ECG Interpretation - Made Incredibly Easy 5th Edition (Chy Yong)

27/9/2015
Echocardiographicevaluationofthethoracicandproximalabdominalaorta
OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate
Authors
NelsonBSchiller,MD
XiushuiRen,MD
BryanRistow,MD,FACC,
FASE,FACP
SectionEditor
WarrenJManning,MD
DeputyEditor
SusanBYeon,MD,JD,
FACC
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Aug2015.|Thistopiclastupdated:Jul16,2015.
INTRODUCTIONEchocardiographyenablesqualitativeandquantitativeevaluationofthethoracicandproximal
abdominalaorta.Transthoracicechocardiography(TTE)providesviewsoftheproximalascendingaorta,aortic
archandportionsofthedescendingaorta.However,transesophagealechocardiography(TEE)ratherthanTTEis
indicatedforcomprehensiveimagingoftheaorta,especiallyintheemergencyevaluationofaorticdissectionor
traumaticruptureoftheaorticisthmus.(See"Clinicalmanifestationsanddiagnosisofaorticdissection"and
"Transesophagealechocardiographyintraumaticruptureoftheaorticisthmus".)
Echocardiographicevaluationoftheaortaforatheroscleroticplaque,sinusofValsalvaaneurysms,aorticdilation,
anddissectionwillbereviewedhere.
NORMALAORTICROOTANDASCENDINGAORTATheproximalascendingaortaattachestotheleft
ventricleattheannulus(hingelineoftheaorticleaflets)andincludestheaorticroot(comprisedofthethree
sinusesofValsalva),thesinotubularjunction,andthetubularascendingportionoftheaorta.Theaorticrootisa
directcontinuationoftheleftventricularoutflowtractandislocatedrightandposteriortothepulmonary
infundibulum.Thelowerportionoftheaorticrootisconnectedtothemuscularinterventricularseptum,the
membranousseptum,andtothemitralaorticfibrouscontinuity(alsoknownasthemitralaorticintervalvular
fibrosa).
TwodimensionalechocardiographyTransthoracicechocardiography(TTE)examinationoftheproximal
ascendingaortaisgenerallyperformedintheleftparasternallongaxisview(image1).Manysonographerslimit
theirinterrogationoftheaortatotheproximalsinusesofValsalva,missingtheopportunitytomorefullyvisualize
theaorta.Movingupanintercostalinterspace,movingtheprobeclosertothesternum,ortiltingtheprobecranially
enablesimagingofthemoresuperiorascendingaorta.
Rightparasternalviews,recordedwiththepatientinarightlateraldecubitusposition,mayalsoberevealing[1].
Thismethodisespeciallyusefulwhentheaortadilatestotherightofthesternum.
Acrosssectionalimageoftheaorticrootisobtainedintheparasternalshortaxisview(figure1).Thesuprasternal
notchviewvisualizestheaorticarch.
Transesophagealechocardiography(TEE)providesmorehighlyresolvedimagesoftheascendingaorta,aortic
arch,anddescendingthoracicaortathanTTE,althoughasmallportionofthedistalascendingaortaandproximal
archcannotbeseenduetointerpositionoftheleftmainstembronchusandtrachea.
Allimagedportionsoftheaortashouldbeevaluatedforthepresenceofplaque,dilationanddissection(including
intramuralhematoma).Viewsusedformeasurementshouldbethosethatshowthemaximumdiameterofthe
aorticroot[1].Theaorticrootatthelevelofthesinusesgenerallyhasthelargestdiameter(normal3.7cm),while
theascendingaorticdiameteratthesinotubularjunctionandaboveisslightlysmaller(normal<3.5cm).Ageand
bodysurfaceareaadjustednormalvaluesfortheaorticroothavebeenreported[2]andhavebeenrecommended
foruseasnormativestandardsbytheAmericanSocietyofEchocardiography(ASE)[1].
EvaluationofcoronaryarteriesTheoriginsofthecoronaryarteryarevisibleinbothshortandlongaxis
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viewsonadequateTTEorTEEimages.Theleftmainarterycanoftenbefollowedtoandbeyonditsbifurcation
intotheanteriordescendingarteryandcircumflexartery(image2AB)therightcoronaryarterycanusuallybe
followedforupto3cmfromitsorigin.Whileechocardiographyisnotapracticalmethodtodetectluminal
obstruction,carefulgainmanipulationmakesitpossibletodetectlargerbrightdensitiesalongthecourseofthe
vesselthatprobablyrepresentproximalcalcification.
Inadults,ananomalousoriginofthecoronaryarteriesisdifficulttoestablishwithanechocardiogram.Thebest
cluetothepresenceofasinglecoronaryartery,oronethatendsinacoronarycameralfistula,istoobservethe
greatlyenlargedcoronaryarteryoriginoftenassociatedwiththisabnormality.Attimes,thesevesselsdilatetothe
pointthattheymaybeconfusedwithasinusofValsalvaaneurysm.(See"Congenitalandpediatriccoronaryartery
abnormalities".)
