Aorta

Aorta
Normal anatomy
The aorta is the main conductance artery of the body carrying blood from
the heart to all major branch vessels.

It has a functional role, distending during systole and recoiling in diastole to

propel blood.

The aortic wall has three layers: tunica intima, a thin inner layer, lined by
endothelium; tunica media, a thicker middle layer of elastic tissue for
tensile strength and elasticity; tunica adventitia, a thin outer layer,
predominantly collagen, housing the vasa vasorum and lymphatics.
There are four major sections;

(1) ascending aorta from aortic valve annulus including sinuses of Valsalva,
sinotubular junction (the narrowest point), and up to right brachio-cephalic
artery;

(2) aortic arch from brachiocephalic to aortic isthmus just distal to left
subclavian artery);

(3) descending aorta from isthmus to diaphragm;

(4) abdominal aorta from diaphragm to aortic bifurcation and origin of iliac
arteries.
NormaI findings
Views
Parts of the aorta can be seen in all windows. Full evaluation requires a
combination of views and additional, non-standard transducer positions.

Proximal ascending aorta

Proximal ascending aorta is best seen in the parasternal long axis view.
Additional views include, particularly if dilated, the right parasternal views or
left parasternal views from higher intercostal spaces for ascending aorta
(particularly with patient in extreme left lateral position to bring aorta more
anterior).
Doppler interrogation is limited to qualitative assessment of flow and aortic
regurgitation severity.
Apical views. The ascending aorta can also be visualized in apical 5- and 3-
chamber views. 2D image quality is limited at this depth but orientation is
optimal for Doppler to assess aortic regurgitation.
Aortic arch

Suprasternal views (and supraclavicular views) allow assessment of aortic

arch and brachiocephalic vessels.

Both transverse and longitudinal views are possible but the latter is most
useful to identify head and neck vessels.

Descending aorta is only partially in plane and, artefactually, appears to

taper. Descending aorta blood flow can be used to assess aortic
regurgitation severity and aortic coarctation.
Descending thoracic aorta

Descending thoracic aorta is seen in cross-section posterior to the left

atrium in the parasternal views.

The proximal segment of descending aorta is seen in the suprasternal

view.

Additional views of the longitudinal section of the descending thoracic

aorta can normally be visualized from an apical 2-chamber view with
lateral angulation and clockwise rotation of probe.

The distal thoracic aorta and proximal abdominal aorta can be visualized
from the subcostal view.
Key views to assess the aorta.
The pathological significance of the isthmus
The isthmus is the point where the relatively mobile ascending aorta and
arch become fixed to the thorax and thus the aorta is vulnerable to
trauma at this point
Coarctations also commonly develop here.
Aortic size

The terms proximal aorta or aortic root refer to the aortic annulus,
sinuses of Valsalva, sinotubular junction, and proximal ascending aorta.

Measurement of the aortic root is of crucial importance in the diagnosis

of Marfan syndrome, and in the serial monitoring of patients with, or at
risk of, progressive dilation of the ascending aorta.

While a single measurement of the proximal aorta may suffice in the

normal examination, a minimum of four measurements should be
routinely made and recorded from the parasternal long axis view when
monitoring aortic disease.
Assessment

Make measurements from a parasternal long axis view in systole (with

valve leaflet tips open to their maximum).

They can be made from 2D images frozen in systole or from M-mode

aligned at different positions through the proximal aorta.

Measurement at onset of QRS, from leading edge to leading edge

(except abdominal aorta and descending thoracic aorta from outer edge
to outer edge)

A complete assessment includes measurement of annulus (normal 2.3 ±

0.3cm);
sinus of Valsalva, at aortic leaflet tip level (normal 3.4 ± O.3cm; <2.1
cm/m²) ;
sinotubular junction; proximal ascending aorta (normal 2.6 ± 0.3cm).
Assessment
2D measurement at the sinuses gives higher values than M-mode
measurements. Comment on how the measurements were made and
use the appropriate normal values.
In a normal study a single aortic diameter may be sufficient. When
possible report size relative to body surface area.

Where needed, continue the assessment by providing measurements

of the arch from suprasternal views, descending aorta from parasternal
views, and, for completeness, abdominal aorta from subcostal views.

Aortic arch.
Descending thoracic aorta (normal <1.6cm/m² ).
Abdominal aorta (normal <3cm; <1.6cm/m² ).
Serial measurements and identification of dilatation
In serial measurements the annulus is not prone to dilatation. Any
significant change should raise suspicious of methodological error and
caution over interpreting measurements elsewhere. In effect, the annulus
acts as a control of serial studies.

Measurements at the sinus of Valsalva are the key. They tend to be the site
of initial ectasia when the aortic root does dilate in Marfan syndrome. In
the normal adult it measures less than 3.7cm but can vary with body
surface area.

Normograms that adjust for body surface area maximize sensitivity for the
detection of aortic dilatation in adults, but for practical purposes the upper
normal limit in the adult is 2.1cm/m² and anything below this can be
reported as normal.
 Aortic pathologies
1. Aneurysm
2. Aortic syndrome:
– Dissection
– Intramural hematoma
– Penetrating ulcer
3. Congenital:
– Coarctation
– Bicuspid aortic valve
– Connective tissue disorder
4. Atheromas, atherosclerosis
Aortic dilatation
Dilatation of the aorta is an increase in diameter more than expected for age and
body size and is the most commonly identified aortic abnormality.

When localized to the sinus of Valsalva the risk of complications is significantly

lower than when there is generalized aortic dilatation but still higher than no
dilatation!

Causes include: degenerative disease (hypertension, atherosclerosis, cystic medical

necrosis, post-stenotic); collagen vascular disease (Marfan syndrome, Ehlers-
Danlos); inflammatory disorders (rheumatoid, systemic lupus erythematosus,
ankylosing spondylitis, Reiter syndrome, syphilis, aortic arteritis); trauma (blunt or
penetrating).

Assessment
Measure the degree of dilatation at multiple positions and report where and how
the measurements were made.
Example of dilatation of the proximal ascending aorta seen in a parasternal long axis
view.
 Aneurysm
1. True aneurysm:
– Definition: localized dilatation > 50% of reference
segment; circumscriptive or diffuse.
2. Pseudoaneurysm:
– Definition: lumen expansion due to perforation
(involving all layers of the wall)
 Ascending aortic aneurysm
• Aortic root
• Ascending aorta
• Aortic arch
 Distribution of aneurysm
• 51% ascending Aorta
• 11% aortic arch
• 38% descending aorta
• Thoracic aortic aneurysm (TAA) and thoracic abdominal aortic
aneurysm (TAAA) are less common than infrarenal aneurysm.

