Although diagnostic sensitivity is suboptimal, it is very useful in assessing potential
echocardiography high risk features or complications, such as pericardial effusion, and diagnosing potential differential
conditions. A negative transthoracic echocardiography (TTE), however, does not exclude AAS. In
patients with a high risk of type A dissection or IMH (identified clinically or by TTE), the safest and
most rapid ‘gold standard’ investigation is transoesophageal echocardiography, ideally performed
with the cardiac surgical team standing by. This is of particular importance in the haemodynamically
unstable patient. Transoesophageal echocardiography, helical CT, and MRI have similar diagnostic accu-
racy and, when there is diagnostic uncertainty or no indication for immediate intervention, should be
used according to clinical need, local availability, and expertise.

Introduction radiate to the neck in ascending aortic disease or the back

In this article, we review the role of echocardiography in the
emergency management of acute aortic syndromes (AAS).
We focus on the importance of echocardiography in
the early assessment of patients with suspected AAS in the
emergency and critical care settings. In particular, the
value of transthoracic echocardiography (TTE), often over-
looked, in the immediate management of such patients is
explored. The pivotal role of transoesophageal echocardio-
graphy (TEE) is reviewed, with particular emphasis on its
value in patients requiring cardiac surgery. Finally, we
describe a locally developed approach that optimizes the
strengths of TTE, TEE, and other imaging modalities.
Acute aortic syndrome (AAS) is a collective term for
several life-threatening acute aortic conditions: aortic
dissection, intramural haematoma (IMH), penetrating ather-
osclerotic ulcer (PAU), and traumatic transection.1 Trau-
matic transection does not share pathophysiological or
clinical features with the other conditions and will not be
considered in this article.
Patients with AAS may have similar presenting symptoms,
clinical features, and co morbid disease. Classically, AAS
patients present with severe acute chest pain which can
* Corresponding author. Tel: þ44 2920744086; fax: þ44 2920743916.
E-mail address: navroz.masani@cardiffandvale.wales.nhs.uk
in descending aortic disease.2 The chest pain may have a
pleuritic or pericarditic nature. In type A dissection or
IMH, there may be acute aortic regurgitation (AR) and
associated cardiac failure. There may be differences in
upper limb blood pressure, pulse deficits, and evidence of
end-organ ischaemia.3 Transient loss of consciousness is an
important presenting feature of type A dissection. Well-
recognized risk factors include longstanding hypertension
and atherosclerosis as well as collagen disorders such as
Marfan’s syndrome (Table 1). These patients often have sig-
nificant co morbid disease such as hypertension, coronary
artery disease, and renal impairment.3
Pathophysiology, classification, and
implications for management
Aortic dissection
Aortic dissection occurs as a result of a tear in the intimal
lining of the aorta resulting in intimal exposure to elevated
aortic pressures. The intima separates from the aortic wall
forming a false lumen, which runs alongside the true
lumen (Figure 1). The elevated pressures lead to pro-
pagation of the dissection proximally, distally or in both
directions. A re-entrant tear may allow blood to circulate
through the false lumen.

Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009.
For permissions please email: journals.permissions@oxfordjournals.org.

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 i32 E.L. Meredith and N.D. Masani

Table 1 Risk factors for the development of acute aortic

syndrome

Hypertension
Atherosclerosis
Collagen disorders
Marfans
Turners
Noonans
Ehlers danlos
Osteogenesis imperfecta
Bicuspid aortic valve
Coarctation of the aorta
Pregnancy
Trauma
Deceleration injuries, blunt trauma, penetrating injuries
Iatrogenic
Post-cardiac surgery
Cross-clamping
Coronary cannulation
Aortic valve replacement
Post-coronary angiography/angioplasty
Post-renal angioplasty
Inflammatory
Giant cell arteritis, Bechets, syphilis, aortitis