Mostcameralfistulaethatterminateinoneoftheventriclescanbedetectedandlocalizedbyobservingthe
abnormalcolorflowsignalthatmarkstheentranceofthefistulaintothechamber.Thereareseveralreportsfrom
JapanofsuccessinidentifyingtheproximalaneurysmsofKawasaki'sdiseasebyechocardiography.(See
"CardiovascularsequelaeofKawasakidisease".)
MmodeechocardiographyThemotionoftheaorticrootontheMmodeechocardiogramisanindicatorof
globalleftventricularsystolicanddiastolicfunction[35].Sinceaorticrootmotionreflectstheeventsofatrialfilling
andemptying,italsoprovidesinformationaboutleftatrialfunction(image3AC).
Duringsystole,theaorticrootnormallymovesanteriorlyover7mmandreturnsalmostcompletelytoitsstarting
pointimmediatelyaftertheconclusionofejection.Theatrialorpresystoliccontributiontoaorticrootmotionis
normallyminimal.
AbnormalaorticrootmotiononMmodeechocardiographyIfthesystolicexcursionoftheaorticrootis
decreased,strokevolumeisprobablyreduced,aneffectthatisindependentoftheleftventricularejectionfraction.
Asanexample,iftheleftventricleishypovolemicbutcontractsnormally,theaorticrootmotionwillbedecreased.
Aorticrootmotionwillalsobedecreasediftheejectionfractionisseverelyreducedandtheventricleisincreased
insize(image4).
Augmentedrootmotionwithfullopeningoftheaorticvalvesuggestsahighcardiacoutput.Highoutput
statesarequiteeasytorecognizeandtheirappreciationishelpfulinclinicalmanagement.(See"Highoutput
heartfailure".)
Normaloraugmentedsystolicmotionoftheaorticrootinthefaceofreducedaorticleafletseparation
suggestsatrialfillingoutofproportiontoaorticflowandistypicalofmitralinsufficiency.
Iftheinitialdiastolicposteriormotionoftheaorticrootisslowed,andthelatediastolicposteriormotionofthe
aortaisexaggeratedwithatrialsystole,reducedLVcomplianceissuspected.
Aorticrootmotiontendstobeflatinrestrictivediastolicstates,reflectingthereducedcardiacoutput
generallyassociatedwithrestrictivecardiomyopathy.
AORTICPLAQUEAtheroscleroticplaqueisvisualizedasaregionofintimalthickeningorprotrusion.Plaque
maybeaccompaniedbyfocalcalcifications,ulcerations,and/orsuperimposedthrombi.Thepresenceofthoracic
aorticplaque,evenwhenvisualizedinthedescendingaorta,hasbeenassociatedwithanincreasedriskof
ischemicstroke[6].Aorticplaquemaybeamarkerofvasculardiseaseandotherriskfactorsforcerebrovascular
disease[7,8].Caremustbetakennottoconfuseanterioraorticwallthickeningwiththerightcoronaryartery.
Studieshavefoundincreasedriskofstrokeamongpatientswithprotrudingaorticatheroma4or5mmthick.Our
institutionusesthefollowingtransesophagealechocardiography(TEE)gradingscaleforaorticintimalthickness:
grade0=normal,grade1=mildintimalthickening,grade2=moderateintimalthickeninglessthan5mm,grade3
=protrudingatheroma5mmthick,andgrade4=mobilethrombionatheroma.
OnTEE,thepresenceoflarge,mobile,orulceratedplaquesisassociatedwithincreasedriskofstroke[9,10].The
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managementofaorticplaquesisdiscussedseparately.(See"Embolismfromaorticplaque:Thromboembolism"
and"Embolismfromatheroscleroticplaque:Atheroembolism(cholesterolcrystalembolism)".)
Calcificationoftheaorticvalve,aorticroot,andsinotubularjunctionisassociatedwithreducedsurvivalamong
individualswithcoronaryarterydisease[11].Thepresenceofcalcificationalongthesesitesmaybeamarkerof
increasedvasculardiseaseindependentofothermedicalriskfactors.
SINUSOFVALSALVAANEURYSMSSinusofValsalvaaneurysmsareoccasionallyseenonlongandshort
axisviewsofthetwodimensionalechocardiogram.However,quantitativecriteriaforsinusofValsalvaaneurysm
arelacking.Sinceasymmetryofthesinusesisoccasionallyencounteredinclinicalpractice,suchadefinition
wouldbehelpful.Lackingapublisheddefinition,weproposethatadiameterfromthewidestportionofthe
asymmetricsinustotheopposingwallofgreaterthan4cminadultsbeadoptedasaworkingdefinition.
