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Imaging and Diagnostic Testing

The role of transthoracic echocardiography in


the diagnosis and management of acute type A
aortic syndrome
Moreno Cecconi, MD,
a
Fabio Chirillo, MD,
b
Carlo Costantini, MD,
a
Gianfranco Iacobone, MD,
a
Ercole Lopez, MD,
a
Raffaele Zanoli, PhD,
c
Alberto Gili, MD,
a
Stefano Moretti, MD,
a
Marcello Manfrin, MD,
a
Christopher Mnch, MD,
a
Lucia Torracca, MD,
a
and Gian Piero Perna, MD
a
Ancona, and Treviso, Italy
Background Transthoracic echocardiography (TTE) has been traditionally considered inadequate for the diagnosis of
acute type A aortic syndrome (AAAS). In the last decade, high-resolution probes and harmonic imaging have been
implemented in new echocardiographic systems. However, studies assessing the diagnostic accuracy of TTE for the
identification of AAAS in large populations using modern ultrasound technology are lacking.
Methods The diagnostic value of harmonic imaging TTE was assessed in 270 consecutive patients with suspected AAAS
in whom TTE was the initial diagnostic test.
Results Acute type A aortic syndrome was diagnosed in 67 patients and excluded in 203 patients (disease prevalence
25%). Sixty-two patients had a classic acute type A aortic dissection, and 5, an acute type A intramural hematoma. Image
quality achieved was considered optimal in 244 patients (90%). In the whole study population, TTE had sensitivity, specificity,
positive predictive value, and negative predictive value for the diagnosis of AAAS of 87%, 91%, 75%, and 95%, respectively.
When evaluating only patients with optimal image quality, these values increased to 97%, 100%, 100%, and 99%,
respectively. Forty-seven patients with clear-cut evidence of AAAS were transferred immediately to the operative room, where
transesophageal echocardiography confirmed the diagnosis obtained by TTE in all patients.
Conclusions Transthoracic echocardiography is a useful imaging modality for the diagnosis of classic acute type A
aortic dissection. It cannot be used as the sole screening technique for detecting AAAS, but in the light of the predictive values
observed, patients with optimal image quality and clear-cut diagnosis of AAAS should proceed to the operative room,
whereas in patients with negative or indeterminate studies, other imaging techniques are needed to refine the diagnosis.
(Am Heart J 2012;163:112-8.)
Acute type A aortic syndrome (AAAS) is a collective
term for several life-threatening acute aortic conditions
involving the ascending aorta, namely, aortic dissection,
intramural hematoma, penetrating atherosclerotic ulcer,
and traumatic transection.
1
It is a life-threatening
condition requiring immediate diagnosis and prompt
surgical treatment.
1,2
Transthoracic echocardiography
(TTE) is a rapid, safe, and easily available imaging
modality that can be performed on an emergency basis
at the bedside; therefore, it might represent an ideal
diagnostic tool in patients with suspected AAAS.
3
However, TTE is commonly considered to be inadequate
for the diagnosis of AAAS because of suboptimal imaging
quality, especially in patients with pulmonary emphyse-
ma, obesity, and abnormal chest wall configuration.
1,3, 4-6
In previous studies, TTE was reported to have a 57% to
82% sensitivity and a 65% to 96% specificity for the
detection of classic type A acute aortic dissection
(CAAAD) as compared with a 95% to 100% sensitivity
and 94% to 100% specificity when using computed
tomography (CT), transesophageal echocardiography
(TEE), and magnetic resonance imaging (MRI).
2,5,7,8
However, these results were obtained when current
imaging technology was not yet available.
9-13
Recent
advances in ultrasound technology, including the devel-
opment of high-resolution probes and the introduction of
harmonic imaging, have greatly improved the diagnostic
value of TTE, ameliorating the imaging quality and
From the
a
Department of Cardiology and Cardiac Surgery, Azienda Ospedaliero
Universitaria, Ospedali Riuniti, Ancona, Italy,
b
Department of Cardiology, Ospedale Ca'
Foncello, Treviso, Italy,
c
Universit Politecnica delle Marche, Ancona, Italy.