The entry tear occurs at sites of greatest wall stress. This

is most commonly within a few centimetres of the aortic
valve on the right lateral wall of the ascending aorta or
close to the ligamentum arteriosum in the descending
aorta. Sixty-five per cent of the cases occur within 3 cm of
the coronary ostia, 10% occur within the arch, and 10% in
the descending thoracic aorta.
Classification systems have been developed to describe
the anatomic location of aortic dissection, which are
useful in determining prognosis and guiding management.
The Stanford classification was developed from a functional
approach based on whether the ascending aorta was
involved. Type A refers to dissections involving the ascend-
ing aorta and type B the remainder.4
In the DeBakey classification, type 1 originates in the
ascending aorta and extends to the arch or beyond. Type 2
is confined to the ascending aorta. Type 3 originated distal
to the left subclavian and propagates to the distal descend-
ing thoracic (3A) or abdominal (3B) aorta.5 We will use the
Stanford system in this article.
More recently, a classification based on the pathophysiolo-
gical features of the aortic lesion rather than its location has
been proposed:6 Class 1: classic aortic dissection with true
and false lumen without communication of the two
lumina; class 2: intramural haemorrhage or haematoma;
class 3: ulceration of aortic plaque following plaque
rupture; class 4: subtle or discrete aortic dissection with
bulging of the aortic wall; class 5: iatrogenic or traumatic
aortic dissection, illustrated by a catheter induced separ-
ation of the intima.
Thus, it is recommended that AAS be classified according
to both lesion type and location.7
Figure 1 Intimal flap and tear in a patient with acute type A aortic
dissection. (A) In the transoesophageal echocardiography short-axis
view, a mobile linear flap is seen in the aortic root, just above
the aortic valve leaflets (which can also be seen). The tear in the
flap, where the small central true lumen communicates with the
false lumen, is shown by the white arrow. (B) In the same patient,
a 26-year-old man with no other co-morbidities, a short-axis view
just below the origin of the flap, showing a bicuspid aortic valve.
disruption.8,9 Blood collects within the aortic media
without the presence of a tear in the intimal lining and is
caused by rupture of the vasa vasorum or possibly athero-
sclerotic plaque (Figure 2). Intramural haematoma has a
higher rate of rupture (35%) than dissection due to its
closer relationship to the adventitia.10,11 Extension
towards the lumen may result in dissection in up to 33% of
the cases and therefore surgical management is usually
required in cases involving the ascending aorta.12
Penetrating aortic ulcer
Penetrating atherosclerotic ulcer is caused by erosion of an
intimal atherosclerotic plaque into the media (Figure 3).
Erosion into the vasa vasorum may lead to IMH formation
and possibly dissection. Adventitial erosion may cause
aneurysm formation or rupture. Rupture has been reported
in up to 42% of cases.10

Intramural haematoma Life-threatening effects of acute aortic syndrome

Intramural haematoma accounts for 3–5% of the cases of Mortality from acute ascending aortic (type A) dissection
aortic dissection that occur without apparent intimal increases rapidly immediately after presentation, reaching

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 Echocardiography in the emergency assessment of AAS
Figure 2 Intramural haematoma. In the transoesophageal echocar-
diography short-axis view, a cross-section of the aortic root is
shown. The aortic wall is markedly thickened (white arrowheads).
The intima has areas of focal echo brightness, characteristic of
atherosclerosis—this is one method of distinguishing IMH from
thrombus within the lumen of aortic aneurysm. There is an area
of echo lucency within the haematoma, but no dissection flap or
false lumen is seen. An echo free rim is seen around the aorta,
suggestive of free blood.
Figure 3 Penetrating atherosclerotic aorta. A transoesophageal
echocardiography image of the descending aorta showing severe
atheroma with a localized, bulge associated with plaque rupture
(white arrow).
1–2% per hour for the first 48 h,13 i.e. there is an approximate
50% mortality rate after 48 h. Ascending aorta IMH and PAU
are likewise at increased risk of lethal complications.
In all AAS, death can ensue from aortic rupture. In
addition, the potential lethal complications of type A dissec-
tion arise from (i) its proximity to the heart, (ii) the intra-
pericardial nature of the aortic root, and (iii) proximity to
the head and neck vessels. Thus, the effects of type A dis-
section may include acute severe AR (acute dilatation of
the aortic root, aortic leaflet prolapse, dissection flap pro-
lapse, pre-existing disease, e.g. bicuspid valve), coronary
ostial occlusion, haemorrhagic pericardial effusion and tam-
ponade, or extension to the head and neck vessels causing
stroke. For these reasons, early surgical intervention is rec-
ommended for type A aortic dissection and has been shown
to improve prognosis; delays in surgical treatment subject
the patient to a mortality risk of 1% per hour.
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i33
In the emergency setting, the clinical presentation of
patients with AAS may include chest pain, dyspnoea, hypo-
tension, and signs of heart failure. The chest X-ray may or
may not reveal a widened mediastinal contour. ECG
changes (non-specific, pericarditic, ischaemic, or infarction)
are common. Thus, there is an important differential
diagnosis, which includes acute coronary syndrome, acute
myocardial infarction (MI), pericarditis, and pulmonary
embolism (PE). Not only may consideration of these con-
ditions result in crucial delay in the diagnosis of type A
AAS, but also their initial management (in three of the
above) includes anti-platelet, anticoagulant, and thrombo-
lytic therapies, with potential disastrous results.
Therefore, a high index of clinical suspicion and the rapid
availability of diagnostic tests that are safe, sensitive, and
specific are required to make the correct diagnosis and
identify those patients who need early surgery.
Emergency assessment of suspected aortic
dissection: the role of transthoracic
echocardiography
Transthoracic echocardiography is safe, rapid, and readily
available in the emergency department. It should be per-
formed without delay in patients with suspected AAS, to
evaluate the presence or absence of several important fea-
tures. An ascending aortic dissection flap may be visible:
TTE has a reported sensitivity of 59–83% and a specificity of
63–93% for the diagnosis of aortic dissection.4,14,15 However,
there are no recent studies, using modern ultrasound technol-
ogy, assessing the diagnostic accuracy of TTE in AAS. It is
important to note that its sensitivity is 78–100% in type A
dissection (in which the diagnosis needs to be made most
rapidly) but is only 31–55% in dissection of the descending
aorta (in which there is less urgency, since there is a lower
early mortality and no indication for early surgery). Regardless
of the visualization of a dissection flap, TTE is useful in
almost all such patients: the presence of a bicuspid aortic
valve (particularly in a young patient with chest pain), AR, a
dilated aortic root with associated pericardial effusion, or
regional wall motion abnormality (particularly inferior hypoki-
nesia) is suggestive of acute type A dissection, whereas their
absence is reassuring (but cannot definitely exclude AAS).
Transthoracic echocardiography is also useful in establish-
ing or excluding the differential diagnosis in the acutely
unwell patient, particularly in the absence of aortic root
dilatation: MI (large regional wall motion abnormality), peri-
cardial effusion, and PE (right heart dilatation, etc.).
Finally, in those patients in whom a dissection flap can be
seen, TTE can identify those features of type A dissection
that indicate high risk—severe proximal aortic dilatation or
pericardial effusion (suggestive of impending rupture),
associated regional wall motion abnormality (coronary occlu-
sion), and AR—facilitating immediate surgical referral and
appropriate emergency management. If there is high clinical
suspicion and the TTE provides direct or corroborative evi-
dence for type A dissection, we recommend transfer of the
patient immediately to a cardiothoracic unit, where further
pre- and intra-operative echocardiographic (TEE) imaging
(or alternatively CT or MRI) can take place. This approach
minimizes any delays, particularly while the patient is in an
environment in which potentially life-saving cardiac surgery
 i34 E.L. Meredith and N.D. Masani