ThemostcommonlocationistherightsinusofValsalva,fromwhichrupturemayextendintotherightventricleor,
lessfrequently,therightatriumorinterventricularseptum[12].
Thenextmostlikelylocationoftheaneurysmisthenoncoronarysinus,followedbytheleftsinus.Infrequently,the
aneurysmrupturesintotheleftventricle(mimickingaorticregurgitation)orintotheleftatrium.Inareportof86
patientsundergoingsinusofValsalvaaneurysmrepair,44percenthadassociatedaorticregurgitation[12].
Contrastechocardiographyishelpfulindelineatingtheaneurysmandshuntarisingfromrupture[13].However,
colorflowDopplerimagingisthetechniqueofchoiceforidentifyingarupturedsinusofValsalvaaneurysm.
AORTICDILATIONThe2011ACC/AHApracticeguidelinesforechocardiographyrecommend
echocardiographyforevaluationofsuspecteddilationoftheproximalaorta(movie1)[14].Transthoracic
echocardiography(TTE)isrecommendedasthefirstchoiceforthisindicationwithtransesophageal
echocardiography(TEE)usedonlyiftheTTEexaminationisincompleteoradditionalinformationisneeded.
MultimodalityimagingguidelinesfromtheAmericanSocietyofEchocardiographyrecommendmeasuringaortic
dimensionsfromleadingedgetoleadingedgeatenddiastole,basedonreferencestudiesusingthistechnique
[15].
TheACC/AHAguidelinesalsorecommendechocardiographytoevaluateaorticrootdilationinMarfansyndromeor
otherconnectivetissuesyndromes.Inaddition,theguidelinesrecommendTTEtoexaminefirstdegreerelativesof
patientswithMarfansyndromeorotherconnectivetissuedisorders.The2010ACC/AHAguidelinesforthe
diagnosisandmanagementofpatientswiththoracicaorticdiseaserecommendechocardiogramshouldbe
performedatthetimeofdiagnosisofMarfansyndrome,sixmonthsthereaftertodeterminetherateof
enlargement,andannuallyifstabilityoftheaorticdiameterisdocumentedandlessthan4.5cm[16].The
diagnosisandmanagementoftheMarfansyndromearediscussedseparately.(See"Genetics,clinicalfeatures,
anddiagnosisofMarfansyndromeandrelateddisorders"and"ManagementofMarfansyndromeandrelated
disorders".)
The2014ACC/AHApracticeguidelinesforvalvulardiseaserecommendmeasuringthediametersoftheaorticroot
andascendingaortabyTTEforpatientswithabicuspidaortic[17].Magneticresonanceimaging(MRI)or
computedtomography(CT)isrecommendediftheaorticrootorascendingaortacannotbeadequatelymeasured
byechocardiography.Yearlyechocardiography,MRI,orCTisrecommendedforpatientswithbicuspidaortic
valvesanddilationoftheaorticrootorascendingaorta(diametergreaterthan4.0cm,withconsiderationofa
lowerthresholdforpatientsofsmallstature).Issuesrelatedtobicuspidaorticvalvediseasearediscussed
separately.(See"Clinicalmanifestationsanddiagnosisofbicuspidaorticvalveinadults"and"Managementof
adultswithbicuspidaorticvalvedisease"and"Naturalhistoryandmanagementofchronicaorticregurgitationin
adults"and"Pregnancyinwomenwithabicuspidaorticvalve".)
LimiteddataareavailabletocompareechocardiographyandCTevaluationofthoracicaorticdilationandthoracic
aneurysm.Inasmallprospectivestudyof44patientswithknownascendingaorticaneurysm,TTEandCT
measurementsofaorticdiameterscorrelatedwell[18].Ectasiaisdefinedasaorticdilationupto50percentgreater
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thanthenormalreferencediameter,andaneurysmisdefinedasgreaterthan50percentdilation[16].
Causesofaorticrootandascendingaorticdilationandaneurysmformationincludehypertension(themost
commoncause),atherosclerosis,aorticdissection,aorticstenosis(poststenoticdilation),bicuspidaorticvalve
(associatedwithaorticdilationevenwithoutsignificantstenosis),aorticregurgitation,andtheMarfansyndrome
andothercausesofannuloaorticectasia.Lesscommonetiologiesofaorticdilationincludeinflammatorycauses,
suchasTakayasuarteritisandinfectiouscauses,suchassyphilis.(See"Clinicalmanifestationsanddiagnosisof
thoracicaorticaneurysm".)
Variousdiseaseprocessesareassociatedwithdifferentpatternsofaorticdilation:
HypertensionappearstohaveaminorimpactonaorticrootdiameteratthelevelofthesinusesofValsalva
[1921],butisassociatedwithenlargementatthesinotubularjunctionandtubularascendingaorta[19].
Congenitalaorticstenosisisassociatedwithmoresignificantpoststenoticdilationthandegenerativeaortic
stenosiswithsimilarvalveareas(image5)[22].