Submitted April 5, 2011; accepted September 25, 2011.
Reprint requests: Fabio Chirillo, MD, Department of Cardiology Ca' Foncello Hospital,
31100 Treviso, Italy.
E-mail: fchirillo@tin.it
0002-8703/$ - see front matter
2012, Mosby, Inc. All rights reserved.
doi:10.1016/j.ahj.2011.09.022
reducing the number of suboptimal studies.
14,15
Harmon-
ic imaging has been introduced N10 years ago, and it is
now implemented in all new echocardiographic systems.
However, to date, only 1 study evaluating the diagnostic
accuracy of TTE in acute ascending aortic dissection
using the harmonic ultrasound technology has been
published.
16
Moreover, there are no published data on
the diagnostic value of TTE in patients with acute type A
intramural hematoma (AAIH). The aim of this study was
to assess the current diagnostic value and the possible
role of TTE in the management of patients with
suspected AAAS.
Methods
Patients
In 1990s, echocardiography was identified as the first-line
imaging technique for the diagnosis of cardiovascular emergen-
cies at Ancona hospital; consequently, the department organi-
zation chart was modified to have a cardiologist with high
expertise in both TTE and TEE on site or available at short notice
24 hours/7 days.
In 1999, harmonic imaging TTE was adopted as first imaging
test in patients with suspected AAAS. According to the
hospital's management protocol patients in whom the diagnosis
of AAAS could have been obtained by TTE proceeded directly
to the operative room, where TEE had to be performed, after
induced hypotension and tracheal intubation to confirm the
diagnosis and to provide complementary information to be
used for the surgical planning. If TTE resulted negative or
provided indeterminate results, other imaging techniques (CT,
TEE, and MRI, depending on the preference of the physician in
charge and the availability at the moment of admission) should
have been performed. No patient was excluded from the
protocol because of inadequate acoustic window.
A predefined data set containing the findings of imaging
techniques and information of in-hospital outcome had been set.
To define the diagnostic value of TTE for the identification of
AAAS, we retrospectively evaluated all consecutive patients
with suspected AAAS admitted to our hospital between January
1999 and December 2007 in whom TTE was the initial
diagnostic technique. A further retrospective analysis was run
to identify all eligible patients not included in the protocol and
all patients with AAAS seen at our hospital during the study
period who did not meet the inclusion criteria. Acute type A
aortic syndrome was defined as any aortic syndrome involving
the ascending aorta with presentation within 14 days of the
onset of symptoms.
Echocardiography
All TTE studies were performed with a Sonos 5500 ultrasound
system using a S3 probe and harmonic imaging (Agilent Medical
system; Philips Medical system, Andover, MA) on an emergency
basis in the intensive care unit or in the emergency department.
The result was reported immediately for clinical decision
making. Images were stored on videotape and/or on magneto-
optical disks for later analysis.
Considering the visibility of the aortic valve leaflets and of
the wall of the ascending aorta, 2 levels of imaging quality were
defined: (1) optimal image quality (complete visualization of
valve structures and the ascending aorta within 5 cm from the
valve without or with minimal clutter) and (2) suboptimal
image quality (whenever these conditions were absent).
Anevaluationof the entire aorta was performed withthe patient
inthe supine, left lateral, andright lateral decubitus positions using
multiple views including left parasternal, left high parasternal,
right parasternal, right high parasternal, apical, subcostal,
suprasternal, and abdominal views. The diagnosis of CAAAD was
made if a flap separating 2 aortic lumens was seen in the
ascending aorta. Diagnostic criteria for intimal flaps included
(1) undulating motion concordant with pulsatile blood flow,
independent of the excursions of the aortic wall; (2)
visualization in N1 view; and (3) clear distinction from the
reverberations originating from adjacent structures.
17,18
The motion of the intimal flap was also evaluated by M-mode
echocardiography to identify artifacts. Linear artifacts in the
ascending aorta were distinguished from intimal flaps by (1)
fuzzy and indistinct borders, (2) the lack of rapid oscillatory
movements generally associated with intimal flaps in acute
dissections, (3) the extension of the artifact through the aortic
wall, and (4) the fact that the color Doppler pattern within
the aorta was not modified by the presence of the linear
artifact.