cannot take place, and ensures that emergency management

is undertaken by appropriate experts—cardiologists, cardiac
anaesthetists, and surgeons.
Therefore, despite its relatively poor diagnostic accuracy,
TTE is an extremely valuable clinical tool in diagnosing and
assessing AAS in the emergency setting, identifying its
related complications and diagnosing potential differential
conditions. Most importantly, it has a vital role in identifying
patients at high risk and directing their referral to the
relevant cardiac surgical department promptly.

Performing transthoracic echocardiography

in suspected acute aortic syndrome
Where the clinical situation allows, a full TTE study should
be performed, as soon as possible, using standard and
off-axis views (Figure 4). Standard two-dimensional and
colour flow imaging in parasternal long axis (Figure 4A),
apical five- (Figure 4B) and three-chamber views are used
to image the aortic valve and root. In the parasternal and
modified apical two-chamber views, parts of the descending
aorta (behind the left atrium) can be visualized (Figure 4A).
Right parasternal or high left parasternal views allows visu-
alization of the ascending aorta in some patients. Using the
suprasternal view, the arch, origin of the head and neck
vessels, and proximal descending aorta can be imaged.
The subcostal view allows imaging of the abdominal aorta
in most patients (Figure 4C).
Transthoracic echocardiography should also be used to
assess the presence of pericardial or pleural effusions.
Assessment of any AR should be made, assessing the severity
and mechanism of AR. This may provide valuable infor-
mation to the surgeon about the need for aortic valve
repair or replacement. Left and right ventricular function
should be assessed. Regional wall abnormalities may
represent coronary involvement in the dissection flap or
pre-existing coronary disease.

Definitive imaging in acute aortic syndromes:

the role of transoesophageal echocardiography
The ideal diagnostic technique in AAS should be safe, rela-
tively rapid, and have high sensitivity and specificity. The
primary objectives are to immediately identify an intimal
tear (or haematoma) and delineate the extent of thoracic
dissection. Important secondary objectives are to evaluate
complications and, in type A dissection or IMH, provide
important information to cardiac surgeons: the presence
and mechanism of AR; branch occlusion, coronary/head
and neck; extravasation of blood, pericardial/pleural
effusions.
Transoesophageal echocardiography, helical CT, and MRI
are all excellent imaging modalities in AAS.16 Transoesopha-
geal echocardiography is reported to have a sensitivity of
94–100% and specificity of 77–100% for identifying an
intimal flap.16,17 The reduced specificity in early studies
relates to the false-positive interpretation of reverberation
artefacts in the aortic root (discussed later),15 particularly
with the use of mono- or bi-plane TEE. In a comprehensive
meta-analysis16 of all three modalities, the most recent
studies reported 100% sensitivity and 100% specificity for
TEE,18 helical CT, and MRI, whereas conventional CT
Figure 4 Transthoracic echocardiography in a patient with
Marfan’s syndrome and type A dissection. (A) Parasternal long-axis
view. There is severe dilatation of the aorta and a linear echo is
seen just above the aortic valve (white arrow). Note the normal
caliber and appearance of the descending thoracic aorta, posterior
to the left atrium (black arrow). LV, left ventricle; LA, left atrium;
Ao, aorta. (B) Apical five-chamber view. The dilated aortic root,
with two reflections of the intimal flap, (white arrows) is seen.
Severe aortic regurgitation (right panel) is seen with colour flow
mapping. (C ) Subcostal view. Normal caliber, no dissection flap
and normal flow are seen.
(probably the most widely used technique) is less accurate
(sensitivity 83–94%, specificity 87–100%).16 In various
reports, the ‘TEE blindspot’ caused by the interposition of
the trachea between oesophagus and upper ascending

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 Echocardiography in the emergency assessment of AAS i35

aorta is mentioned as a potential disadvantage of TEE. In our

experience, this has not been a problem, given the extre-
mely low probability of dissection of IMH confined to this
precise location only.19 A detailed discussion of the relative
merits of each of these imaging modalities is beyond the
remit of this article and has been performed elsewhere,16
but is considered in brief in the final section.
Transoesophageal echocardiography is rapid and safe. It
may be performed at the bedside in a critical care environ-
ment: this is of particular importance in the haemodynami-
cally unstable patient and avoids the need to transfer the
patient to another department for imaging. When there is
a high degree of suspicion for type A dissection or IMH,
TEE can be performed in the operating room, with anaesthe-
tists and surgeons standing by. In such cases, unnecessary
and dangerous delays can be incurred by transferring
patients to CT or MRI scanners; expert TEE can provide all
of the required diagnostic and pre-surgical information.19
There are anecdotal reports of deterioration of patients
with aortic dissection, during TEE, possibly related to discom-
fort, gagging or distress.20 However, no mortality has been
reported in larger studies.16,17,19 Moreover, given the mor-
tality rate of 1–2% per hour, there is a high risk of fatal
deterioration while transferring patients for, or during, CT
or MRI. Nevertheless, it is vital that TEE is performed by
suitably trained and experienced operators in this setting.
Performing transoesophageal
echocardiography in suspected acute
aortic syndrome
Scrupulous attention must be paid to the medical and sup-
portive treatment of the patient with AAS during TEE (and
during CT, MRI, etc.).7 Careful and continuous monitoring
of heart rate, blood pressure, and oxygen saturation is
necessary. Adequate opiod analgesia should be given. Intra-
venous beta-blockers, nitroprusside, or nitrates should be
used to maintain a low blood pressure (we avoid beta-
blockers in the presence of severe AR). We recommend
careful conscious sedation during TEE, using intravenous
midazolam. The aim is to introduce the TEE probe with
maximal patient cooperation and minimal agitation, follow-
ing which further sedation may be given if needed.
Assessing the aorta
Intimal flap
The classic sign of aortic dissection is the intimal flap. This is
seen as a mobile linear echo separating the true from the
false lumen with flow on either side. The false lumen is
often much larger than the true lumen. The intimal flap
moves throughout the cardiac cycle. With chronic dissec-
tions, there is a decrease in mobility. It is important to be
able to identify the proximal extension of the dissection as
this determines whether an urgent surgical approach is
used. It is not important to identify the distal extent of
the flap, if this extends below the diaphragm, during the
emergency presentation of AAS since this will not alter man-
agement unless there is evidence of an intra-abdominal
complication or end-organ ischaemia.
When the aorta is dilated, linear artefacts are common
and may appear in the transverse or longitudinal plane.
Figure 5 Reverberation artefact seen by M-mode transoesopha-
geal echocardiography. An apparent linear echo in the aorta is
seen (white arrow)—it mirrors the motion of the echo bright pos-
terior aortic wall, is twice the distance from the probe, and has
twice the amplitude of movement. PA, pulmonary artery; Ao, aorta.
They may be difficult to distinguish from intimal flaps and
account for some of the false-positive diagnoses of aortic
dissection. Reverberation artefacts in the aortic root can
occur from the walls of the left atrium and in the ascending
aorta from the right pulmonary artery. Using M-mode, the
artefact can be seen to be double the distance from
the probe as the original structure with movement,
which is in time but twice the amplitude of the original
structure (Figure 5). Colour flow mapping, which shows
differential flow between true and false lumens in true
dissection, is also useful in recognizing reverberation
artefacts.
False lumen
It is important to be able to distinguish the true from the false
lumen. This has particular (surgical) relevance when the dis-
section extends to the origins of the coronaries and/or head
and neck vessels, which may originate from the false
lumen. In dissections of the descending aorta, visceral
arteries may be involved having surgical or endovascular
implications. The false lumen is often much larger than the
true lumen. Flow in the true lumen is usually greater than
in the false lumen, antegrade during systole, with the flap
moving toward the false lumen. However, in cases where
the proximal entry tear is large, flow in the false lumen
may be similar to that in the true lumen with systolic
forward flow similar in velocity and timing along with dias-
tolic reversal.21,22 With small or more distal entry tears,
flow in the false lumen is much slower and spontaneous
echo contrast or thrombus may be identified. An aortic wall
thickness of greater than 15 mm suggests dissection with
thrombosis in the false lumen (Figure 6). In this situation,
an aortic flap may not be identified—this is unusual in the
emergency setting. Thrombus formation is dependent on
the flow within and location of the tear: it is more common
in the descending aorta and infrequent in the ascending
aorta, being described in only 7% of dissections.23,24

