Aortic & Systemic Disease Classification 65% 20%10%

Aortic & Systemic Disease

Classification 65% 20%10% 5%

Symptoms Pain 96% of patients Sudden severe onset Tearing, ripping, sharp, stabbing Migrating pain (17%) Location • Anterior only: ascending aorta in 90% • Interscapular only: descending thoracic aorta in 90% • Neck, throat, jaw, face: ascending aorta • Back, abdomen, lower extremities: descending aorta Pleuritic pain • Hemopericardium

Laboratory Findings Chest X-ray Widening of the aortic silhouette • 81 – 90% Calcium sign • Intimal calcification from the outer aortic border > 1 cm • Suggestive Pleural effusion • Left side Normal chest X-ray • Up to 12%

Calcium Sign

Diagnostic Techniques Contrast-enhanced CT Diagnostic clues • 2 distinct aortic lumen and intimal flap • 3 -dimensional display by spiral CT – Aorta and branches

Diagnostic Techniques Contrast-enhanced CT Advantages • Noninvasive • High sensitivity and specificity (96 -100%) • Readily available • Thrombus in the false lumen • Pericardial effusion • Branch vessel compromise Disadvantages • Contrast materials

Diagnostic Techniques Transthoracic echocardiography (TTE)

Diagnostic Techniques Transthoracic echocardiography (TTE)

Diagnostic Techniques Transthoracic echocardiography (TTE)

Diagnostic Techniques Transthoracic echocardiography (TTE)

Diagnostic Techniques Transthoracic echocardiography (TTE)

Diagnostic Techniques Transthoracic echocardiography (TTE)

Diagnostic Techniques Echocardiography Advantages • Readily available • Noninvasive • Quick to perform at the bedside Transthoracic echocardiography (TTE) • Sensitivity: 59 – 85% • Specificity: 63 – 96% • Limited by image quality

Diagnostic Techniques Transesophageal echocardiography (TEE) Advantages • High imaging quality with high frequency ultrasound • Not require contrast materials • Aortic regurgitation • Pericardial effusion • High sensitivity and specificity – Sensitivity: 98 – 99% – Specificity: 94 – 97% Disadvantages • Not visualize distal ascending aorta and proximal arch

Diagnostic Techniques Transesophageal Echocardiography (TEE)

Diagnostic Techniques Transesophageal Echocardiography (TEE)

Diagnostic Techniques Transesophageal Echocardiography (TEE)

Diagnostic Techniques Transesophageal Echocardiography (TEE)

Diagnostic Techniques Transesophageal Echocardiography (TEE)

Immediate Medical Management Blood pressure reduction Goal • Systolic BP: 100 – 120 mm. Hg • Heart rate: 60 – 80 / m • Reducing d. P/dt (beta blocker) Pain control • Morphine

Immediate Medical Management Blood pressure reduction Anticipating aorta surgery • Sodium nitroprusside • Esmolol Labetalol • Alpha and beta blocking Contraindicated to beta blocker • Severe sinus bradycardia, AV block, bronchospasm, congestive heart failure • Diltiazem, verapamil • ACE inhibitors

Definitive Therapy Surgery Acute proximal dissection Complicated acute distal dissection • Progression with vital organ compromise • Rupture or impending rupture (saccular aneurysm) • Retrograde extension into the ascending aorta • Dissection in Marfan syndrome Medical Uncomplicated acute distal dissection Stable isolated arch dissection Stable chronic dissection

Aortic Intramural Hematoma Pathology Hemorrhage contained within the medial layer Without an evident intimal tear Pathogenesis Rupture of the vasa vasorum Small or micro tears in the intima

Aortic Intramural Hematoma Computed tomography

Aortic Intramural Hematoma T

Aortic Intramural Hematoma T

Aortic Intramural Hematoma T

Abdominal Aortic Aneurysm

Abdominal Aortic Aneurysm

Behcet’s Disease

Behcet’s Disease

Behcet’s Disease T

Takayasu’s Arteritis

Takayasu’s Arteritis

Takayasu’s Arteritis T

Severe Aortic Atherosclerosis

Severe Aortic Atherosclerosis

End-Stage Renal Disease LV hypertrophy Pericardial effusion Early stage: diastolic dysfunction Late stage: systolic dysfunction

End-Stage Renal Disease

End-Stage Renal Disease

End-Stage Renal Disease

Cardiac Amyloidosis LV hypertrophy Atrial enlargement Sparkling texture of myocardium Restrictive physiology Pericardial effusion Valvular thickening & regurgitation Low QRS voltage

Cardiac Amyloidosis

Cardiac Amyloidosis

Cardiac Amyloidosis

Cardiac Amyloidosis

Cardiac Amyloidosis

Carcinoid Syndrome Common in hepatic involvement Caused by secretion of serotonin, bradykinin Fibrosis & thickening of TV & PV stenosis or regurgitation Lt side valve: 10%

Carcinoid Syndrome

Carcinoid Syndrome

Cardiac Sarcoidosis Cardiac involvement: 20% Cardiac fibrosis & RWMA • Basal & lateral LV • Wall thinning & aneurysm formation • restrictive morphology

Cardiac Sarcoidosis

Cardiac Sarcoidosis

Cardiac Sarcoidosis