17,18
With the use of color Doppler flow mapping,
attempts were made to study the flow characteristics in the
2 lumens; the identification of 2 different flow patterns within
the aorta strengthened the diagnosis of classic aortic dissection.
The diagnosis of AAIH was made in the presence of a circular or
crescentic thickening of the ascending aortic wall N7 mm in the
absence of an intimal flap.
19
The displacement of intimal
calcifications was an additional diagnostic criterion.
Other echocardiographic findings indicative of high-risk
features or complications of AAAS, such as pericardial effu-
sion/tamponade, pleural effusion, left ventricular regional wall
motion abnormalities, and aortic regurgitation (graded accord-
ing to the criteria of Perry et al
20
) were searched for.
Transthoracic echocardiography studies were aimed to
rapidly confirm or exclude the diagnosis of AAAS; for sake of
time, no effort was made to assess detailed anatomical features
of the aorta and its branches.
Patients' management
In patients undergoing TTE as first imaging diagnostic test, 3
possible situations were observed: (1) patients with optimal image
qualityandclear-cut diagnosis of AAAS (ie, evident andcharacteristic
intimal flap and specific aortic wall thickening); (2) patients with
optimal image quality and negative studies; and (3) patients with
suboptimal image quality and/or equivocal diagnostic findings (ie,
isolated linear image in the ascending aorta).
According to the management protocol, patients in the first
group proceeded immediately to the operative room where
they underwent TEE under controlled hemodynamic condi-
tions. Patients in the second and third groups underwent
additional diagnostic tests to obviate the expected low
diagnostic sensitivity of TTE for AAAS.
Data interpretation and statistical analysis
All echocardiographic studies were initially evaluated by the
physician performing the examination. All images were jointly
reevaluated using a consensus method by 2 experienced readers
Cecconi et al 113
American Heart Journal
Volume 163, Number 1
(MC and FC), unaware of the results provided by the initial
reader, of the findings of other imaging techniques, and patient's
outcome. The diagnosis was confirmed at surgical inspection, at
autopsy, or at least by 2 concordant imaging modalities.
Sensitivity, specificity, positive predictive value, and negative
predictive value of TTE were calculated from the percentage of
validated true positive and true negative results. Two different
evaluations of echocardiographic findings were carried on: a
for protocol analysis considering only patients with clear-cut
evidence of AAAS and those with negative studies in presence of
optimal acoustic window and an intention-to-treat analysis in
which all TTE studies were evaluated, independently of the
image quality.
Continuous variables were reported as mean SD and cate-
gorical variables as frequencies. Statistical comparison between
the study groups was tested with the independent-samples t test
for continuous variables and the
2
test for categorical variables.
Differences were considered significant at the P b .05 level.
No extramural funding was used to support this work. The
authors are solely responsible for the design and conduct of
this study, all study analyses, and drafting and editing of
the manuscript.
Results
Patients' demographic and clinical characteristics are
summarized in Table I.
Among the 270 patients included in the study, AAAS was
present in 67 patients (disease prevalence 25%). Sixty-two
patients had a CAAAD, and 5, an AAIH. The diagnosis was
confirmed by surgery (62 patients), autopsy (2 patients), or
at least 2 imaging modalities (3 patients). In the remaining
203 patients, AAAS was excluded by CT (155 patients), TEE
(39 patients), CT and TEE (5 patients), and CT and MRI (4
patients). The image quality provided by TTE was
considered optimal in 244 patients (90%) and suboptimal
in the remaining 26. Mean duration of TTE study was 12
5.2 minutes. Transthoracic echocardiography correctly
identified AAAS in 58 patients.