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 i36
Figure 6 Thrombosis and spontaneous echo contrast in the
descending thoracic false lumen in a patient with repaired type A
dissection. The aorta is severely dilated. Characteristically, the
false lumen is much larger than the true lumen. In the right
panel, colour flow mapping demonstrates vigorous flow in the true
lumen only.
Entry tears
The intimal tear is usually .5 mm and is situated in the
proximal ascending aorta (Figure 1A) or in the descending
aorta just distal to the left subclavian artery. A principal
aim of cardiac surgery in type A dissection is to obliterate
the entry tear in the ascending aorta, thereby preventing
flow into the false lumen, encouraging thrombosis of the
false lumen and healing of the aorta.25
Transoesophageal echocardiography identifies the intimal
tear in 78–100% of the cases.26,27 In cases where it is not
visualized by two-dimensional echocardiography, colour
Doppler may show a turbulent jet directed toward the
false lumen. Using pulsed Doppler, flow velocity is usually
,1.5 m/s in systole. Secondary tears, in up to 20% of the
cases,26,27 may be identified with TEE using colour
Doppler. These are small communications between the
true and false lumen and occur more commonly in the
descending aorta.
Intramural haematoma (Figure 2)
Echocardiography reveals an aortic wall thickness of over
7 mm, with no dissection flap, entry tear, or false lumen.
The thickened aorta in transverse section may have a cres-
centic shape with distortion of the circular contour. Intra-
mural echo-free spaces are seen. Intramural haematoma is
more common in the descending aorta and there may be
signs of more widespread arteriosclerosis. Intramural hae-
matoma may regress or progress to dissection or rupture.
Supplementary imaging in the form of MRI or CT is often
required and is used for serial imaging of these lesions.
Penetrating aortic ulcer
Penetrating aortic ulcers occur predominantly in the des-
cending thoracic and abdominal aorta (Figure 3). They
occur more commonly in the elderly and there is often
widespread atheromatous disease. Penetrating athero-
sclerotic ulcer is usually a focal lesion appearing as an
outpouching of the aortic wall with jagged edges. Concomi-
tant aneurysms of the descending aorta may be found. If a
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E.L. Meredith and N.D. Masani
Figure 7 Prolapsing intimal flap, causing severe aortic regurgita-
tion. Transoesophageal echocardiography in the same patient as in
Figure 1. The flap interferes with closure of the aortic valve. LA,
left atrium; LV, left ventricle; Ao, aortic root (which is severely
dilated, also contributing to aortic regurgitation).
PAU extends to dissection, the dissection is usually shorter,
limited by neighbouring fibrosis and calcification. The flap
is usually thicker, may be calcified, and is less mobile than
in a true dissection.
Pericardial and pleural effusions
Pericardial effusions occur in 20–30% of ascending aorta and
6% of descending aorta dissections.17,21,28 Pericardial effu-
sions may occur due to rupture of the false lumen into the
pericardium or due to irritation of the pericardium second-
ary to aortic haematoma. The presence of a pericardial effu-
sion with an ascending aortic dissection is a sign of poor
prognosis.
Aortic regurgitation
Both TTE and TEE are able to accurately assess the severity
of AR. Transoesophageal echocardiography often gives
greater information about the mechanism of the AR. There
are several mechanisms that may contribute to the AR.
(1) Dilatation of the annulus, leading to incomplete valve
closure and resultant AR.
(2) Aortic leaflet prolapse occurs when the dissection
extends into the root and disrupts the suspension of
one of the cusps. Abnormal leaflet coaptation occurs
and there is eccentric AR. This is best seen in a long-axis
view when the cusp is seen to prolapse back onto the
left ventricular outflow tract.
(3) Dissection flap prolapse can occur through the aortic
valve, during diastole, distorting the valve and causing
regurgitant flow (Figure 7). Prolapse of redundant
intimal flap tissue and the resultant AR may be intermit-
tent. This unusual mechanism of severe AR, in which the
valve itself may be inherently normal, is particularly
well visualized by TEE.29
(4) Pre-existing valvular disease, for example, a bicuspid
valve (Figure 1B), annular dilatation secondary to
Marfan’s syndrome, or degenerative valve disease may
cause significant AR. In these cases, the dissection may
be of the descending or ascending aorta.
 Echocardiography in the emergency assessment of AAS i37