SymmetricdilationofthethreesinusesismostcommonlyseeninpatientswithMarfansyndrome[23,24].
Thisdilationusually,butnotalways,terminatesabruptlyatthesinotubularjunctionandgivestheserootsa
distinctiveappearanceunlikethatofothercausesofannuloaorticectasia(image6AB).Inadditiontoroot
dilation,patientswithMarfansyndromefrequentlyhaveaorticregurgitationbecauseaorticannulusdilation
causescuspmalcoaptation(image6AB).IssuesrelatedtoechocardiographyinMarfansyndromeare
discussedseparately.(See"Genetics,clinicalfeatures,anddiagnosisofMarfansyndromeandrelated
disorders".)
AorticdissectionTEEisanappropriateinitialtesttoevaluatesuspectedaorticdissection(image7)[25].
ChoiceamongTEE,MRIorCTforinitialnoninvasiveimagingofaorticdissectionisgovernedbyclinical
considerationsandavailability(see"Clinicalmanifestationsanddiagnosisofaorticdissection").
TEEimagingcanhelpdeterminethepotentialforaorticvalvesparingoperations[26].The0degreehigh
esophagealviewisappropriatefordiagnosingascendingaorticdissection.However,TEEevaluationofbranch
vesselinvolvementmaybeincompleteandadditionalimagingwithothertechniquesmayberequired[27].
TheroleofTTEinsuspectedaorticdissectionisprimarilyfordiagnosisofcardiaccomplicationsofdissection,
includingaorticinsufficiency,pericardialeffusion/tamponade,andregionalleftventricularsystolicfunction.
AdvancesinechocardiographyhaveimprovedthesensitivityofTTEforaorticdissectiontoapproximately85
percentormore[15],althoughTTEremainslesssensitivefordetectionofaorticdissectionthanTEE,CT,and
MRI.Thus,absenceofadissectionflaponTTEshouldnotbeusedtoexcludeaorticdissection.Inastudyof172
consecutivepatientsreceivingoperationsforproximalaorticdissection,TTEidentifiedintimaldissectionflapsin
159[28].TTEmaybeabletovisualizeanundulatingintimalofadissection(image8),butthenormal
brachiocephalicveincanoftenbeseenadjacentandsuperiortotheaorticarchinthesuprasternalnotchview
(image9),andthisshouldnotbemistakenforadissection.
DESCENDINGTHORACICAORTAANDAORTICARCHThedescendingthoracicaortacanbeseen
posteriortothelongandshortaxisparasternalviewsontransthoracicechocardiography(TTE)(image10AD).In
theparasternallongaxisview,thedescendingaortacanbeseenincrosssectionattheposterioratrioventricular
groove,situatedoutsidethepericardium.Intheparasternalshortaxisplane,anobliquelongitudinalsectionofthe
descendingaortacanbeseen.
Imagingcanidentifydilationorananeurysmandmaypermitdetectionofdissection.Thedescendingaortaisa
usefullandmarkfordistinguishingpleuralandpericardialeffusions,sincethepericardiumenclosestheheart
anteriortothedescendingaorta.
OnTTE,theaorticarchisvisualizedinthesuprasternalnotchview.Thisviewisrecommendedasaroutine
componentofTTEexamination,particularlyincaseswithbicuspidaorticvalvewhichisfrequentlyassociatedwith
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coarctationoftheaorta.Inthesuprasternalnotchview,colorandspectralDopplerinterrogationoftheproximal
descendingaortamaydetectacceleratedflowcharacteristicofcoarctation.Ifforwardvelocityinthedescending
aortabycontinuouswaveDopplerexceeds2m/sec,aorticcoarctationshouldbesuspected.Iftherunoffatthe
siteofcoarctationisdelayed,severecoarctationmustbeconsidered,andalternateimagingmodalitiessuchas
MRIcanbehelpfulinconfirmingdiagnosisandgradingseverity.(See"Clinicalmanifestationsanddiagnosisof
coarctationoftheaorta",sectionon'Echocardiography'.)
Viewsofthedescendingthoracicaortaasitcoursesalongthespinecanbeobtainedintheapicalviewsposterior
angulationoftenproduceslongaxis(inthetwochamberview)andshortaxis(inthefourchamberview)images
(image10C).Althoughtheaortaistoodeepinthefarfieldtobewellresolved,thesizeoftheaortacangenerally
bemeasured.Anormalcaliberaortaisevidenceagainstdissectionatthatlocation.
3Dechocardiographicimagingprovidesanintuitiveoverviewofstructuresandtheirrelationtoeachotheras
illustratedbyanexampleofamobileaorticmass(movie2).However,2Dimages(movie3)provideadditional
cluestotheaccuratediagnosisofavegetation,includingthickeningoftheaorticwallconsistentwith
inflammation,afluidfilledcollectionaroundtheaortaconsistentwithabscess,andtheabsenceofcalcificationor
shadowingthatwouldhavebeenmoretypicalofatheroscleroticdiseasewithadjacentthrombus.
