Diagnosis Of Acute Aortic Syndrome Research Articles

Imaging modalities for the early diagnosis of acute aortic syndrome

The term acute aortic syndrome (AAS) incorporates aortic dissection, intramural haematoma, and penetrating atherosclerotic ulcer. The common feature of these entities is disruption of the medial layer of the aortic wall. Owing to the life-threatening nature of these conditions, prompt and accurate diagnosis is of paramount importance--misdiagnosis can be fatal. The noninvasive imaging techniques that have a fundamental role in the diagnosis and management of patients with AAS include CT, MRI, transoesophageal echocardiography (TEE), and transthoracic echocardiography (TTE). CT is the most-commonly used imaging modality owing to its wide availability, accuracy, and large field of view. CT plus TTE is the best combination for diagnosing AAS and its complications, and allows important morphological and dynamic aspects of AAS to be assessed and appropriately managed. Ideally, TEE should be performed immediately before surgery or endovascular treatment, in the operating theatre and under general anaesthesia. In stable patients with an uncertain diagnosis of intramural haematoma despite high clinical suspicion, MRI is the technique of choice to make a definitive diagnosis. Imaging techniques have an important role in the primary diagnosis, treatment strategy, and risk stratification of patients with AAS.

Diagnosis of acute aortic syndromes

Acute aortic syndromes are fatal medical conditions including classic acute aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer. Given the nonspecific symptoms and signs, a high clinical index of suspicion followed by an imaging study, namely transesophageal echocardiography, computed tomography, and magnetic resonance imaging (sensitivity 98-100% and specificity 95-100%), is a conditio sine qua non for prompt diagnosis of acute aortic syndromes. This article provides an overview of established and emerging approaches for the assessment of acute aortic syndromes, with focus on imaging and biomarkers. In this regard, D-dimer levels (cut-off: 500 ng/ml) may be useful to rule out aortic dissection, if used within the first 24 h after symptom onset.

Recent advances in the diagnosis of acute aortic syndromes

Acute aortic syndrome (AAS) is an acute lesion of the aortic wall involving the aortic media. In patients presenting with AAS, establishing a timely diagnosis is of paramount importance as mortality from AAS increases by 1 - 2% per hour. Acute aortic syndrome comprises a variety of pathologically distinct life-threatening conditions such as aortic dissection, intramural hematoma (IMH) of the aorta, penetrating aortic ulcer (PAU), traumatic transection and symptomatic aortic aneurysm. The aim of this article was to review recent progress in the diagnosis and therapeutic management of these syndromes. In the past few years, imaging techniques have increased our understanding of the natural history of these disease entities. Patients presenting with AAS require immediate diagnosis in order to rapidly initiate adequate therapeutic measures. Diagnostic imaging modalities that can be used for diagnosing this condition are transthoracic and transesophageal echocardiography (TTE and TEE, respectively), computed tomography angiography (CTA), magnetic resonance imaging and angiography in combination with intravascular ultrasound (IVUS). Patients presenting with AAS require immediate diagnosis for rapid initiation of adequate therapeutic measures. The best method to correctly diagnose acute aortic dissection and its complications is complementary use of CTA, TEE and angiography in combination with IVUS to improve visualization of aortic syndromes and to guide aortic stent graft implantation.

Cardiovascular imaging in aortic disease. Multimodality approach in clinical practice