Figure 8 Visualization of the left coronary ostium. Transoesopha-

geal echocardiography short-axis view: in the left panel, a small
true lumen is seen, from which the left coronary artery (asterisk)
arises. Separate origins of the left anterior descending and circum-
flex branches can be seen—this was invaluable information for the
cardiac surgeon. In the right panel, colour flow mapping shows
unobstructed flow from true lumen into the left coronary branches.

It is critically important to provide accurate information

about the severity and mechanism of the aortic valve regurgi-
tation, as this will influence the surgical decision to repair or
replace the valve: in the first three mechanisms above, it is
usually possible to surgically ‘re-suspend’ the native valve.

Arterial involvement
Figure 9 Visualization of the head and neck vessels. Off-axis trans-
In 10–20% cases of dissection, the intimal flap propagates oesophageal echocardiography view of the aortic arch. (A) A linear
retrogradely to involve the origin of one or both coronary dissection flap is seen. The origins of the left common carotid and
arteries,30 thereby obstructing flow. Coronary involvement subclavian arteries as seen to arise from the smaller, true lumen
is suggested by left ventricular regional wall abnormalities, (white arrows). (B) In the right panel, colour flow mapping shows
unobstructed flow from true lumen into the head and neck vessels.
although these may represent pre-existing coronary disease.
Transoesophageal echocardiography allows direct visualiza-
tion of the coronary ostia and their spatial relationship to
the proximal extent of the dissection flap; proximal flow Table 2 Transoesophageal echocardiography in
can be seen with colour Doppler. This is achieved in the mid- patients undergoing surgery for type A dissection:
oesophageal short- and long-axis views. It is possible to information for the surgeon
identify whether the coronaries originate from the true or
false lumen or whether the dissection extends into the cor- Proximal extent of dissection flap
onary (Figure 8). It should be remembered that coronary Site of entry tear(s)
Pericardial effusion/cardiac tamponade
angiography is hazardous, and therefore frequently not per-
Aortic regurgitation
formed, in patients with aortic dissection. Severity
In most cases, the upper oesophageal views of the aortic Mechanism
arch can be used to identify the origin of the head and Coronary involvement
neck vessels and assess whether flow is from the true or Head and neck vessel involvement
false lumen (Figure 9). Left ventricular function
Additional cardiac pathologies

Operative assessment: pre, intra, and post

Cardiac surgery is indicated in patients with acute type A
aortic dissection (or IMH), reducing 14-day mortality from
50% to 20%.31 The aims of cardiac surgery are to repair or
replace the aortic root/ascending aorta, to obliterate the
entry site (tear) into the false lumen, to repair or replace
a regurgitant aortic valve, and to secure antegrade flow to
the coronary and proximal head/neck vessels.
Transthoracic echocardiography and, in particular, TEE
provide the cardiac surgeon with invaluable information,
as detailed in the above section (Table 2). When a diagnosis
of type A dissection or IMH has already been made (by TTE,
TEE, CT, or MRI) before transfer to the operating room, we
recommend the use of peri-operative TEE to augment and
review the available diagnostic information. Furthermore,