Whenaorticdissectioninvolvesthethoracicaorta,especiallyifthereisextravasationofbloodaroundtheaorta,
thevesselcanbeimagedfromtheleftparaspinalwindow.Thisstrategycanbeusedtosupplyadditionalevidence
aboutthestateofthethoracicaorta.However,transesophagealechocardiographyisthemethodofchoicefor
detectingpathologyofthethoracicaorta.
AbdominalaortaSubcostalimagingoftheproximalabdominalaortaisoftenincludedintheTTEexamination
[29].Thestructurecanbefoundtotheleftofthespinerunningparallel,buttotheleftofanddeepto,theinferior
venacava(image11AB).Differentiationoftheaortafromthevenacavacanbemadebyappreciatingthesystolic
pulsationsoftheaorta,whichareusuallyeasytorecognize.
Usingthesubcostalapproach,atheromatousirregularitiesandaneurysmsoftheproximalabdominalaortaare
readilyseen(image12AC).SincethedescendingaortaisclosertothetransducerinthisviewthaninotherTTE
views,theyieldforintimalflapsofaorticdissectionishigherfromthiswindow.Inaddition,comparingthe
smoothnessoftheinnerlayeroftheaortatothevenacavagivessomeindicationofthedegreeofatheromatous
changethatispresentintheaortaand,byinference,intheremainderofthevasculartree.Atheromatouschange
istypicallyappreciatedasobviousirregularitiesalongtheusuallysmoothinteriorofthevessel.
Althoughtransesophagealechocardiography(TEE)isthepreferredtechniqueforevaluatingtheaorta,itdoesnot
imagetheaortaveryfarbelowthediaphragm[30].Ideally,lineararraysshouldbeusedformorecomprehensive
evaluationoftheabdominalaorta.
TranscatheteraorticvalveimplantationEchocardiographicevaluationoftheaortaisacriticalcomponentof
multimodalityimagingfortranscatheteraorticvalvereplacementasdiscussedindetailseparately.(See"Imaging
fortranscatheteraorticvalvereplacement".)
OTHERGREATVESSELSTransthoracicechocardiography(TTE)isusefulinevaluatingtheothergreat
vessels.
PulmonaryarteryIntheparasternallongaxisview,imagingjustsuperiortotheleftatriumusually
demonstratestheleftpulmonaryarteryasitcrossesundertheascendingaorta.Inspectingthebifurcationofthe
pulmonaryarteryinitslongaxis(intheparasternalshortaxisview)mayrevealtherelationshipbetweentheleft
pulmonaryarteryandthedescendingaorta(image13AB).ColorDopplernearthepulmonaryarterybifurcationin
thisviewcandetecttheretrogradecontinuousflowcharacteristicofapatentductusarteriosus.
CarotidarteriesandsubclavianvesselsTheinnominate,leftcommoncarotid,andleftsubclavianvessel
originscanbeimagedbyTTEfromthesuprasternalnotch.Fromtheneck,thecarotidandvertebralarteriescan
bestudiedeffectivelybytrainedvascularsonographersusingdedicatedlineararraytransducers.Skillin
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performingthisexaminationishelpfulwhenevaluatingapatientfordissectionoftheaortabecausedetectionof
extensionofthedissectionintothecarotidarterieshasimportantclinicalimplications.
SUMMARYANDRECOMMENDATIONS
Transthoracicechocardiography(TTE)providesviewsoftheproximalascendingaorta,aorticarch,and
portionsofthedescendingaorta.However,transesophagealechocardiography(TEE)issuperiortoTTEfor
comprehensiveimagingoftheaorta,especiallyintheemergencyevaluationofaorticdissectionortraumatic
ruptureoftheaorticisthmus.(See"Clinicalmanifestationsanddiagnosisofaorticdissection"and
"Transesophagealechocardiographyintraumaticruptureoftheaorticisthmus".)
TEEprovidesmorehighlyresolvedimagesoftheascendingaorta,aorticarch,anddescendingthoracicaorta
thanTTE,althoughasmallportionofthedistalascendingaortaandproximalarchcannotbeseenbyTEE
duetointerpositionoftheleftmainstembronchusandtrachea.(See'Twodimensionalechocardiography'
above.)
Thepresenceoflarge,mobile,orulceratedplaquesinthethoracicaortaonTEEisassociatedwithan
increasedriskofstroke.(See'Aorticplaque'above.)
EchocardiographyistheprimarymodalityforidentificationofsinusofValsalvaaneurysmsandany
associatedshuntarisingfromrupture.(See'SinusofValsalvaaneurysms'above.)