In the last decade, remarkable advances have been made in noninvasive imaging of aortic diseases. The aim of this article was to provide a comprehensive review of these imaging modalities. Echocardiography plays an important role in the diagnosis and follow-up of aortic diseases. Transthoracic echocardiography (TTE) permits adequate assessment of several aortic segments, particularly aortic root and proximal ascending aorta. Transoesophageal echocardiography (TEE) overcomes the limitations of TTE in thoracic aorta assessment. TTE and TEE should be used in a complementary manner. Although TEE is the technique of choice in the diagnosis of aortic dissection, TTE may be used as the initial modality in the emergency setting. Intimal flap in proximal ascending aorta, pericardial effusion/tamponade and left ventricular function can be easily visualised by TTE. TEE information (entry tear location, mechanisms and severity of aortic regurgitation and true lumen compression) is essential for selecting and monitoring surgical and endovascular treatment and detecting possible complications. Computed tomography has the advantage of providing optimum morphological information of the entire aorta and the accuracy of size measurements. Magnetic resonance imaging offers good morphological and dynamic information on the aorta without radiation, although in clinical practice its availability is lower. The considerable advances in imaging techniques have greatly increased our understanding of aortic diseases. Not only clinical presentation and required information, but also local availability of imaging equipment and staff expertise in this field, should be considered to indicate echocardiography, computed tomography or magnetic resonance, in the assessment of different aortic diseases and their circumstances. Nell’ultima decade si sono avuti notevoli sviluppi dell’imaging non invasivo della patologia aortica. Lo scopo di questo articolo è stato quello di fornire una completa review delle diverse tecniche di imaging. L’ecocardiografia ha un ruolo importante nella diagnosi e follow-up delle patologie dell’aorta. L’ecocardiografia transtoracica (TTE) consente un’adeguata valutazione di alcuni segmenti aortici, in particolare la radice aortica e la porzione prossimale dell’aorta ascendente. L’ecocardiografia transesofagea (TEE) supera le limitazioni della TTE nella valutazione dell’aorta toracica. La TTE e la TEE dovrebbero essere utilizzate in maniera complementare. Benchè la TEE sia la tecnica da scegliere nella diagnosi della dissecazione aortica, la TTE può essere utilizzata come esame iniziale nella fase di emergenza. Il flap intimale nell’aorta ascedente prossimale, il versamento/tamponamento pericardico e la funzione ventricolare sinistra possono essere facilmente visualizzate con l’esame TTE. Le informazioni derivate dalla TEE (localizzazione del foro intimale di ingresso, meccanismi e severità dell’insufficienza aortica e la compressione del vero lume) sono essenziali nella selezione e monitorizzazione del trattamento chirurgico o endovascolare, e nella identificazione delle possibili complicanze. La tomografia computerizzata ha il vantaggio di fornire delle ottime informazioni sulla morfologia dell’intera aorta e una buona accuratezza delle misurazioni. La risonanza magnetica consente una buona valutazione morfologica e dinamica dell’aorta senza l’utilizzo di radiazioni, benché nella pratica clinica la sua disponibilità sia bassa. I notevoli progressi nelle tecniche di imaging hanno notevolmente aumentato la nostra comprensione delle malattie dell’aorta. Nella valutazione delle differenti patologie dell’aorta la scelta di una tecnica di imaging quale l’ecocardiografia, la tomografia computerizzata o la risonanza magnetica, non dipende solamente dalla presentazione clinica e dalle informazioni richieste, ma dovrebbero essere considerate anche altre condizioni quali la disponibilità delle attrezzature e l’esperienza dello staff in questo settore diagnostico.

Spontaneous Left Atrial Hematoma Mimicking an Acute Aortic Syndrome

A 69-year-old man with no history of chest trauma was admitted to our institution complaining of blunt and severe central chest pain of cataclysmic onset radiating to the back. His medical history was remarkable only for a chronic atrial fibrillation treated with warfarin and amiodarone. On arrival, his ECG showed atrial fibrillation at 120 bpm with no signs of myocardial ischemia. Laboratory examination was uneventful except for an international normalized ratio of 7. With the presumptive diagnosis of acute aortic syndrome, a thoracoabdominal high-resolution contrast-enhanced computed tomography scan was performed that showed a large mass at the level of the left atrium (LA) and a moderate pericardial effusion (Figure 1 and Movie I in the online-only Data Supplement). Linear attenuation coefficients of the LA mass and pericardial fluid were suggestive of acute clot and blood (60 and 50 Hounsfield units, respectively). No signs of malignancy, pulmonary embolism, or aortic disease were found. During evaluation, our patient's clinical condition …

Syndrome aortique : quelle imagerie réaliser ?

Acute aortic syndrome is an emergency that requires prompt diagnosis and treatment because of its high morbidity and mortality rates. The chosen imaging modality should allow to diagnose or eliminate the presence of an acute aortic syndrome but also identify signs of severity of the aortic disease. Computed tomography, transesophageal echocardiography and MRI have high sensitivity and specificity values and roughly equivalent for the diagnosis of acute aortic syndromes. Computed tomography has the advantage of identifying involvement of aortic collaterals including visceral branches of the abdominal aorta. In clinical practice, Computed tomography is the diagnostic modality the most often performed, followed by trans esophageal echocardiography. If a high clinical suspicion exists for acute aortic syndrome but initial aortic imaging is negative, a second imaging study should be obtained without delay.