• Death from aneurysm = 0.7/100,000 per year

• Death from dissection = 1.5/100,000 per year

• Aneurysm + dissection: 20% do not reach the hospital alive

• Aortic rupture occur in 74% of all TAA with a mortality rate of
94.3%
 Pathophysiology
• Hypertension Intimal thickening
• Hyperlipidemia Plaque formation
• Diabetes millitus Ulceration
Increase vessel stiffnes
• Smoking
Thrombus formation

Laplace law:

W= pxr/2h
W = wall stress
P = pressure Hypertension, dilatation, thin aortic wall>>>
r = radius increase wall stress
h = wall thickness
 Complication of aneurysms
• Dissection
• Rupture
• Shunt (i.e. RV)
• Thromboembolism
– Compression
– SVC
– Phrenic nerve, vagus, recurrent laryngeal n.
• Risk of rupture
– Ascending aorta = 6 cm ---- 30 % rupture
– Descending aorta = 6 cm ----40% rupture
• Natural history:
– TAA : survival rate = 24% at 2 years ( patients who
are unfit for or refuse surgery)
• Indication for surgery:
– Symptoms
– Ascending Ao. 55-60 mm (< 2.75 cm/m²)
– > 45-50 mm in Marfan
– > 50 mm in bicuspid aortic valve
– Descending Ao. ≥ 60 mm
– Accelerated growth ≥ 10 mm/year
– Aortic regurgitation
– Aortic valve surgery AO. ≥ 45 mm
Differentiation of degenerative dilatation from Marfan
When the aorta dilates due to degenerative disease, the contours of the sinuses of
Valsalva and the normal slight narrowing at the sinotubular junction are
maintained.
In contrast, dilatation of the aorta in Marfan syndrome is characterized by
enlargement of the sinuses of Valsalva, resulting in loss of narrowing at the
sinotubular junction.
 Marfan syndrome
Marfan syndrome is an autosomal dominant connective tissue disorder due to
mutation in the fibrillin 1 gene.
It is a multisystern disorder that affects both locomotor and cardiovascular
systems, and the eyes.
The incidence is approximately 1 in 10,000 births of whom approximately 26% are
a spontaneous mutation, i.e. have no family history.
Many individuals have some of the skeletal features of Marfan syndrome without
the actual condition and the diagnosis is dependent on diagnostic criteria (Ghent
criteria).
Assessment
Echocardiography is key for the criteria and should report on the presence of the
following.
Major criteria: at least one
(1) dilatation of the ascending aorta-with or without aortic regurgitation-involving
at least the sinuses of Valsalva;
(2) dissection of the ascending aorta.
Minor criteria:
(1) mitral valve prolapse, with or without mitral regurgitation;
(2) main pulmonary artery dilatation in the absence of stenosis under 40 years of
age;
(3) calcification of the mitral annulus under 40 years of age;
(4) dilatation or. dissection of the descending thoracic or abdominal aorta under
50 years of age.
Indications for considering elective aortic root replacement

Prophylactic surgery is indicated for progressive aortic root dilatation:

1. aortic diameter >55mm in adults with connective tissue disease;

2. aortic diameter >50mm in children and adults with a family history of
dissection;
3. rapid change in the aortic root size--more than 2mm per year
4. aortic diameter >60mm in adults with out connective tissue
(atherosclerotic aneurysm).
There is an increased risk in pregnancy. If the aortic diameter is >40mm,
monitoring with echocardiography and clinical examination should be
considered monthly.

Progressive root dilatation should lead to consideration of surgery prior to, or

contemporaneous with delivery of the child.

Special precautions would also be required at the time of delivery which should
take place under the care of a specialist team managing complex pregnancy
with cardiac disease.
 Aortic dissection
Aortic dissection originates from an intimal tear, leading to sub-intimal
haemorrhage, which can extend within a false lumen back to the aortic valve or
forwards, throughout the aorta.
Aortic dissection is Iifethreatening, with an early mortality of 1% per hour.

Presentation is usually with severe chest pain.

The differential includes other causes of chest pain such as acute myocardial
infarction or chest wall pain, and aortic intramural hemorrhage or expanding
thoracic aneurysm.

•Risk factors for dissection include:

Marfan syndrome, and other connective tissue disorder
aortic dilatation / aneurysm,
hypertension,
aortic valve disease-particularly bicuspid valve (risk 5x normal).
Penetrating ulcer
The Stanford classification is the simplest and most pragmatic.
Type A: involvement of the ascending aorta irrespective of involvement elsewhere.
Type B: limited to the arch and/or descending thoracic aorta.

De Backey classification
Ascending & descending Ao.------------type I
Ascending aorta ----------------------------type II
Descending aorta --------------------------type III
Assessment

Prompt diagnosis is crucial and transthoracic echocardiography is of value in initial

management.

Examine for diagnostic features and for secondary complications.

A negative transthoracic study does not exclude aortic dissection and, where there is
a high index of suspicion, further imaging with transoesophageal echocardiography,
CT, or magnetic resonance imaging will be required.
Diagnostic features

Look for the presence or absence of any possible dissection flap in all aortic views
(parasternal, suprasternal, subcostal).

A flap will appear as a linear mobile structure with motion independent of the aortic
wall.

Look for a false lumen using colour flow Doppler placed over the aorta in all aortic
views.

There will be different patterns of flow in the true and false lumen.
Beam width artifact and reverberation
Beam-width artifact and reverberation can mimic a dissection flap.

M-mode of aortic wall motion and a suspected flap will demonstrate flap motion that
is different from aortic wall movement.

Whereas a reverberation artifact will move with the wall.

Secondary complications
Measure aortic root size from parasternal views, size of arch and descending aorta
from suprasternal views, and size of descending thoracic and abdominal aorta from
subcostal views.

Comment on and quantify aortic regurgitation.

Comment on pericardial fluid and perform Doppler analysis of transmitral and trans-
tricuspid blood flow to diagnose tamponade. A small acute collection can cause
tamponade without obvious pericardial fluid.

Assess left ventricular systolic function, and comment on any regional wall motion
abnormalities that might suggest coronary artery involvement.
Examples of aortic dissection flap seen in parasternal long axis and suprasternal
views.
 Aortic coarctation

Aortic coarctation is a congenital narrowing in the proximal descending thoracic aorta,

usually located immediately proximal to the entry site of the ductus arteriosus.

It may be suspected in a patient with hypertension and a weak femoral pulse,

radiofemoral delay, or systolic murmur.

Aortic coarctation first diagnosed in adulthood is usually asymptomatic as the stenosis

is not usually severe and collaterals are present.

50-80% will have a bicuspid aortic valve and other cardiac abnormalities (e.g. subaortic
membrane, supravalvular aortic stenosis).
Assessment
Echocardiography is required in diagnosis and follow-up.
Aortic coarctation can be relatively complex and further imaging (usually magnetic
resonance imaging) is performed if intervention is being considered.
Diagnosis
The suprasternal view is the most useful.
Identify the brachiocephalic vessels-coarctation usually occurs just distal to the left
subclavian with post-stenotic dilatation common.
Use colour flow mapping of the descending aorta to identify a high velocity narrowed
flow stream with turbulence (even if 2D poor).
Place continuous wave Doppler through the point of maximum colour flow turbulence
to measure a typical systolic velocity gradient. The gradient will typically persist to
end-diastole ('diastolic tail').
Continuous wave Doppler tends to overestimate the gradient and better correlation
with catheter gradients can be obtained if the proximal velocity is measured with
pulsed wave Doppler and the modified Bernoulli equation used to calculate flow.
If coarctation is suspected but difficult to image, continuous wave Doppler using a
pencil probe in the suprasternal position will often allow measurement of a gradient
in the descending aorta.
Follow-up
All patients with previous repair of coarctation of the aorta should be followed up
throughout adult life.

Echocardiography should be repeated annually. Where visualization is inadequate

alternative imaging such as CT or magnetic resonance imaging may be needed.

Examine and report the residual gradient.

Look for abnormalities in the aorta and comment an development of any aneurysm at
the site of previous repair.
Doppler profile in coarctation of the aorta from a suprasternal view.
Note the Increased peak velocity and prolonged flow throughout diastole (‘diastolic
tail').
 Sinus of Valsalva aneurysm

Sinus of Valsalva aneurysms can be congenital resulting from incomplete fusion

of the distal bulbar septum that divides the aorta and pulmonary arteries.
They tend to have a long sac of mobile tissue projecting into adjacent
structures, forming a 'wind sock' appearance.