Echocardiographyenablesidentificationofaorticdilationandisindicatedformonitoringofindividualsatrisk
forprogressiveaorticdilation,particularlythosewithMarfansyndromeorabicuspidaorticvalve.(See'Aortic
dilation'above.)
TEEisanappropriateinitialtesttoevaluatesuspectedaorticdissection.ChoiceamongTEE,MRI,orCTfor
initialnoninvasiveimagingofaorticdissectionisgovernedbyclinicalconsiderationsandavailability.(See
"Clinicalmanifestationsanddiagnosisofaorticdissection".)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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aorticstenosissecondarytocongenitalversusdegenerativeversusrheumaticetiologies.AmJCardiol2005
96:1549.
23. EisenbergMJ,RiceSA,ParaschosA,etal.Theclinicalspectrumofpatientswithaneurysmsofthe
ascendingaorta.AmHeartJ1993125:1380.
24. DevV,GoswamiKC,ShrivastavaS,etal.Echocardiographicdiagnosisofaneurysmofthesinusof
Valsalva.AmHeartJ1993126:930.
25. DouglasPS,KhandheriaB,StainbackRF,etal.ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR2007
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SocietyofNuclearCardiology,SocietyforCardiovascularAngiographyandInterventions,Societyof
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investigationinpatientswithsuspectedthoracicaorticdissection.BrHeartJ199472:461.
Topic5293Version12.0
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GRAPHICS
Twodimensionaltransthoracicechocardiogram
(2DTTE)parasternallongaxisview
Thisparasternallongaxisechocardiogramwasobtainedinsystole
theaorticvalveisopenandthemitralisclosed.
RV:rightventricleIL:inferolateralleftventricularwallIVS:interventricular
septumNCC:noncoronarycuspoftheaorticvalveRCC:rightcoronarycusp
oftheaorticvalveaML:anteriormitralvalveleafletpML:posteriormitral
valveleaftletdAo:descendingaorta.
Graphic77446Version4.0
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Twodimensionaltransthoracicechocardiogram(2DTTE)parasternal
shortaxisviewoftheaorticroot
(A)Adiagramofthetransducerpositionforobtainingashortaxistwodimensionalimagethe
shortaxisisobtainedbya70to110clockwiserotationofthetransducerfromtheparasternal
longaxis,withsuperiorandinferiortransducermanipulationsandtheplaneisorientedatthe
baseoftheheart(leftpanel).
(BandC)Theparasternalshortaxisviewfromatransthoracicechocardiogramshowsthe
noncoronary(NCC),rightcoronary(RCC)andleftcoronary(LCC)leafletsoftheaorticvalve.
Alsoseenaretheleftatrium(LA),rightatrium(RA),tricuspidvalve(TV),rightventricle(RV)
andpulmonicvalve(PV).
http://www.uptodate.com/contents/echocardiographicevaluationofthethoracicandproximalabdominalaorta?topicKey=CARD%2F5293&elapsedTimeMs
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Shortaxisviewofleftmaincoronaryartery
Theshortaxisview,withtheimagingplanethroughtheaorticroot
(AO)justabovetheaorticvalve,demonstratestheleftmaincoronary
artery(LMCA).PanelBshowstheMmodeechocardiogramofthe
LMCA.
PV:pulmonaryvalve.
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(2DTTE)fromtheparasternalshortaxisviewat
thelevelofthecoronaryarteries
Theoriginsoftheright(RCA)andleft(LCA)coronaryarteriescanbe
seenontheshortaxisprecordialview,obtainedthroughtheaortic
root(Ao)justabovethevalvesthereisavague"pinwheel"
relationshipofthesweepofthearteries.Additionally,theleftatrial
appendage(LAA)isseenjustinferiortotheLCAandthepulmonary
valve(PV)justsuperior.
LA:leftatrium.
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2DandMmodeechocardiographicimagesofthe
normalaorticrootfromtheparasternalshortaxis
position
TheMmodebeamisdirectedthroughthetwodimensionalimageofthe
aorticrootatthebaseoftheheart(panelA).TheresultingMmode
echocardiogram(panelB)demonstratesnormalsystolicanddiastolic
motionpatternstheanteriorexcursionisover14mmandthediastolic
posteriorexcursionmainlyoccursearlyindiastole.Theaortic(Ao)valve
leafletsopenaswidelyastheinternaldimensionsoftherootpermitand
remainopenthroughoutsystole,creatingaboxlikeconfiguration.The
anteriormotionoftherootandthebehaviorofthevalvearetypical
findingswhenthestrokevolumeisnormal.
PA:mainpulmonaryarteryLA:leftatriumRVOT:rightventricularoutflowtract.
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Mmodeechocardiogramofnormalaortaandleft
atrium
TheMmodeechocardiogramisobtainedfromthelongaxis
parasternaltwodimensionalview(panelA)thedottedlinerepresents
theMmodebeampassingthroughtheaorticroot,theright(R)and
noncoronary(N)cuspsoftheaorticvalve,andtheleftatrium(LA).