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Figure 10 Algorithm for the use of echocardiography in acute aortic syndrome (see text for details). RWMA, regional wall motion abnorm-
alities; AR, aortic regurgitation; C-T unit, cardiothoracic unit; CCU, coronary care unit; OR, operating room.
dissection and IMH are dynamic and rapidly progressing con-
ditions, and contemporaneous imaging at the time of
surgery frequently provides important information (such as
the development of pericardial effusion, rapid expansion
of the aortic root, etc.).
Post-operatively, TEE is valuable in assessing competence
of the aortic valve, integrity of upper32 and lower anasta-
moses of interposition grafts, and, in haemodynamically
unstable patients, ventricular function and the presence of
pericardial collections. Because of the severe nature of
the presenting illness, often with cardiovascular collapse,
and the complexity and duration of surgery required, post-
operative complications are common. The rapid availability
and portability of TEE (including in the operating room or
intensive care unit) are invaluable in assessing these
complex patients.32
Suggested approach for echocardiography in
patients with suspected acute aortic syndrome
Untreated, AAS can be a rapidly fatal condition (Figure 10).
For this reason, prompt and accurate assessment is required
to identify high-risk patients. A high index of clinical suspi-
cion is required, to distinguish AAS from other causes of
chest pain and dyspnoea.
We recommend TTE as the first-line imaging modality.
Where more definitive imaging (such as CT) is regarded as
the conventional first-line investigation, TTE can be per-
formed in the emergency department, while the prep-
arations for the CT scan are being made. This serves to
highlight complications or high-risk features (such as peri-
cardial effusion) that may alter the management plan—this
is particularly important in non-surgical centres.
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E.L. Meredith and N.D. Masani
If TTE identifies type A dissection or high-risk features in
association with a strong clinical suspicion, we recommend
performing TEE with cardiac surgeons and anaesthetists
standing by. If the diagnosis is confirmed, surgery can
proceed with minimal delay. Importantly, TEE (and TTE)
allows the assessment of AR, its severity, mechanism, and
need for replacement or repair.
In the absence of TTE, suspicion of type A dissection (or
IMH) or high-risk features, there is less urgency. The defini-
tive imaging modality will depend upon clinical circum-
stances, availability of facilities, and operators: helical CT,
MRI, and TEE are equally accurate and have relative
strengths and weaknesses. Although both allow visualization
of the entire aorta including branch vessel involvement, this
is less important in the first few hours. Both CT and MRI may
have time delays and practical difficulties in monitoring
patients whilst in the scanner. Occasionally, multiple modal-
ities may be needed to clarify suspicious or incongruous
results. The choice of modality will depend on the resources
available in individual centres and the expertise available.
In patients undergoing surgery, TEE offers invaluable
information for the surgeon operating on these most
challenging of patients.
Conflict of interest: none declared.
References
1. Vilacosta I, San Roman J. Acute aortic syndrome. Heart 2001;85:365–8.
2. Ince H, Nienaber C. The concept of interventional therapy in acute aortic
syndrome. J Card Surg 2002;17:135–42.
3. Ahmad F, Cheshire N, Hamady M. Acute aortic syndrome: pathology and
therapeutic strategies. Postgrad Med J 2006;82:305–12.
 Echocardiography in the emergency assessment of AAS
4. Daily P, Trueblood H, Stinson, Wuerflein R, Shumway N. Management of
acute aortic dissections. Ann Thorac Surg 1970;10:237–47.
5. DeBakey M, McCollum C, Crawford E, Morris G, Howell J, Noon G. Dissec-
tion and dissecting aneurysms of the aorta: twenty-year follow-up of five
hundred twenty-seven patients treated surgically. Surgery 1982;92:
1118–34.
6. Svensson LG, Labib SB, Eisenhau JR. Intimal tear without haematoma.
Circulation 1999;99:1331–6.
7. Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A et al. Diagnosis
and management of aortic dissection. Recommendations of the Task
Force on Aortic Dissection, European Society of Cardiology. Eur Heart J
2001;22:1642–81.
8. Hirst A, Johns V, Kime S. Dissecting aneurysm of the aorta: a review of
505 cases. Medicine (Baltimore) 1958;37:217–79.
9. Eichelberger J. Aortic dissection without intimal tear: case report and
findings on transesophageal echocardiography. J Am Soc Echocardiogr
1994;7:82–6.