Acquired aneurysms, usually due to endocarditis, lead to more symmetrical

dilatation, with no excess tissue.

If rupture occurs, a fistula develops between aorta and adjacent chamber, with
left to right shunting and clinical features that can vary in severity from acute
haemodynamic compromise to a new continuous murmur.

85% affect right coronary sinus and project/rupture into the right ventricle; 10%
affect non-coronary sinus and project/rupture into the right atrium; 5% affect
left coronary sinus and project/rupture into the left atrium.
 Sinus of Valsalva aneurysm
Assessment
Use parasternal long and short axis views to diagnose and measure.
If rupture suspected, use parasternal short axis view at and above the aortic valve.

Colour flow mapping will usually confirm site of communication and continuous
flow.

If possible the coronary artery should be visualized to exclude coronary artery

fistulae.

Continuous wave Doppler will show a high velocity systolic and diastolic signal.

Comment on the size of the right atrium (Which reflects acute right atrial
overload) and left atrial and left ventricular size (Which will reflect the extent of
chronic volume overload).
 Aortic atherosclerosis

Atherosclerosis of the aorta can result in dilatation, aneurysm, or dissection and is

a risk factor for coexisting coronary artery disease and cerebrovascular disease
 Aortic atherosclerosis

Assessment
Aortic atheroma can be visualized with transthoracic echocardiography (although
transoesophageal is more appropriate) in either the proximal, ascanding aorta or,
more commonly, in the descending abdominal aorta.

Atherosclerotic thoracic aortic aneurysm may also be detected by transthoracic

imaging, either at the aortic root or behind the left atrium in the descending thoracic
aorta (parasternal long axis view).

More rarely, descending abdominal aortic aneurysm may be picked up in subcostal

views. The extent of the aneurysm cannot usually be accurately quantified, but the
extent of dilatation and presence or absence of laminar
thrombus can be commented upon.

Further imaging will frequently be required.

A subcostal view aligned to view the abdominal aorta. Note the thickening of the wall
and irregular appearance consistent with an atherosclerotic plaque.
Diseases of the Aorta
TABLE 20.1 Diseases Affecting the Aorta