Theatriumismeasuredatendsystole(arrows)whenthedescentof
theleftventriclebasehasresultedinmaximalfilling.
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Twodimensionaltransthoracicechocardiogram(2DTTE)and
Mmodeechocardiographicimagesalongwitha
phonocardiogramofthenormalaorticrootfromthe
parasternalshortaxisposition
PanelAshowstheshortaxisviewfromatwodimensionalechocardiogramrecorded
atthebaseoftheheartattheleveloftheaorticvalvetheline(M)bisectingthe
aorticvalverepresentstheplaneoftheMmodebeamusedtogeneratetheM
modeechocardiograminpanelB.Theaorticvalveopensnearlytotheaortic(Ao)
walls(panelB)andwhileopenedithasaboxlikeconfiguration.Thelinemarksthe
peakoftheRwaveontheECG.Thereisabriskanteriorsystolicmotionofthe
entireAorootandevenfasterearlierdiastolicrelaxation(posteriormotion)the
posteriormovementoftheaorticrootoccurspredominantlyinearlydiastolewith
verylittlemovementinlatediastole.Thispatternoccursinyounghealthyhearts
thatrelypredominantlyonearlyrelaxationforfillingratherthanatrialcontraction.
TheMmodeechocardiogramwithsimultaneousphonocardiogramisseeninpanel
C.Thevibrationsontheposteriormovingnoncoronaryaorticleaflet(downarrows)
aresimilarintimingandfrequencywiththelowintensity,earlysystolic"innocent"
murmurrecordedonthephonocardiogram(uparrows).Thesevibrationsare
commoninnormalvalveswithnormalorelevatedcardiacoutput.
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Mmodeechocardiogramofaorticrootin
cardiomyopathy
Incardiomyopathywithreducedstrokevolumethesystolicanterior
excursionoftheaortic(Ao)rootisgreatlyreducedincomparisonto
thenormalpattern.Additionally,theaorticvalve(AoV)openingis
greatlyreducedanditsdurationabbreviated.Justafterachievingtheir
maximumseparation,theAoVleafletsimmediatelybegindrifting
closed,withalossofthenormalboxlikeconfiguration.
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Aorticdilationinaorticstenosis
Aorticpathologycanbebetterseenbyimagingtheascendingaorta
oneinterspaceabovetheusuallongaxisprecordialwindow.The
normalappearanceofthesinusesandascendingaorta(AscAo)is
seeninpanelA.Forcomparison,panelBshowspoststenoticdilatation
whichisquitetypicalandalmostalwaysfoundinaorticstenosis.
AV:aorticvalveLA:leftatriumLV:leftventricle.
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Mmodeechocardiogramofaorticregurgitation
TheMmodeechocardiographicfindingsinaorticregurgitation,dueto
theMarfansyndromeinthiscase,includeflutteringofthemitral
valve(MV)(panelA)andagreatlydilatedaorticroot(Ao),measuring
48mm,inrelationshiptoasmallappearingleftatrium(LA)(panelB),
whichmeasures27mm.Theaortictoatrialdiameterratiohasbeen
usedasasignoftheMarfansyndrome.
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Aorticrootenlargement
Thenormalaorticroot(RT)andascendingaorta(AAo)areseenin
panelAslightprominenceofthesinusesofValsalva(SinV)canbe
appreciated.PanelBistheaorticRTandAAofromapatientwiththe
MarfansyndrometheSinVarelargewhiletheAAoisrelatively
normal,apatternthatseemsuniquetotheMarfansyndrome.Inpanel
C,agreatlyenlargedaortic(Ao)RTisalsoseen,butthepattern
differsfromthatseenintheMarfanpatientthedilatationbeginsat
theaorticringandcontinuesbeyondthesinotubularjunctionwellinto
theAAo,consideredtorepresentaortoannularectasia.
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TEEdescendingaorticdissection
Aorticdissectionischaracterizedbytheformationofan"intimalflap"seenasahyperechoicline
extendingacrossthevesseldelimitingtwodistinctlumens(A).ColorflowDoppler(B)depicts
higher(orange)bloodflowvelocityandintraluminalvelocityintheinferiorofthetwolumens,
butdoesnotprovidedefinitiveinformationregardingwhichisthetruelumenandfalselumen.
CourtesyofWManning,MD.
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Ascendingaorticdissectiononechocardiogram
Modifiedlongaxisviewshowsaproximaldissectionoftheaorticroot
(Ao),withaflapextendingtotheaorticvalve(V).Thisaortic
pathologyisseenbyimagingtheascendingaortaoneinterspace
abovetheusuallongaxisprecordialwindow.
LA:leftatriumLV:leftventricle.