Multidetector computed tomography scanning is still the gold standard for diagnosis of acute aortic syndromes

Multidetector computed tomography scanning is still the gold standard for diagnosis of acute aortic syndromes

Diagnosing acute aortic syndromes: The role of specific biochemical markers

Acute aortic syndromes (AAS) remain one of the most challenging medical emergencies. Making a prompt and accurate diagnosis is a race against time, where delay may be disastrous for the patient's life. Prompt and accurate diagnosis using imaging modalities has been available for many years, but the major concern is how the clinician's suspicion should be aroused concerning the possibility of an acute aortic syndrome, especially in cases of atypical clinical presentation and/or poor signs during clinical examination. Since the first case report publication in 1995, novel biochemical markers have been used for the rapid diagnosis of AAS, such as smooth muscle myosin heavy chains, serum soluble elastin fragments, and d-dimers, with the latter being the most widely used in clinical trials. Despite their potential, all these substances need to be re-evaluated in large randomized trials before they can be included as biomarkers of high sensitivity and specificity in clinical practice.

Spanish Acute Aortic Syndrome Study (RESA). Better Diagnosis Is Not Reflected in Reduced Mortality

Because acute aortic syndrome (AAS) is associated with high mortality, early diagnosis and treatment are vital. The aim of the Spanish Acute Aortic Syndrome Study (RESA) was to investigate the effectiveness of current treatment of AAS in a broad range of tertiary care hospitals in Spain. Between January 2005 and December 2007, 24 tertiary care hospitals reported data on 519 patients with AAS (78% male, mean age 61 +/- 13 years, range 20-92 years): 357 had type-A AAS and 162 had type B. The time delay between symptom onset and diagnosis was <24 hours in 67% of cases and >72 hours in 11%. Some 80% of patients with type-A AAS were treated surgically. The interval between diagnosis and surgery was <24 hours in 90% of cases. In patients with type-B AAS, 34% received invasive treatment: 11% had surgery and 23% underwent endovascular procedures. Mortality during hospitalization in patients with type-A disease was 33% in those treated surgically and 71% in those treated medically. Mortality in patients with type-B disease was 17% with medical treatment, 27% with endovascular treatment and 50% with surgical treatment. Despite significant advances in the diagnosis of AAS, in-hospital mortality remains high. The findings of this study are representative of a broad range of unselected patients undergoing treatment for the disease and support the need for continuing improvements in therapeutic approaches to AAS.

Frequency, Determinants, and Clinical Relevance of Acute Coronary Syndrome-Like Electrocardiographic Findings in Patients With Acute Aortic Syndrome

We investigated frequency/characteristics of acute coronary syndrome-like (ACS-like) electrocardiographic (ECG) profiles among patients with a final diagnosis of acute aortic syndrome (AAS), and explored pathophysiologic determinants and prognostic relevance within each Stanford subtype. We blindly reviewed presentation electrocardiograms of 233 consecutive patients with final diagnosis of AAS (164 Stanford type A) at a regional treatment center. Prevalence of ACS-like ECG findings was 27% (type A, 26%, type B, 29%); most were non-ST-elevation myocardial infarction-like. Patients with ACS-like ECG findings more often had coronary ostia involvement (p=0.002), pleural effusion (p=0.02), significant aortic regurgitation (p=0.01), and troponin positivity (p=0.001). ACS-like ECG profile in type A disease was independently associated with coronary ostia involvement (odds ratio [OR] 5.27, 95% confidence interval [CI] 1.75 to 15.88). ACS-like ECG profile predicted in-hospital mortality (OR 2.90, 95% CI 1.24 to 6.12), as did age (each incremental 10-year: OR 1.59, 95% CI 1.14 to 2.22), and syncope at presentation (OR 2.90, 95% CI 1.16 to 7.24). In conclusion, about 25% of our AAS patients (in either Stanford subtype) presented ACS-like ECG patterns-often with non-ST-elevation myocardial infarction characteristics-which could cause misdiagnosis. ACS-like ECG profile was associated with more complicated disease, and in type A disease was a strong independent predictor of in-hospital mortality.

Management of Acute Aortic Syndromes

Acute aortic syndrome (AAS) describes the acute presentation of patients with characteristic "aortic pain" caused by one of several life threatening thoracic aortic conditions including aortic dissection, intramural hematoma or penetrating atherosclerotic ulcer. Recent advances in imaging and therapeutic techniques have emphasized the importance of early diagnosis of acute aortic syndrome because it is crucial for survival. Not just because the cardiovascular community knows little, the management of AAS remains a therapeutic challenge, while diverse surgical and percutaneous strategies for the treatment of aortic syndromes are continuously evolving. As a result of increasing knowledge and better management strategies in this area, the outcomes of patients treated for acute aortic syndromes have improved. This review discusses the etiology and clinical presentation, but mainly focuses on modern management and both established and emerging therapeutic approaches to acute aortic syndromes.