Transthoracic echocardiography was falsely positive in
19 patients; in all these cases (7 CAAAD and 12 AAIH),
the image quality was considered suboptimal. Although
TTE findings were not entirely diagnostic for an intimal
flap or an intramural hematoma and linear artifacts or
nonspecific aortic wall thickness had been suspected,
studies were considered positive for AAAS in the
intention-to-treat analysis. An additional imaging modality
was performed in all 19 patients (CT in 11 cases, TEE in
5 cases, CT and TEE in 1 case, and CT and MRI in 2 cases)
to definitively exclude AAAS.
There was a false-negative diagnosis in 9 patients
(6 patients with CAAAD and 3 patients with AAIH). In 7
of them, the quality of imaging was inadequate. One
patient had a localized dissection at the distal ascending
aorta and proximal arch. Another patient had an entry
tear in the arch and a thrombosis of the false lumen in
the proximal thoracic aorta. In 2 patients, the intimal
flap was seen only in the abdominal view; this finding
was not considered sufficient for a diagnosis of CAAAD.
Additional testing (CT in 5 cases, TEE in 3 cases, and CT
and MRI in 1 case) proved AAAS in all 9 patients.
Overall sensitivity, specificity, positive predictive value,
and negative predictive value of TTE for the diagnosis of
AAAS, CAAAD, and AAIH are reported in Table II. The
diagnostic accuracy was better for CAAAD when
compared with that obtained for AAIH. Transthoracic
echocardiography showed a poor sensitivity (40%) for
the diagnosis of AAIH. Of note, the only 2 patients in
whom AAIH had been correctly identified by TTE
presented with a thickening of the ascending aortic
wall N10 mm.
Finally, when considering the 244 patients in whom
the image quality achieved was considered optimal
(Table III), both sensitivity and specificity increased to
97% and 100%, respectively, with a 100% positive
predictive value and a 99% negative predictive value.
The bedside reading deviated from the post hoc
analysis in 3 cases (2 interpreted as false positives and 1
as false negative by the initial operator). In all 3 patients,
the image quality was poor. There was a complete
agreement in all patients with optimal image quality.
Among the 67 patients with AAAS, aortic regurgitation
was present in 41 patients (61.2%) and was considered
severe in 20 (29.8%). Pericardial effusion was identified in
25 patients (37.3%), cardiac tamponade in 15 (22.4%),
and pleural effusion in 14 patients (21%). There were 4
patients presenting with chest pain and ST-segment
elevation: all of them were correctly identified as having
CAAAD by means of TTE.
Among patients with negative studies, TTE suggested
alternative diagnosis in 67 cases (36%), namely, acute
coronary syndrome in 39, pulmonary embolism in 10,
pericarditis in 15, and pneumothorax in 3.
Outcome of patients
Among patients with clear-cut evidence of AAAS at TTE,
2 were refused surgery because of severe comorbidities
and died a few hours after admission; the diagnosis of
Table I. Characteristics of 270 patients with suspected AAAS
Variable Value
Age (y) 66 15
Male sex 191 (71%)
Hypertension 196 (73%)
Known thoracic aortic aneurysm 43 (16%)
Marfan syndrome 16 (6%)
Previous cardiac surgery 32 (12%)
Chest pain 212 (79%)
Congestive heart failure 57 (21%)
Shock/hypotension 48 (18%)
Neurologic dysfunction 43 (16%)
Acute renal failure 24 (9%)
114 Cecconi et al
American Heart Journal
January 2012
CAAAD was confirmed in both cases at necropsy. The
remaining 47 patients were transferred immediately to
the operative room where a TEE was performed. Time
from admission to the operative room among these
patients was 43 25 minutes.
Both TEE and operative inspection confirmed the
diagnosis obtained by TTE in all patients.
Among patients in whom the diagnosis was achieved
by techniques different from TTE, 2 died before
operation. Time interval from admission to operation
was significantly longer (220 110 minutes) when
compared with the group of patients proceeding to the
surgical suite immediately after a positive TTE. Overall
in-hospital mortality was 22.2% and did not differ
between groups.