Atherosclerotic
Aneurysm
Atheroembolic disease
Rupture
Pseudoaneurysm
Penetrating ulcer
Dissection
Intramural hematoma
Non-atherosclerotic
Cystic medial necrosis
Aneurysm
Aortic dissection
Intramural hematoma
Anuloaortic ectasia
Inflammatory/infectious
Takayasu arteritis
Giant cell arteritis
Endocarditis
Miscellaneous
Trauma
Intraluminal thrombus
Poststenotic dilation
Hypertension
Aortic insufficiency/Stenosis
Iatrogenic injury
NORMAL AORTIC ANATOMY
Schematic of normal aortic anatomy. The thoracic aortic can be characterized as having
three distinct segments. The ascending aorta consists of that portion that extends from the
anulus to the innominate artery and includes the three Valsalva sinuses, the three cusps of
the aortic valve, the sinotubular junction, the ostia of the coronary arteries, and the
proximal ascending aorta. The arch is defined as that portion that extends from a left
innominate to the ligamentum arteriosum and includes the great vessels arising off of the
arch. The descending thoracic aorta extends from the ligamentum arteriosum to the level
of the diaphragm. The normal dimensions of the aorta are noted on the schematic and
vary with location. Dimensions are given both indexed to body surface area (BSA) and as
the range anticipated in routine adult echocardiography. PA, right pulmonary artery.
Detailed schematic of the proximal aorta. The relative dimensions of the anulus,
Valsalva sinuses, sinotubular junction, and proximal ascending aorta can be
appreciated. In the normal disease-free state, the sinuses dilate symmetrically
so that their greatest dimension exceeds that of the anulus by approximately 6
mm/m2 of body surface area. At the level of the sinotubular junction, the aorta
narrows to within 2 to 3 mm of its anular dimension and then gradually tapers
throughout its course. Note that the aortic cusps coapt along a 2 to 3 mm
coaptation zone and do not meet tip to tip.
FIGURE 20.3. Transthoracic parasternal long-axis view of the normal aorta. This
view includes the normal attachment of the anterior mitral valve leaflet to the
posterior wall of the aorta and also visualization of the left atrium. Note the
similar relationship in size of the anatomically viewed aorta compared with the
schematic in Figure 20.2. Arrows, internal limits of the aorta.
FIGURE 20.4. Transthoracic view of the arch of the aorta from a suprasternal
view. Note the normal caliber of the arch of the aorta, which is similar to that of
the proximal ascending aorta, and the orientation of the innominate artery and
left carotid and subclavian arteries (arrows). AscAo, ascending aorta; DescAo,
descending aorta.
FIGURE 20.5. Transthoracic
Echocardiograms depict the
appearance of a normal descending
thoracic aorta. A: Parasternal long-axis
view of the heart in which the normal
circular descending thoracic aorta can
be seen behind the left atrium
(arrow). B: Longitudinal view of the
descending thoracic aorta coursing
behind the heart.
FIGURE 20.5. Transthoracic
Echocardiograms depict the
appearance of a normal descending
thoracic aorta. A: Parasternal long-axis
view of the heart in which the normal
circular descending thoracic aorta can
be seen behind the left atrium
(arrow). B: Longitudinal view of the
descending thoracic aorta coursing
behind the heart.
FIGURE 20.6. Transesophageal
longitudinal view of the heart
including visualization of the
ascending aorta. Transesophageal
echocardiogram of the ascending
aorta recorded in a normal disease-
free individual. A: Longitudinal
(127-degree) view that provides
imaging analogous to that of the
transthoracic longaxis view seen in
Figure 20.3. Again note the
symmetric dilation at the level of
the sinuses and the narrowing at
the level of the sinotubular junction.
B: Image recorded in systole
demonstrates closure of the aortic
cusps along a 2 to 3 mm length
(arrows in the small inset).
FIGURE 20.6. Transesophageal longitudinal view of the heart including
visualization of the ascending aorta. Transesophageal echocardiogram of the
ascending aorta recorded in a normal disease-free individual.
FIGURE 20.7. Transesophageal
echocardiogram recorded at 53-
degree probe rotation at the base of
the heart. These images were
acquired at the same transducer
position as those in Figure 20.6. With
this probe orientation, a short-axis
view of the aorta is obtained at the
level of the sinuses, revealing the left
(L), right (R), and non (N) coronary
sinuses. The left atrium (LA), right
atrium (RA), and proximal pulmonary
artery (PA) are well visualized. A:
Image recorded in diastole, and three
symmetric sinuses are noted as well
as three coaptation lines of the cusps.
B: Image recorded in systole and
shows the relatively triangular and
symmetric opening of all three cusps.
FIGURE 20.7. Transesophageal echocardiogram recorded at 53-degree probe
rotation at the base of the heart.
FIGURE 20.8. Transesophageal
echocardiogram of the descending
thoracic aorta. A: Recorded at 0
degrees and provides a short-axis view
of a circular and symmetric normal
aorta with little or no atherosclerotic
disease. Because of the highly
reflective nature of the aortic wall, a
reverberation artifact mimicking a
second aorta behind the real image is
frequently encountered. B: Recorded
with the imaging plane at 90 degrees
providing a longitudinal view of the
descending thoracic aorta.
FIGURE 20.8. Transesophageal
echocardiogram of the descending
thoracic aorta. A: Recorded at 0
degrees and provides a short-axis view
of a circular and symmetric normal
aorta with little or no atherosclerotic
disease. Because of the highly
reflective nature of the aortic wall, a
reverberation artifact mimicking a
second aorta behind the real image is
frequently encountered. B: Recorded
with the imaging plane at 90 degrees
providing a longitudinal view of the
descending thoracic aorta.
FIGURE 20.9. Transesophageal
echocardiographic view of the arch of the
aorta. A: Recorded with the imaging plane
at 0 degrees with marked clockwise
rotation of the probe. In occasional
patients, even more marked probe
angulation can allow visualization of the
ascending aorta to a level near to the
sinotubular junction. B: Recorded from the
same transducer position with the probe at
a 85-degree angle providing a short axis
view of the apex of the arch. The takeoff of
the left subclavian (LSC) can often be
visualized from this view.
FIGURE 20.9. Transesophageal
echocardiographic view of the arch of the
aorta. A: Recorded with the imaging plane
at 0 degrees with marked clockwise
rotation of the probe. In occasional
patients, even more marked probe
angulation can allow visualization of the
ascending aorta to a level near to the
sinotubular junction. B: Recorded from the
same transducer position with the probe at
a 85-degree angle providing a short axis
view of the apex of the arch. The takeoff of
the left subclavian (LSC) can often be
visualized from this view.
FIGURE 20.10. Intravascular ultrasound (IVUS) of the thoracic aorta. The
intravascular ultrasound probe is in the lumen of the descending thoracic aorta.
Note the circular smooth lumen of the aorta. From approximately 2 o'clock to 4
o'clock there is minimal intimal thickening, consistent with early atheroma
formation.
AORTIC DILATION AND ANEURYSM
FIGURE 20.11. Transthoracic parasternal long-axis view of the ascending aorta
recorded in a patient with significant valvular aortic stenosis and proximal aortic
dilation. Note the dilation of the aorta at the level of the sinuses, sinotubular
junction, and proximal ascending aorta. This represents poststenotic dilation. In
many instances, dilation to the degree seen here may be due to both disease of
the aortic valve and concurrent aortic aneurysm. Ao, aorta; LA, left atrium; LV, left
ventricle.
FIGURE 20.12. Parasternal long-axis view
of the left ventricle and aorta
demonstrates a dilated ascending aorta
with effacement of the sinotubular
junction. There is classic effacement, with
the sinotubular junction having the same
dimension as the Valsalva sinus. The
dimension at each segment of the aorta is
as noted. Effacement of the sinotubular
junction often results in aortic
insufficiency due to malcoaptation of the
aortic cusps. Ao, aorta; LA, left atrium; LV,
left ventricle.
MARFAN SYNDROME
FIGURE 20.13. Parasternal long
axis thoracic echocardiograms
recorded in patients with
ascending aortic aneurysms. A:
Note the relatively normal
dimension of the anulus and
sinuses with maximal dilation in
true ascending aorta (Ao) which
measures approximately 43 mm in
greatest dimension. B: There is
more diffuse dilation that begins
at the sinuses and continues at the
level of the sinotubular junction.
The maximal dimension is 73 mm,
as noted by the measurement bar
in the lower right. LA, left atrium;
LV, left ventricle; RVOT, right
ventricular outflow tract.
FIGURE 20.13. Parasternal long axis thoracic echocardiograms recorded in
patients with ascending aortic aneurysms.
FIGURE 20.14. Transesophageal echocardiogram recorded in a patient with an
ascending aortic aneurysm. Recorded in a longitudinal (144-degree probe angle)
view demonstrating the marked dilation of the ascending aorta beginning at the