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Suprasternalnotchviewofaorticarchandbrachiocephalicvein
Inthisview,takenwiththeneckextendedandtheprobepositionedatthesuprasternalnotchandangled
caudally,theaorticarchisvisualizedcentrally.Theaorticvesselwallisalinearstructurethatseparates
theaortafromthebrachiocephalicveinthisshouldnotbeconfusedwithadissection.The
brachiocephalicveinhascontinuousflowinbothsystoleanddiastolewhenvisualizedbycolorDoppler,
andthisfurtherdifferentiatesthestructurefromtheaortaorbrancharteries.
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Mildlydilatedthoracicaorta
Thelongaxisprecordialviewshowsslightdilationofthethoracic
aorta(ThAo).
CS:coronarysinus.
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(2DTTE)fromtheparasternallongandshortaxis
viewsshowingthedescendingthoracicaorta
Thedescendingthoracicaortacanbeseenfromtheparasternallong
axisview.Boththelong(panelA)andshortaxis(panelB)precordial
viewsshowthedescendingthoracicaorta(TAo).Notethattheshort
axisimagingplanedemonstratesthelongaxisoftheTAo.
LV:leftventricleRA:rightatriumLA:leftatriumAoR:aorticroot.
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(2DTTE)fromamodifiedtwochamberview
showingthedescendingthoracicaorta
Thedescendingthoracicaorta(TAo)canbeimagedfromtheapical
twoandfourchamberview.Posteriorangulationofthetransducer
(panelA)oftenopenstheTAosuchthatitcanbeseeninitslong
axis.Majorpathologysuchasaneurysmscanoftenbedetectedinthis
way.Anteriorangulationintheapicaltwochamberview(panelB)
demonstratestheproximalaorticarch(Ao).
LA:leftatriumLV:leftventriclerpa:rightpulmonaryartery.
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(2DTTE)fromamodifiedfourchamberview
showingthedescendingthoracicaorta
Thethoracicordescendingaorta(TAo)canbeimagedfromthe
apicaltwoandfourchamberview.Posteriorangulation(panelB)
showstheTAoinitsshortaxis,locatedbelowtheleftatrium(LA).
Anteriorangulationinfourchamberview(panelA)showstheoriginof
aorticroot(Ao).
RA:rightatriumLA:leftatrium.
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(2DTTE)fromthesubcostalviewshowingthe
abdominalaorta
Theabdominalaorta(AbAo)canbeseeninsubcostallong(panelA)
andshortaxis(panelB)views.Theneuralcanal(NC)isseenthrough
theintervertegraldiscinthisthinpatient.
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Echocardiographicimageoftheabdominalaorta
Theabdominal(Ab)aorta(Ao)isseenfromthesubcostallongaxis
(panelA)andshortaxisviews(panelB).Inthisthinpatientthe
neuralcanal(NC)isseenthroughtheintervertegraldiscintheshort
axisview.
RA:rightatrium.
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Abdominalaorticaneurysmlongandshortaxis
(A)Thelongaxisviewshowsananeurysmoftheabdominalaorta(A
AoAn)astheaortacrossesthediaphragm.Prominentplaquesjust
beyondtheaneurysmcanbeappreciated.
(B)Theshortaxisthroughtheaneurysm(An)alsoshowstheinferior
venacava(IVC).
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Dissectionoftheabdominalaortaonlongitudinal
ultrasound
Thelongaxisviewshowsadissectionoftheabdominalaorta(AAo)
andthepresenceofaspiralflap(f).
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Dissectionoftheabdominalaortaontransverse
ultrasound
Theshortaxisviewshowsadissection(Dis)oftheabdominalaorta
(AoAb)andaspiralflap(arrows).
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(2DTTE)fromtherightventricular(RV)outflow
tractviewshowingthepulmonicvalveandthe
pulmonaryarterybifurcation
Pulmonaryartery(PA)bifurcationintotheright(RPA)andleft(LPA)
pulmonaryarteriescanbeseenintheshortaxisprecordialview.Note
thatinthisviewtheLPAisproximaltothedescendingaorta(dAo).
Ao:aortaRVOT:rightventricularoutflowtractpv:pulmonicvalve.
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Pulmonaryartery
Therightpulmonaryartery(RPA)canbeseenintheprecordiallong
axisviewasitcrossesunderthetransverseaorta(Ao),superiorto
theleftatrium(LA).
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Disclosures
Disclosures:NelsonBSchiller,MDNothingtodisclose.XiushuiRen,MDNothingtodisclose.Bryan
Ristow,MD,FACC,FASE,FACPNothingtodisclose.WarrenJManning,MDEquityOwnership/Stock
Options:Pfizer(Pharmaceuticals).EquityOwnership/StockOptions(Spouse):GeneralElectric(Imaging
equipment).SusanBYeon,MD,JD,FACCNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmust
conformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy
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ECG Interpretation - Made Incredibly Easy 5th Edition (Chy Yong)

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