Patients not enrolled in the protocol
In a retrospective analysis, we identified 41 patients
eligible for the protocol who underwent CT scanning
as first diagnostic technique during the study period
based on the decision of the emergency department
physicians. Computed tomographic scan excluded AAAS
in 31 and identified it in 10 patients (8 CAAAD and 2
AAIH). All patients with positive CT scan underwent
complementary echocardiography (TTE in 3 cases and
TEE in 7 cases) to get important preoperative informa-
tion (especially on the status of the aortic valve). There
were 2 false-positive and 1 false-negative cases at CT scan
(sensitivity 88.8%, specificity 93.7%, positive predictive
value 80%, and negative predictive value 96.7%).
In the same period, a total of 119 patients with AAAS
were transferred from referring hospitals. Initial diagnosis
had been obtained by CT scan (n = 81, 67%), TEE (n = 33,
28%), MRI (n = 5, 4%). Ten patients died before reaching
the operative room. All the remaining patients underwent
intraoperative TEE. When comparing the clinical charac-
teristics of these patients with those evaluated directly at
our center with TTE, shock, cardiac tamponade, and
pericardial effusion without tamponade were more
frequent in patients directly admitted to Ancona hospital
and rapidly transferred to the operative room after the
diagnosis had been obtained by sole TTE (Table IV).
Notwithstanding the worse clinical characteristics in the
Ancona group and the same operative procedures
performed, the mortality rate observed did not differ
between the 2 populations.
Discussion
Acute aortic syndrome involving the ascending aorta
represents a medical emergency because of a high
mortality rate concentrated within few hours from
presentation.
1,2
Therefore, rapid and accurate diagnostic
imaging techniques are essential.
Transthoracic echocardiography has been generally
considered limited in the diagnosis of AAAS: older series
reported sensitivity levels as low as 57%, which was
inadequate for clinical purposes.
9-13
In the present study, the diagnostic accuracy of TTE for
early identification of AAAS has been evaluated in a large
retrospectively collected group of consecutive patients.
The sensitivity for the detection of AAAS was 87%, and
the specificity, 91%, with a positive predictive value of
75% and a negative predictive value of 95%, respectively.
The results are significantly better than those reported
by the literature of the past and by the recent article by
Evangelista et al.
16
This can be explained by 3 main
reasons: (1) the use of harmonic imaging technology, (2)
operators' experience, and (3) patients' selection.
Harmonic imaging technology has been in clinical use
for over a decade, emerging as a promising additional
modality in echocardiography, and it is now implemen-
ted in all new echocardiographic systems.
14,15
Harmonic
imaging TTE uses the second harmonic (twice the
fundamental frequency) to minimize artifactual echoes
that originate from indistinct tissue-tissue and tissue-
blood interfaces. Therefore, harmonic imaging creates a
cleaner echographic signal with increased signal-to-noise
ratio and improvement in lateral resolution. As a result,
the overall image quality increases, and the identification
of thin linear structures such as aortic intimal flaps or
discrete wall thickening may improve.
One of the main limitations of echocardiography is
operator's dependence. Transesophageal echocardiogra-
phy has now an acknowledged diagnostic accuracy
Table II. Diagnostic accuracy of TTE for AAAS in the whole study group according to the type of syndrome
Sensitivity (%)
(95% CI)
Specificity (%)
(95% CI)
PPV (%)
(95% CI)
NPV (%)
(95% CI)
All patients (n = 270) 87 (75-93) 91 (85-94) 75 (64-84) 95 (91-98)
CAAAD (n = 62) 90 (79-96) 96 (92-98) 89 (78-95) 97 (92-100)
AAIH (n = 5) 40 (8-83) 94 (88-98) 14 (2-45) 98 (93-100)
NPV, Negative predictive value; PPV, positive predictive value.
Table III. Diagnostic accuracy of TTE for AAAS in the patients
with optimal acoustic window (n = 244)
Sensitivity (%)
(95% CI)
Specificity (%)
(95% CI)
PPV (%)
(95% CI)
NPV (%)
(95% CI)
97 (87-99) 100 (97-100) 100 (92-100) 99 (96-99)
Cecconi et al 115
American Heart Journal
Volume 163, Number 1
comparable with that of CT and MRI for the diagnosis of
aortic syndromes.