Valsalva sinuses. The outer boundary of the sinuses is noted by the arrows.
FIGURE 20.14. Transesophageal echocardiogram recorded in a patient with
an ascending aortic aneurysm
FIGURE 20.15.
Transesophageal
echocardiogram
reveals a large
aneurysm of the
ascending aorta. Note
the somewhat
asymmetric dilation
with a maximal
dimension of 53 mm in
the ascending aorta,
distal to the sinotubular
junction. LA, left
atrium; LV, left
ventricle.
FIGURE 20.16. Transthoracic suprasternal notch view of the aortic arch recorded in
a patient with an ascending and arch aneurysm. Note the pathologically dilated arch
(38 mm), which was contiguous with a more proximal ascending aortic aneurysm.
FIGURE 20.17. Transesophageal echocardiogram of the aortic arch shows a discrete
aneurysm of the arch. The lumen of the arch is noted by the double-headed arrow.
The remaining horizontal and vertical arrows outline the boundary of the discrete
aneurysm, which is filled with a thrombus (Th).
FIGURE 20.18. Transesophageal echocardiogram of a descending thoracic aortic
aneurysm. A: In the upper right, one can appreciate the actual flow containing lumen
of the aorta (Ao). The black vertical and remaining horizontal white arrow delineate the
absolute external boundary of the aorta and the maximal dimensions of the aneurysm,
which is largely filled with a thrombus and atheroma. B: A descending thoracic aortic
aneurysm is depicted. The double-headed white arrow outlines the dimension of the
aortic lumen. The double-headed black arrow denotes a thrombus and atheroma filling
an aneurysmal cavity. The total dimension of the aorta would be the summed lengths
of black and white arrows.
FIGURE 20.18. Transesophageal echocardiogram of a descending thoracic aortic
aneurysm. A: In the upper right, one can appreciate the actual flow containing lumen
of the aorta (Ao). The black vertical and remaining horizontal white arrow delineate the
absolute external boundary of the aorta and the maximal dimensions of the aneurysm,
which is largely filled with a thrombus and atheroma. B: A descending thoracic aortic
aneurysm is depicted. The double-headed white arrow outlines the dimension of the
aortic lumen. The double-headed black arrow denotes a thrombus and atheroma filling
an aneurysmal cavity. The total dimension of the aorta would be the summed lengths
of black and white arrows.
FIGURE 20.19. Short-axis view of a descending thoracic aorta with aneurysm and
chronic dissection. A: Short axis view of the aorta at the mid-thoracic level. Note the
maximal dimension, which exceeds 4 cm. Note also that a substantial portion of the
lumen is filled with thrombus, which in turn contains a lucent nonflow cavity. The flow
containing lumen is at the lower right of the image. B: Color flow Doppler has been
employed to demonstrate flow in the larger lumen.
FIGURE 20.19. Short-axis view of a descending thoracic aorta with aneurysm and
chronic dissection. A: Short axis view of the aorta at the mid-thoracic level. Note the
maximal dimension, which exceeds 4 cm. Note also that a substantial portion of the
lumen is filled with thrombus, which in turn contains a lucent nonflow cavity. The flow
containing lumen is at the lower right of the image. B: Color flow Doppler has been
employed to demonstrate flow in the larger lumen.
FIGURE 20.20. A: Parasternal long-axis transthoracic echocardiogram recorded in
patients with Marfan syndrome. Notice the pathologic dilation of the aorta
comparing the anulus (point 1) to the Valsalva sinuses (point 2) and the sinotubular
junction (point 3). The aorta narrows to a nearly normal dimension in its ascending
portion (point 4). B: Recorded in a patient with substantially greater dilation at the
level of the sinuses, which measure 5.8 cm compared with 2.8 cm at the anulus. LA,
left atrium; LV, left ventricle.
FIGURE 20.20. A: Parasternal long-axis transthoracic echocardiogram recorded in
patients with Marfan syndrome.
FIGURE 20.21. Parasternal long-axis (A) and apical transthoracic (B) views in a
patient with Marfan syndrome. In each instance, note the marked dilation of the
proximal aorta (Ao), which is maximal at the level of the Valsalva sinuses. B: Often
the dilated proximal aorta may compress the right atrium. LA, left atrium; LV, left
ventricle.
FIGURE 20.21. Parasternal long-axis (A) and apical transthoracic (B) views in a
patient with Marfan syndrome. In each instance, note the marked dilation of the
proximal aorta (Ao), which is maximal at the level of the Valsalva sinuses. B: Often
the dilated proximal aorta may compress the right atrium. LA, left atrium; LV, left
ventricle.
FIGURE 20.22. A: Longitudinal plane transesophageal echocardiogram recorded in
a patient with Marfan syndrome and proximal aortic dilation. Again, note the
effacement of the sinotubular junction, which has resulted in malcoaptation of the
aortic cusps and significant aortic regurgitation as noted in the color flow Doppler
image (B). Ao, aorta; LA, left atrium; LV, left ventricle.
FIGURE 20.22. A: Longitudinal plane transesophageal echocardiogram recorded in
a patient with Marfan syndrome and proximal aortic dilation. Again, note the
effacement of the sinotubular junction, which has resulted in malcoaptation of the
aortic cusps and significant aortic regurgitation as noted in the color flow Doppler
image (B). Ao, aorta; LA, left atrium; LV, left ventricle.
FIGURE 20.23. Transesophageal longitudinal view of the ascending aorta recorded
in a patient with Marfan syndrome. Note the marked dilation of the aortic sinuses
with some tapering at the level of the sinotubular junction. Note, however, that the
sinotubular junction dimension still exceeds the anular dimension by a substantial
degree. Note also the malcoaptation of the aortic cusps with the normal position of
the left cusp (horizontal arrow) and malcoaptation of the noncoronary cusp (angled
arrow). The malcoaptation results in a substantial degree of aortic insufficiency, which
is highly eccentric, the initial portion of which is directed posteriorly to anteriorly (top
to bottom) on the accompanying color flow Doppler image.
FIGURE 20.23. Transesophageal longitudinal view of the ascending aorta recorded
in a patient with Marfan syndrome. Note the marked dilation of the aortic sinuses
with some tapering at the level of the sinotubular junction. Note, however, that the
sinotubular junction dimension still exceeds the anular dimension by a substantial
degree. Note also the malcoaptation of the aortic cusps with the normal position of
the left cusp (horizontal arrow) and malcoaptation of the noncoronary cusp (angled
arrow). The malcoaptation results in a substantial degree of aortic insufficiency, which
is highly eccentric, the initial portion of which is directed posteriorly to anteriorly (top
to bottom) on the accompanying color flow Doppler image.
VALSALVA SINUS ANEURYSM
FIGURE 20.24. Valsalva sinus aneurysm recorded from a transthoracic echocardiogram (A, B)
and transesophageal echocardiogram (C, D). All images are from the same patient. A: Note the
marked asymmetric bulging of the right Valsalva sinus into the right ventricular outflow tract
(arrow). This is appreciable both on the parasternal long-axis view (upper left) and parasternal
short-axis view (upper right). Virtually identical anatomy is seen in the longitudinal and shortaxis
views of the ascending aorta recorded from the transesophageal approach (C, D). L, N, R; left,
non-, and right Valsalva sinuses.
FIGURE 20.25. Short-axis
transthoracic echocardiogram at the
base of the heart. Note the marked
asymmetric bulging of the Valsalva
sinus into the right ventricular outflow
tract (RVOT) (arrows). B: Longitudinal
transesophageal view image of the
aorta from the same patient. Note the
aneurysm of the right sinus prolapsing
along the ventricular septum into the
right ventricular outflow tract
(arrows). Ao, aorta; LA, left atrium; LV,
left ventricle; RVOT, right ventricular
outflow tract; L, N, R, left, non-, and
right Valsalva sinuses.
FIGURE 20.25. Short-axis
transthoracic echocardiogram at the
base of the heart. Note the marked
asymmetric bulging of the Valsalva
sinus into the right ventricular outflow
tract (RVOT) (arrows). B: Longitudinal
transesophageal view image of the
aorta from the same patient. Note the
aneurysm of the right sinus prolapsing
along the ventricular septum into the
right ventricular outflow tract
(arrows). Ao, aorta; LA, left atrium; LV,
left ventricle; RVOT, right ventricular
outflow tract; L, N, R, left, non-, and
right Valsalva sinuses.
FIGURE 20.26. Transesophageal
echocardiogram of a Valsalva sinus
aneurysm arising from the right coronary
sinus. A: Recorded at 43-degree probe
rotation. Note the normal size and
geometry of the left (L) and non- (N)
coronary sinuses and the elongated
windsock aneurysm rising off the right
coronary sinus (arrows) and protruding
into the right atrium (RA). B: Recorded at
a 118-degree image plane (orthogonal to
that in A), and the aneurysm now
appears as a circular or cystic, highly
mobile structure in the right atrium
(arrow). Note the position of the
tricuspid valve (TV) as well. RVOT, right
ventricular outflow tract.
FIGURE 20.26. Transesophageal echocardiogram of a Valsalva sinus aneurysm