Acute intramural hematoma of the aorta: A mystery in evolution

Conclusion: There is a 5-7% prevalence of intramural hematoma (IMH) in patients with acute aortic syndromes with 16% of patients evolving to classic aortic dissection (AD) on subsequent imaging studies and a 40% mortality rate of ascending aorta IMH. Summary: Acute aortic syndromes are characterized by a sudden onset of thoracic pain and consist of both classic AD and intramural aortic hemorrhage. There is an incomplete knowledge of the natural history of IMH. The International Registry of Aortic Dissection (IRAD) involves eighteen referral centers in six countries. Potential patients for inclusion in IRAD are identified prospectively or retrospectively by searching hospital discharge records. Diagnosis of acute aortic syndrome is suspected on history and physical examination and confirmed by imaging study or surgical exploration or post mortem examination. The current study represents 1,1010 patients enrolled between January 1, 1996 and November 19, 2001. Fifty-eight (5.7%) of patients had IMH. Patients with IMH tended to be older (68.7 years) than those with classic AD (61.7 years, P < 0.001). Patients with IMH were also more likely to have distal aortic involvement than patients with classic AD (60.3% versus 35.3%; P < 0.001). Patients with IMH described more severe initial pain than those with classic AD. Patients with IMH, however, were less likely to have pulse deficits, ischemic leg pain, or aortic valvular insufficiency. Overall, mortality of IMH was similar to AD (20.7% versus 23.9%; P = 0.57). Mortality of patients with IMH of the descending aorta was 8.3% versus 13.1% of patients with AD of the descending aorta (P = 0.60). Mortality of patients with IMH of the ascending aorta was 39.1% versus 29.9% of patients with classic AD of the ascending aorta; P = 0.34. Sixteen percent of patients with an initial diagnosis of IMH progressed to AD on serial imaging studies. Comment: The natural history of acute IMH of the aorta as well as its prevalence is difficult to determine. The current study suggests that the prevalence of IMH in patients with non-traumatic acute aortic syndromes is about 6%. This is lower than previously reported. Overall, however, this study, and others suggest, that despite the more limited aortic involvement of IMH and the absence of true dissection flaps at initial presentation, the overall natural history of the disease is similar to that of classic AD. At this point the known natural history of IMH suggests treatment and follow up should be similar to AD.

Chest radiography for the diagnosis of acute aortic syndrome

Purpose We sought to assess the diagnostic accuracy of routine chest radiography for the acute aortic syndrome (dissection, intramural hematoma, penetrating ulcer, or nondissecting aneurysm). Methods During a 6-year period, 216 patients (143 men, 73 women; mean [± SD] age, 58 ± 17 years) underwent chest radiography for suspected acute aortic syndrome. Chest films were re-evaluated blindly for aortic disease, based on an overall impression using standard criteria such as widening of the aortic contour and mediastinal shadow. Findings were matched to tomographic images, anatomical inspection, or both, as the criterion standard; aortic disease was confirmed in 109 (50%) of the patients. Results Chest radiography had a sensitivity of 64% (70/109) and a specificity of 86% (92/107) for aortic disease. Sensitivity was 67% (38/57) for overt aortic dissection, 61% (22/36) for nondissecting aneurysm, and 63% (10/16) for intramural hemorrhage or penetrating ulcer. However, sensitivity was lower for pathology confined to the proximal aorta (47% [21/45]) than for disease involving distal aortic segments (77% [49/64]). A receiver operating characteristic curve analysis of aortic diameters failed to identify a threshold for the diagnosis of aortic disease. Conclusion Chest radiography is of limited value for diagnosing the acute aortic syndrome, particularly for conditions confined to the ascending aorta. Since a definitive diagnosis is required in any patient with clinically suspected acute aortic syndrome, routine chest radiography should be replaced by tomographic aortic imaging.

Transesophageal echocardiography in the diagnosis of acute aortic syndrome.

In recent years, technological advances in echocardiography have led to improvements in the diagnosis of acute aortic disease. With transesophageal echocardiography (TEE) and, particularly, bi- and multiplane probes, the physiopathologic understanding of these diseases has widened. Thus, new entities such as penetrating ulcer and intramural hematoma have been described and differentiated from classical aortic dissection.