1-5
However, in the first series pub-
lished, the specificity of TEE was markedly lower than
that found for CT and MRI.
4
This depended on the fact
that many linear and mirror artifacts were interpreted as
intimal flaps by the initial operators. After completing a
learning experience, this was not the case anymore.
Using TTE, which provides an imaging quality inferior
to TEE, the operators' experience is even more critical.
Therefore, it should be stressed that the results of the
present study have been obtained by well-trained
cardiologists with a long-standing experience both in
TTE and TEE diagnosis of AAAS and cannot be generalized
to units where TTE is performed by different operators
(cardiologists, anesthesiologists, and emergency sur-
geons) with different expertise in echocardiography.
This outlines the importance of a learning curve for
operators of TTE in emergency situations to achieve
optimal images and interpret them correctly avoiding
false positives and negatives and the need for a
department organization, which makes expert operators
available 24 hours/7 days.
Notwithstanding the improvements in the TTE
techniques and in the interpretative skills, the diagnostic
accuracy of the technique for the identification of AAAS
observed in the present study was far from being
optimal. If we consider the results of the application of
TTE in the whole study population, there were 19 false
positives, 9 false negatives, and 26 patients with
inadequate images. Therefore, in a significant number
of patients, TTE was useless or misleading. This means
that if one had based the decision to send patients to
immediate surgery on the sole TTE, 19 inappropriate
interventions would have been generated and 9
potentially life-saving operations would have been
missed. Another significant limitation of TTE is repre-
sented by the inability to adequately detect AAIH, which
accounts for 5% to 10% of all aortic syndromes involving
the ascending aorta.
1,2,19,21
To our knowledge, this is
the first study examining the value of TTE in the
diagnosis of AAIH. Although our results are derived from
a small number of patients, we found that TTE was
inadequate for the detection of AAIH because of its low
sensitivity. It should be emphasized that a regional
thickening of the aortic wall N7 mm
19
was assumed as
diagnostic criterion for AAIH; however, some authors
recommend a cutoff limit of 5 mm for diagnosis.
21
It is,
therefore, conceivable that the sensitivity of TTE for
the detection of AAIH would be even lower than 40%,
should the 5-mm value be assumed as cutoff limit.
Based on these findings, it should be concluded that
TTE cannot be used as the sole imaging technique in
patients with suspected AAAS because of suboptimal
sensitivity. Computed tomography, TEE, and MRI have
demonstrated superior diagnostic accuracy; neverthe-
less, it should be emphasized that no technique has
demonstrated a 100% sensitivity and specificity for the
identification of aortic dissection, and even in experi-
enced centers, most patients with acute aortic syndrome
undergo N1 imaging modality.
22
However, when considering our results, one should
keep in mind that with all imaging techniques, the key
factor is the imaging quality achieved and that, in the
present analysis, no patient was excluded because of
poor imaging quality. If we consider only patients in
whom the ascending aorta could be adequately imaged
Table IV. Clinical characteristics, management, and outcome among 168 patients with AAAS according to the initial diagnostic evaluation
Variable
Group 1
Ancona hospital patients
Diagnosis by TTE alone (n = 49)
Group 2
Transferred to Ancona hospital
Diagnosis by CT, TEE, MRI (n = 119) P
Age (y) 65 14 67 13 NS
Male sex 33 (67%) 82 (69%) NS
Hypertension 33 (67%) 87 (73%) NS
Severe aortic regurgitation 15 (31%) 32 (27%) NS
Shock 11 (23%) 10 (8%) b.05
Cardiac tamponade 13 (27%) 11 (9%) b.01
Pericardial effusion without tamponade 9 (18%) 6 (5%) b.01
Congestive heart failure 6 (12%) 9 (8%) NS
Syncope 6 (12%) 13 (11%) NS
Neurologic dysfunction 5 (10%) 15 (13%) NS
Surgical treatment 47 (96%) 109 (92%) NS
Isolated replacement of the ascending aorta 18 (38%) 44 (40%) NS
Hemiarch replacement 14 (30%) 33 (30%) NS
Complete arch replacement 5 (11%) 14 (13%) NS
Overall in-hospital mortality 11 (22%) 27 (23%) NS
Surgical in-hospital mortality 9 (19%) 21 (19%) NS
Intensive care unit stay (d) 5.3 4 4.6 2.6 NS
Hospital stay (d) 16.9 10.8 15.7 8.5 NS
NS, Not significant.