arising from the right coronary sinus. A: Recorded at 43-degree probe rotation.
Note the normal size and geometry of the left (L) and non- (N) coronary sinuses
and the elongated windsock aneurysm rising off the right coronary sinus (arrows)
and protruding into the right atrium (RA).
FIGURE 20.27. Transesophageal echocardiogram with color flow Doppler imaging in
a patient with a Valsalva sinus aneurysm. This image was recorded at 43 degrees,
providing a short-axis view of the Valsalva sinus aneurysm. This image was recorded
from the same transducer position and probe rotation as that in Figure 20.26A. Note
the high volume and highly turbulent flow from the right Valsalva sinus into and
through the aneurysmal cavity before emerging in the right atrium and right
ventricular outflow tract.
FIGURE 20.27. Transesophageal echocardiogram with color flow Doppler
imaging in a patient with a Valsalva sinus aneurysm. This image was recorded
at 43 degrees, providing a short-axis view of the Valsalva sinus aneurysm.
This image was recorded from the same transducer position and probe
rotation as that in Figure 20.26A. Note the high volume and highly turbulent
flow from the right Valsalva sinus into and through the aneurysmal cavity
before emerging in the right atrium and right ventricular outflow tract.
AORTIC DISSECTION
FIGURE 20.28. Schematic representation depicts the forms of acute aortic
pathology. A: Depicts classic aortic dissection in which there is a tear of the
intima from the media. The column of blood propagates proximally and distally,
and there may be multiple communication points between the lumen and the
intima media space. B: The spontaneous intramural hematoma variant of aortic
dissection in which there is rupture of the vasa vasorum resulting in hematoma in
the medial space without communication between the lumen and the hematoma
is depicted. The two right-hand schematics depict the same phenomenon in a
short-axis view of the aorta.
FIGURE 20.29. Schematic
representation of categorization
schemes for aortic dissection. The
schematics include the typical
distinction of proximal ascending
dissection as well as distal
dissection. Additionally, the more
recently appreciated isolated arch
dissection is likewise depicted. PA,
pulmonary artery.
FIGURE 20.30. Transthoracic
echocardiogram in a patient with
acute type A dissection. B: Images
are recorded in a parasternal long-
axis view with color flow Doppler
imaging. A: Note the marked dilation
of the ascending aorta, which is
nearly ubiquitous in type A
dissection. The rightward-pointing
arrows in the left ventricular outflow
tract outline the actual aortic valve.
The leftward-pointing echoes denote
portions of the intimal flap. B: Note
the significant amount of aortic
regurgitation, which is due to
malcoaptation of the aortic valve.
DAo, descending aorta; LV, left
ventricle.
FIGURE 20.30. Transthoracic
echocardiogram in a patient with
acute type A dissection. B: Images
are recorded in a parasternal long-
axis view with color flow Doppler
imaging. A: Note the marked dilation
of the ascending aorta, which is
nearly ubiquitous in type A
dissection. The rightward-pointing
arrows in the left ventricular outflow
tract outline the actual aortic valve.
The leftward-pointing echoes denote
portions of the intimal flap. B: Note
the significant amount of aortic
regurgitation, which is due to
malcoaptation of the aortic valve.
DAo, descending aorta; LV, left
ventricle.
FIGURE 20.31. Parasternal long-
axis view in systole (A) and diastole
(B) in a patient with a type A
dissection. A: Note the remnants of
the intimal flap within the lumen of
the dilated ascending aorta
(arrows). In diastole, the intimal flap
prolapses through the aortic valve
into the left ventricular outflow
tract. This is one of the several
mechanisms for developing aortic
insufficiency in acute aortic
dissection. Ao, aorta; LV, left
ventricle; RVOT, right ventricular
outflow tract.
FIGURE 20.31. Parasternal long-axis view in systole (A) and diastole (B) in a patient
with a type A dissection. A: Note the remnants of the intimal flap within the lumen
of the dilated ascending aorta (arrows). In diastole, the intimal flap prolapses through
the aortic valve into the left ventricular outflow tract. This is one of the several
mechanisms for developing aortic insufficiency in acute aortic dissection. Ao, aorta;
LV, left ventricle; RVOT, right ventricular outflow tract.
FIGURE 20.32. Transesophageal
echocardiogram recorded in a longitudinal
plane of the ascending aorta (Ao). This image
shows a common artifact that could be
confused with a dissection. This is a classic
side lobe artifact arising (small arrows) from
a rather bright echo at the sinotubular
(vertical arrow) resulting in an unnaturally
curvilinear echo extending along the
direction of the scan plane lines within the
lumen of the aorta. B: Color flow imaging
has been superimposed. Note the lack of any
margination of flow by the linear echo,
helping to confirm that this is artifact rather
than a true dissection flap. LA, left atrium.
FIGURE 20.32. Transesophageal
echocardiogram recorded in a longitudinal
plane of the ascending aorta (Ao). This image
shows a common artifact that could be
confused with a dissection. This is a classic
side lobe artifact arising (small arrows) from
a rather bright echo at the sinotubular
(vertical arrow) resulting in an unnaturally
curvilinear echo extending along the
direction of the scan plane lines within the
lumen of the aorta. B: Color flow imaging
has been superimposed. Note the lack of any
margination of flow by the linear echo,
helping to confirm that this is artifact rather
than a true dissection flap. LA, left atrium.
FIGURE 20.33. Venous flow adjacent to
the aortic arch, mimicking aortic
dissection (arrow). This represents
normal venous communication from the
superior vena cava with flow toward the
heart. It is common to encounter this
space, which can occasionally be
confused for aortic dissection. As the
structure contains normal venous flow,
color flow Doppler will demonstrate a
continuous color signal that should not
be confused with flow into a false
lumen. Use of spectral Doppler imaging
will typically demonstrate a normal
venous flow pattern (B). Contrast
injection into an upper extremity vein
will likewise demonstrate the true origin
of this structure.
FIGURE 20.33. Venous flow adjacent to the aortic arch, mimicking aortic dissection
(arrow). This represents normal venous communication from the superior vena cava
with flow toward the heart. It is common to encounter this space, which can
occasionally be confused for aortic dissection. As the structure contains normal
venous flow, color flow Doppler will demonstrate a continuous color signal that
should not be confused with flow into a false lumen. Use of spectral Doppler imaging
will typically demonstrate a normal venous flow pattern (B). Contrast injection into
an upper extremity vein will likewise demonstrate the true origin of this structure.
FIGURE 20.34. Transesophageal
echocardiograms recorded in a longitudinal
plane in two patients with a type A dissection.
A: Note the two linear echos within the lumen
of the aorta that represent margins of a nearly
circumferential aortic dissection that extended
from below the sinotubular junction into the
ascending aorta (arrows). B: Recorded in a
longitudinal plane in a patient with a greater
degree of aortic dilation in a far more complex
intimal flap. Note the multiple linear
serpiginous echoes (arrows) within the lumen
of the aorta that represent almost complete
shearing off of the aortic intima. In real time,
these echoes take on a highly mobile,
undulating motion pattern in the blood flow.
Ao, aorta; LA, left atrium; LV, left ventricle;
LVOT, left ventricular outflow tract.
FIGURE 20.34. Transesophageal
echocardiograms recorded in a
longitudinal plane in two patients with a
type A dissection. A: Note the two linear
echos within the lumen of the aorta that
represent margins of a nearly
circumferential aortic dissection that
extended from below the sinotubular
junction into the ascending aorta
(arrows). B: Recorded in a longitudinal
plane in a patient with a greater degree of
aortic dilation in a far more complex
intimal flap. Note the multiple linear
serpiginous echoes (arrows) within the
lumen of the aorta that represent almost
complete shearing off of the aortic intima.
In real time, these echoes take on a highly
mobile, undulating motion pattern in the
blood flow. Ao, aorta; LA, left atrium; LV,
left ventricle; LVOT, left ventricular
outflow tract.
FIGURE 20.35. Transesophageal echocardiogram recorded in a longitudinal plane in
two patients with type A dissection. A: Note the relatively normal aortic dimensions
and the very limited dissection flap (arrow). A single communication point (open
arrowhead) can be seen as well. B: A similarly localized aortic dissection (white
arrow) is revealed. In this instance, however, note the fairly discrete aneurysmal bulge
of the anterior wall of the aorta (black arrows). This was subsequently confirmed at
the time of corrective surgery to represent a partial rupture of the aortic wall and
