469

Diseases of the Great Arteries | Chapter 16

THE ECHO EXAM

Examination of the Aorta

Aortic
Segment Modality View Recording Limitations
Aortic TTE Parasternal Images of sinuses of Valsalva, Shadowing of posterior
sinuses long-axis aortic annulus, and aortic sinuses
sinotubular junction
TEE High esophageal Standard long-axis plane by
long-axis rotating to about 120°–130°
Ascending TTE Parasternal Move transducer superiorly to Only limited segments
long-axis image sinotubular junction visualized, variable among
and ascending aorta. patients
TTE Doppler Apical LVOT and ascending aorta flow Velocity underestimation if
recorded with pulsed or CW the angle between the
Doppler from an anteriorly Doppler beam and flow is
angulated four-chamber view not parallel
TEE High esophageal From long-axis view, move The distal ascending aorta
long-axis transducer superiorly to may not be visualized.
image ascending aorta.
Arch TTE Suprasternal Long- and short-axis views of Descending aorta appears
aortic arch to taper as it leaves the
image plane.
TEE High esophageal From the short-axis view of the View is not obtained in all
initial segment of the patients. The aortic
descending thoracic aorta, segment at the junction
turn the probe toward the of the ascending aorta
patient’s right side, and and arch may not be
angulate inferiorly. visualized.
Descending TTE Parasternal and Rotate from long-axis view to Depth of thoracic aorta on
thoracic modified image thoracic aorta in long TTE limits image quality.
apical views axis posterior to LV. TEE is usually needed for
From apical 2-chamber view, diagnosis.
use lateral angulation and
counterclockwise rotation to
image aorta.
TTE Doppler Suprasternal Descending aorta flow recorded Low wall filters needed to
with pulsed Doppler from evaluate for holodiastolic
SSN view flow reversal
TEE Short-axis aorta Sequential short-axis views of Long-axis views allow
the aorta from the level of further evaluation of
the diaphragm to the arch abnormal findings.
with the image plane turned
posteriorly and the transducer
slowly withdrawn
Proximal TTE Subcostal Long axis of proximal abdominal Only the proximal segment
abdominal aorta is visualized.
TTE Doppler Transgastric Proximal abdominal aorta flow Low wall filters needed to
recorded with pulsed Doppler evaluate for holodiastolic
flow reversal
TEE Transgastric From the transgastric position, Does not allow evaluation of
portions of the abdominal entire abdominal aorta
aorta may be seen
posteriorly.

LVOT, LV outflow tract; SSN, suprasternal notch.

Continued
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Chapter 16 | Diseases of the Great Arteries

Key Features of Aortic Diseases

Aortic Dissection Key Features Associated Findings

Dissection flap In aortic lumen Independent motion
True and false lumen Entry sites
Thrombosis of false lumen
Intramural hematoma Crescent-shaped thickening of aortic wall
Indirect findings Aortic dilation
Aortic regurgitation
Coronary ostial involvement
Pericardial effusion
Complications of Aortic Dissection
Aortic regurgitation Due to aortic root dilation
Due to leaflet flail
Coronary artery occlusion Ventricular fibrillation
Acute myocardial infarction
Distal vessel obstruction Carotid (stroke)
Subclavian (upper limb ischemia)
Aortic rupture Into the pericardium Pericardial effusion
Pericardial tamponade
Into the mediastinum
Into the pleural space Pleural effusion
Exsanguination
Sinus of Valsalva Aneurysm
Congenital Complex shape
Protrusion into RV outflow tract
Fenestrations
Acquired Infection or inflammation
Symmetric shape
Communication with aorta
Potential for rupture
Aortic Atheroma
Complex (≥4 mm or mobile)
Associated with: Coronary artery disease
Cerebroembolic events

SUGGESTED READING
Guidelines
1. Goldstein SA, Evangelista A, Abbara
S, et al: Multimodality imaging of
diseases of the thoracic aorta in
adults: from the American Society of
Echocardiography and the European
Association of Cardiovascular
Imaging: endorsed by the Society of
Cardiovascular Computed
Tomography and Society for
Cardiovascular Magnetic Resonance,
J Am Soc Echocardiogr 28(2):119–182,
2015.
Recommendations for imaging the aorta with
details of image acquisition, strengths, and
limitations of each modality. Normal aortic
size is related to age, body size, and sex. In
children, aortic size is normalized to height,
but indexing aortic size in adults is more
problematic. The regressions equations in
Fig. 16.5 and upper limits of normal in
Tables A.9 and A.10 are recommended as
benchmarks. All imaging modalities are
subject to physiologic and measurement
variability, so small changes on serial studies
should be interpreted with caution.
2. Evangelista A, Flachskampf FA, Erbel
R, et al: European Association of
Echocardiography; Pepi M, Breithardt
OA, Plonska-Gosciniak E (document
reviewers): Echocardiography in aortic
diseases: EAE recommendations for
clinical practice, Eur J Echocardiogr
11(8):645–658, 2010. Erratum in: Eur
J Echocardiogr 12(8):642, 2011.
This guideline recommends TEE as the
ultrasound procedure of choice for the
evaluation of the thoracic aorta. The
relationships among age, body size, and
aortic diameter should be considered in the
diagnosis of aortic enlargement.
Echocardiography also allows evaluation of
aortic elastic properties, detection of
atheroma, and diagnosis of aortic dissection.
However, CT and MRI imaging are more
reliable for evaluation of the arch and
descending aorta. Provides details and
examples of image acquisition and
measurement.
3. Hiratzka LF, Bakris GL, Beckman JA,
et al: 2010 ACCF/AHA/AATS/
ACR/ASA/SCA/SCAI/SIR/STS/
SVM guidelines for the diagnosis and
management of patients with thoracic
aortic disease: a report of the
American College of Cardiology
Foundation/American Heart