116 Cecconi et al
American Heart Journal
January 2012
(90%), the observed specificity reached 100%, and
sensitivity significantly increased to 97%.
From a practical point of view, when reviewing the
results of the protocol, no patients had undergone
inappropriate thoracotomy, and only 3 patients with
AAAS would have been missed by TTE but were
ultimately diagnosed as having AAAS by other techniques.
Transthoracic echocardiography was also useful in
establishing or excluding the differential diagnosis in the
acutely unwell patient, particularly in the absence of
aortic root dilatation, providing alternative diagnosis.
Finally, in those patients in whom a dissection flap could
be seen, TTE could identify those features of AAAS that
indicate high risksevere proximal aortic dilatation,
pericardial/pleural effusion (suggestive of impending
rupture), associated left ventricular regional wall motion
abnormalities (coronary occlusion), and aortic regurgi-
tationfacilitating immediate surgical referral and ap-
propriate emergency management. In our experience,
the initial diagnosis of CAAAD provided by TTE was of
paramount importance in patients with AAAS presenting
with ST-elevation on electrocardiogram, who would
have been exposed to potentially lethal consequences
should they have been administered thrombolysis or
platelet glycoprotein inhibitors.
Finally, even in negative studies, TTE could frequently
establish an alternative diagnosis of chest pain.
Limitations
The present study has several limitations. Our cohort
was assembled retrospectively, making detection bias in
determination of baseline features and clinical outcome
an unavoidable possibility. However, our established
rigorous definitions of clinical and echocardiographic
features and the consecutive collection of patients
decreased the potential bias. It must be recognized that
our results are subject to the referral bias of a large tertiary
care center. Finally, TTE studies were performed by
experienced echocardiographers using current ultrasound
technology; this is significantly different in terms of
operator and interpreter expertise than at most institu-
tions; thus, our results do not apply to centers lacking
such expertise and echocardiographic technology.
Conclusions
Transthoracic echocardiography is a noninvasive diag-
nostic option widely available in almost any community
hospital. Compared with other highly accurate diagnostic
techniques (CT and MRI), echocardiography has the
advantage of being applicable in any hospital setting
(emergency and intensive care), without the need to
transfer the patient who is often in an unstable
hemodynamic situation, monitored, and with intravenous
drugs. However, notwithstanding the use of modern
technology, it cannot be considered a reliable screening
technique in patients with suspected AAAS because of
unavoidable operator dependency, reduced image reso-
lution, and limited field of view.
Despite these limitations, according to a recent recom-
mendation from the European Association of Echocardi-
ography, TTE can be used as the first-line imaging
technique in a diagnostic algorithm on the emergency
management of patients with suspected AAAS.
23
If the
study is nonconclusive, an additional imaging modality
should be performed to obviate the somewhat suboptimal
sensitivity of TTE, especially when anatomical variants
of AAAS rather than CAAAD are present.
If an intimal flap is evident and there are no
contraindications to surgery, patients should proceed
directly to the operative room, thus reducing the time
interval between diagnosis and surgery and increasing
safety; subsequently, the diagnostic evaluation should be
completed by intraoperative TEE to obtain additional
information useful for planning surgery. A management
strategy guided by TTE may be particularly valuable in
clinically unstable patients and in patients with TTE
findings, indicating urgency such as pericardial effusion.
Our study could be considered the first (albeit retrospec-
tive) clinical application of these recommendations.
23
The results are encouraging; however, in our opinion, the
major issue of this approach remains the generalizability
and applicability of our management protocol in other
centers, as most facilities do not have immediate access to
highly trained cardiologists. A word of caution is,
therefore, needed before disseminating this approach
more extensively.
Acknowledgement
We thank Dr Rossella Fattori for her critical review
and suggestions.
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