small aortic pseudoaneurysm. Ao, aorta; LA, left atrium.
FIGURE 20.35. Transesophageal echocardiogram recorded in a longitudinal plane in
two patients with type A dissection. A: Note the relatively normal aortic dimensions
and the very limited dissection flap (arrow). A single communication point (open
arrowhead) can be seen as well. B: A similarly localized aortic dissection (white
arrow) is revealed. In this instance, however, note the fairly discrete aneurysmal bulge
of the anterior wall of the aorta (black arrows). This was subsequently confirmed at
the time of corrective surgery to represent a partial rupture of the aortic wall and
small aortic pseudoaneurysm. Ao, aorta; LA, left atrium.
FIGURE 20.36. Transesophageal echocardiogram recorded in a short-axis view of
the proximal ascending aorta in a patient with a circumferential type A dissection.
Note the circular aorta containing a second circular structure that is the intimal flap,
which now defines a circular true lumen (TL), surrounded by a ring shape and
completely circumferential false lumen (FL). B: Note that color flow in systole is
confined only to the smaller inner true lumen.
FIGURE 20.36. Transesophageal echocardiogram recorded in a short-axis view of
the proximal ascending aorta in a patient with a circumferential type A dissection.
Note the circular aorta containing a second circular structure that is the intimal flap,
which now defines a circular true lumen (TL), surrounded by a ring shape and
completely circumferential false lumen (FL). B: Note that color flow in systole is
confined only to the smaller inner true lumen.
FIGURE 20.37. Transesophageal echocardiogram recorded in a patient with an aortic
arch dissection. This image was recorded approximately 25 cm from the incisors at a 0-
degree imaging plane and with clockwise rotation of the probe. Note the dilation of the
aortic arch with the linear intimal flap running the length of the arch (arrows).
Separating the true (TL) and false lumens (FL). B: Note the higher velocity systolic flow
in the lower true lumen.
FIGURE 20.38. Parasternal long-axis transthoracic echocardiogram shows a
markedly dilated descending aorta. Occasionally, the transthoracic echocardiogram
revealing a dilated descending thoracic aorta (DAo) can be the first clue to the
presence of a descending thoracic aneurysm or dissection. Ao, ascending aorta; LA,
left atrium; LV, left ventricle.
FIGURE 20.38. Parasternal long-axis transthoracic echocardiogram shows a
markedly dilated descending aorta. Occasionally, the transthoracic echocardiogram
revealing a dilated descending thoracic aorta (DAo) can be the first clue to the
presence of a descending thoracic aneurysm or dissection. Ao, ascending aorta; LA,
left atrium; LV, left ventricle.
FIGURE 20.39. Transesophageal short-axis views of aortic dissection from four different patients. A: Note the
relatively preserved circular geometry of the aorta, which is separated into a true lumen (TL) and substantially
larger false lumen (FL). Note that the false lumen is filled with stagnant swirling blood. C: A type B dissection in
which the true lumen and false lumen are of more equal size is demonstrated. Note also in this instance the
atheromatous involvement of the anterior wall of the aorta. B: Recorded in a patient with a type B dissection.
This image was recorded at a site in the aorta not involved by the dissection. Note the normal size circular
aortic lumen (Ao) and the much larger homogeneous mass (black arrowheads) circumferentially surrounding
the aorta. This represents a dissecting adventitial hematoma (AH) external to the aorta at this point. D: A type
B dissection with a smaller, upper true lumen and a much larger false lumen. Note that the false lumen again
contains stagnant swirling blood with some areas of lucency.
FIGURE 20.39. Transesophageal short-axis views of aortic dissection from four different patients. A: Note the
relatively preserved circular geometry of the aorta, which is separated into a true lumen (TL) and substantially
larger false lumen (FL). Note that the false lumen is filled with stagnant swirling blood. C: A type B dissection in
which the true lumen and false lumen are of more equal size is demonstrated. Note also in this instance the
atheromatous involvement of the anterior wall of the aorta. B: Recorded in a patient with a type B dissection.
This image was recorded at a site in the aorta not involved by the dissection. Note the normal size circular
aortic lumen (Ao) and the much larger homogeneous mass (black arrowheads) circumferentially surrounding
the aorta. This represents a dissecting adventitial hematoma (AH) external to the aorta at this point. D: A type
B dissection with a smaller, upper true lumen and a much larger false lumen. Note that the false lumen again
contains stagnant swirling blood with some areas of lucency.
FIGURE 20.40. Transesophageal
echocardiogram recorded in the
descending thoracic aorta at two
different levels with slightly different
angulation. In each instance, notice
the true and false lumens (TL and FL)
and the ragged echoes present within
the false lumen that represent
combinations of organizing thrombus
and aortic wall components that have
been disrupted as part of the
dissection.
FIGURE 20.40. Transesophageal
echocardiogram recorded in the
descending thoracic aorta at two
different levels with slightly different
angulation. In each instance, notice
the true and false lumens (TL and FL)
and the ragged echoes present within
the false lumen that represent
combinations of organizing thrombus
and aortic wall components that have
been disrupted as part of the
dissection.
FIGURE 20.41. Short-axis views of the
aorta in two patients with type B
dissection. A: Recorded in a patient
with a chronic type B dissection and
significant atheromatous involvement.
Note the marked aortic dilation and the
relatively small true lumen and much
larger false lumen. A single entry point
can be noted connecting the true and
false lumens by a distinct color jet in
systole (vertical arrow). B: Recorded in
a patient with an acute type A
dissection that extended into the
descending thoracic aorta. Note the
relatively normal aortic size at this
point and the single fairly large
communication point denoted by color
flow Doppler imaging.
FIGURE 20.42. Transesophageal
echocardiogram recorded in a patient
with arch involvement of a dissection that
extended from the sinotubular junction
through the arch. These images were
recorded in a short-axis view of the arch.
Note the total dimension of the arch,
which is approximately 6 cm. There is a
complex dissection present with the
appearance of one true (TL) and two false
lumens (FL). B: With color flow Doppler
imaging, notice that flow is confined only
to the central true lumen and is excluded
from the more peripheral false lumens.
FIGURE 20.42. Transesophageal
echocardiogram recorded in a patient
with arch involvement of a dissection that
extended from the sinotubular junction
through the arch. These images were
recorded in a short-axis view of the arch.
Note the total dimension of the arch,
which is approximately 6 cm. There is a
complex dissection present with the
appearance of one true (TL) and two false
lumens (FL). B: With color flow Doppler
imaging, notice that flow is confined only
to the central true lumen and is excluded
from the more peripheral false lumens.
FIGURE 20.43. Transesophageal echocardiogram of the aortic arch shows an
intramural hematoma. The black arrows denote the external wall of the aorta, and
the downward-pointing white arrows denote the boundary of the intramural
hematoma and lumen. Notice the space between the two is approximately 1 cm in
distance, filled with a homogeneous organizing thrombus and does not
communicate with the lumen.
FIGURE 20.43. Transesophageal echocardiogram of the aortic arch shows an
intramural hematoma. The black arrows denote the external wall of the aorta, and
the downward-pointing white arrows denote the boundary of the intramural
hematoma and lumen. Notice the space between the two is approximately 1 cm in
distance, filled with a homogeneous organizing thrombus and does not
communicate with the lumen.
FIGURE 20.44. Transesophageal echocardiogram recorded in the descending thoracic aorta in
a patient with a spontaneous intramural hematoma. This image was recorded at a 0-degree
imaging plane of the descending thoracic aorta in a patient presenting with acute chest and
back pain. Notice the relatively normal circular aortic geometry and the crescent-shaped filling
defect distending from approximately 2 o'clock to 6 o'clock. With close scrutiny, one can
appreciate the intima (arrows), which has lifted off the medial layers with the hematoma
within the intima/medial space. There was no evidence of communication between the lumen
and intima.
FIGURE 20.44. Transesophageal echocardiogram recorded in the descending thoracic aorta in
a patient with a spontaneous intramural hematoma. This image was recorded at a 0-degree
imaging plane of the descending thoracic aorta in a patient presenting with acute chest and
back pain. Notice the relatively normal circular aortic geometry and the crescent-shaped filling