10. Coady M, Rizzo J, Elefteriades J. Pathologic variants of thoracic aortic
dissections. Penetrating atherosclerotic ulcers and intramural hemato-
mas. Cardiol Clin North Am 1999;17:637–57.
11. Eggebrecht H, Baumgart D, Schmermund A, Herold U, Hunold P, Jakob H.
Penetrating atherosclerotic ulcer of the aorta: treatment by endovascu-
lar stent-graft placement. Curr Opin Cardiol 2003;18:431–5.
12. Robbins R, McManus R, Mitchell R, Latter D, Moon M, Olinger G et al.
Management of patients with intramural hematoma of the thoracic
aorta. Circulation 1993;88:II1–10.
13. Chirillo F, Marchiori M, Andriolo L, Razzolini R, Mazzucco A, Gallucci V
et al. Outcome of 290 patients with aortic dissection. A 12-year multicen-
tre experience. Eur Heart J 1990;11:311–9.
14. Miller D. Surgical management of aortic dissections: Indications, perio-
perative management and long term results. In: Doroghazi RM,
Slater EE, eds. Aortic Dissection. New York: McGraw-Hill; 1983.
pp. 193–243.
15. Appelbaum A, Karp R, Kirklin J. Ascending vs descending aortic dissec-
tions. Ann Surg 1976;183:296–300.
16. Shiga T, Wajima Z, Apfel C, Inoue T, Ohe Y. Diagnostic accuracy of trans-
oesophageal echocardiography, helical computed tomography, and mag-
netic resonance imaging for suspected thoracic aortic dissection:
systematic review and meta-analysis. Arch Int Med 2006;166:1350–6.
17. Nienaber C, von Kodolitsch Y, Nicolas V, Siglow V, Piepho A, Brockhoff C
et al. The diagnosis of thoracic aortic dissection by noninvasive imaging
procedures. N Engl J Med 1993;328:1–9.
18. Pepi M, Campodonico J, Galli C, Tamborini G, Barbier P, Doria E et al.
Rapid diagnosis and management of thoracic aortic dissection and intra-
mural haematoma: a prospective study of advantages of multiplane vs.
biplane transoesophageal echocardiography. Eur J Echocardiogr 2000;1:
72–9.
Downloaded from https://academic.oup.com/ehjcimaging/article-abstract/10/1/i31/2465433
by guest
on 18 December 2017
i39
19. Banning AP, Masani ND, Ikram S, Fraser AG, Hall RJ. Transoesophageal
echocardiography as the sole diagnostic investigation in patients with
suspected thoracic aortic dissection. Br Heart J 1994;72:461–5.
20. Kristensen S, Ivarsen H, Egeblad H. Rupture of aortic dissection during
attempted tranesophageal echocardiograph. Echocardiography 2007;
13:405–6.
21. Erbel R, Mohr-Kahaly S, Rennollet H, Brunier J, Drexler M, Wittlich N
et al. Diagnosis of aortic dissection: the value of transesophageal
echocardiography. Thorac Cardiovasc Surg 1987;35:126–33.
22. Mohr-Kahaly S, Erbel R, Rennollet H, Wittlich N, Drexler M, Oelert H et al.
Ambulatory follow-up of aortic dissection by transesophageal two-
dimensional and color-coded Doppler echocardiography. Circulation
1989;80:24–33.
23. Ballal R, Nanda N, Gatewood R, D’Arcy B, Samdarshi T, Holman W et al.
Usefulness of transesophageal echocardiography in assessment of aortic
dissection. Circulation 1991;84:1903–14.
24. Armstrong W, Bach D, Carey L, Chen T, Donovan C, Falcone R et al. Spec-
trum of acute dissection of the ascending aorta: a transesophageal
echocardiographic study. J Am Soc Echocardiogr 1996;9:646–56.
25. Erbel R, Oelert H, Meyer J, Puth M, Mohr-Kahaly S, Hausmann D et al.
Effect of medical and surgical therapy on aortic dissection evaluated
by transesophageal echocardiography. Implications for prognosis and
therapy. The European Cooperative Study Group on Echocardiography.
Circulation 1993;87:1604–15.
26. Evangelista A, Gonzalez-Alujas M, Garcia del Castillo H, Anivarro I,
Angel J, Salas A et al. Transesophageal echocardiography in the diagnosis
of aortic dissection. Revista Espanola de Cardiologia 1993;46:805–9.
27. Chirillo F, Cavallini C, Longhini C, Ius P, Totis O, Cavarzerani A et al. Com-
parative diagnostic value of transesophageal echocardiography and ret-
rograde aortography in the evaluation of thoracic aortic dissection. Am
J Cardiol 1994;74:590–5.
28. Keren A, Kim C, Hu B, Eyngorina I, Billingham M, Mitchell R et al. Accu-
racy of biplane and multiplane transesophageal echocardiography in
diagnosis of typical acute aortic dissection and intramural hematoma.
J Am Coll Cardiol 1996;28:627–36.
29. Geyik B, Ozeke O, Ozbakir C, Deveci B, Aras D. Aortic dissection with
diastolic prolapse of intimal flap into left ventricle. European Journal
of Echocardiography 2005;6:311–2.
30. Crawford E. The diagnosis and management of aortic dissection. JAMA
1990;264:2537–41.
31. Tsai T, Neinaber C, Eagle K. Acute aortic syndromes. Circulation 2005;
112:3802–13.
32. Cianciulli T, Fairman E, Saccheri M, Llanos Dethinne S, Prezioso H. Acute
supravalvular aortic stenosis following the replacement of the ascending
aorta. Eur J Echocardiogr 2007;8:232–4.