defect distending from approximately 2 o'clock to 6 o'clock. With close scrutiny, one can
appreciate the intima (arrows), which has lifted off the medial layers with the hematoma
within the intima/medial space. There was no evidence of communication between the lumen
and intima.
FIGURE 20.45. Schematic representation of mechanisms of aortic insufficiency in
acute aortic dissection and disease of the proximal aorta. Multiple mechanisms can
be responsible for aortic insufficiency including effacement of dilation of the
sinotubular junction resulting in malcoaptation of the aortic valve (A), aortic
dissection in the presence of intrinsic aortic valve disease (B), actual disruption of
the insertion of an aortic cusp (C), and prolapse of a portion of the intimal
dissection flap through the aortic valve, which serves as a conduit for aortic
regurgitation (D).
FIGURE 20.46. Transesophageal
echocardiogram recorded in a patient
with dilation of the proximal aorta
resulting in malcoaptation of an
otherwise normal three-cusp aortic
valve. A: Recorded in diastole, note the
failure of the three cusps to completely
coapt at their center (arrow). B: The
aortic insufficiency jet can be visualized
as confined to the area of malcoaptation
(arrow).
FIGURE 20.46. Transesophageal
echocardiogram recorded in a patient
with dilation of the proximal aorta
resulting in malcoaptation of an
otherwise normal three-cusp aortic
valve. A: Recorded in diastole, note the
failure of the three cusps to completely
coapt at their center (arrow). B: The
aortic insufficiency jet can be visualized
as confined to the area of malcoaptation
(arrow).
FIGURE 20.47. Transesophageal
echocardiogram recorded in a patient with
acute type A dissection and severe aortic
insufficiency. A: Recorded in a longitudinal
(113-degree) view of the ascending aorta in
diastole. Note the portion of the dissection
flap (white arrow) that is prolapsing
through the aortic anulus into the left
ventricular outflow tract. B: The
accompanying color flow image was
recorded in diastole. Note the color flow jet
that fills the entire left ventricular outflow
tract and is flowing through the prolapsing
intimal flap. There is a communication point
within the intimal flap resulting in flow of
blood directly into the left ventricle (white
arrows). Note that the amount of blood
escaping from the prolapsing flap (arrows)
is substantially less than that confined by
the flap in the left ventricular outflow tract.
Ao, aorta; LA, left atrium; LV, left ventricle.
FIGURE 20.47. Transesophageal
echocardiogram recorded in a patient with
acute type A dissection and severe aortic
insufficiency. A: Recorded in a longitudinal
(113-degree) view of the ascending aorta in
diastole. Note the portion of the dissection
flap (white arrow) that is prolapsing
through the aortic anulus into the left
ventricular outflow tract. B: The
accompanying color flow image was
recorded in diastole. Note the color flow jet
that fills the entire left ventricular outflow
tract and is flowing through the prolapsing
intimal flap. There is a communication point
within the intimal flap resulting in flow of
blood directly into the left ventricle (white
arrows). Note that the amount of blood
escaping from the prolapsing flap (arrows)
is substantially less than that confined by
the flap in the left ventricular outflow tract.
Ao, aorta; LA, left atrium; LV, left ventricle.
FIGURE 20.48. Transesophageal
echocardiograms recorded in patients
after aortic dissection repair. A:
Transesophageal echocardiogram of the
aortic arch in a patient with a graft repair
of dissection. The margin of the native
aorta and graft is depicted by the longer
downward-pointing arrow and actual
graft tissue is noted by the upward-
pointing arrows. Notice the linear striping
of the prosthetic material that is
characteristic of a graft. B: Recorded in a
patient after graft repair of a descending
thoracic aneurysm. The image was
recorded in a longitudinal view of the
aorta. The downward-pointing arrow
denotes the margin of the native aorta
and graft, which in turn is noted by the
brackets. Again note the striped pattern
of the graft material that is characteristic
of a prosthetic material.
FIGURE 20.48. Transesophageal
echocardiograms recorded in patients
after aortic dissection repair. A:
Transesophageal echocardiogram of the
aortic arch in a patient with a graft repair
of dissection. The margin of the native
aorta and graft is depicted by the longer
downward-pointing arrow and actual
graft tissue is noted by the upward-
pointing arrows. Notice the linear striping
of the prosthetic material that is
characteristic of a graft. B: Recorded in a
patient after graft repair of a descending
thoracic aneurysm. The image was
recorded in a longitudinal view of the
aorta. The downward-pointing arrow
denotes the margin of the native aorta
and graft, which in turn is noted by the
brackets. Again note the striped pattern
of the graft material that is characteristic
of a prosthetic material.
AORTIC ATHEROMA
FIGURE 20.49. Suprasternal notch transthoracic echocardiogram recorded in a
patient with atheromatous involvement of the proximal descending thoracic aorta.
Notice the relatively normal aortic (Ao) arch and the distinct echo density
protruding into the lumen of the proximal descending thoracic aorta (arrow) that
represents focal pedunculated atheroma.
FIGURE 20.49. Suprasternal notch transthoracic echocardiogram recorded in a
patient with atheromatous involvement of the proximal descending thoracic aorta.
Notice the relatively normal aortic (Ao) arch and the distinct echo density
protruding into the lumen of the proximal descending thoracic aorta (arrow) that
represents focal pedunculated atheroma.
FIGURE 20.50. Transesophageal
echocardiograms from two different
patients with varying degrees of
atheroma of the descending thoracic
aorta. A: Note the rather laminar
atheroma of the aorta extending
from approximately 6 o'clock to 9
o'clock (arrows). B: Note the more
pedunculated bilobed atheroma
protruding into the lumen of the
aorta (arrows).
FIGURE 20.50. Transesophageal
echocardiograms from two different
patients with varying degrees of
atheroma of the descending thoracic
aorta. A: Note the rather laminar
atheroma of the aorta extending
from approximately 6 o'clock to 9
o'clock (arrows). B: Note the more
pedunculated bilobed atheroma
protruding into the lumen of the
aorta (arrows).
FIGURE 20.51. Transesophageal
echocardiogram recorded in short-axis and
longitudinal views of the descending thoracic
aorta. A: Note the relatively circular aorta into
which there is marked protrusion by
pedunculated atheroma (arrow). B: Recorded
at the same depth of imaging but in an
orthogonal view where the complex
pedunculated nature of the atheroma can
again be appreciated. An incidental pleural
effusion (Pl) is also noted.
FIGURE 20.51. Transesophageal
echocardiogram recorded in short-axis
and longitudinal views of the
descending thoracic aorta. A: Note the
relatively circular aorta into which
there is marked protrusion by
pedunculated atheroma (arrow). B:
Recorded at the same depth of imaging
but in an orthogonal view where the
complex pedunculated nature of the
atheroma can again be appreciated. An
incidental pleural effusion (Pl) is also
noted.
FIGURE 20.52. Transesophageal echocardiogram recorded in the longitudinal
plane of a descending thoracic aorta with aneurysm. The arrows outline the
external boundary of the aorta with all space in between representing an
aneurysm with complex atheroma. Note the markedly complex atheroma with
multiple pedunculated and mobile components filling the dilated lumen.
FIGURE 20.52. Transesophageal echocardiogram recorded in the longitudinal
plane of a descending thoracic aorta with aneurysm. The arrows outline the
external boundary of the aorta with all space in between representing an
aneurysm with complex atheroma. Note the markedly complex atheroma with
multiple pedunculated and mobile components filling the dilated lumen.
FIGURE 20.53. Transesophageal echocardiogram recorded in a patient with
acute chest and back pains suggesting acute aortic pathology. In this instance, no
typical dissection or intramural hematoma could be detected. There was
substantial atheroma with a distinct area of ulceration (arrow) into the
atheroma. This is a typical ulceration of an atheromatous plaque that can
present with symptoms virtually identical to acute aortic dissection.
FIGURE 20.53. Transesophageal echocardiogram recorded in a patient with
acute chest and back pains suggesting acute aortic pathology. In this instance, no
typical dissection or intramural hematoma could be detected. There was
substantial atheroma with a distinct area of ulceration (arrow) into the
atheroma. This is a typical ulceration of an atheromatous plaque that can
present with symptoms virtually identical to acute aortic dissection.
MISCELLANEOUS CONDITIONS
Aortic Pseudoaneurysm
FIGURE 20.54. Transesophageal
echocardiogram recorded in a patient
with a complex dissection and
subsequent pseudoaneurysm of the
ascending aorta. A: Longitudinal view
of the ascending aorta in which the
true (TL) and false lumens (FL) of the
aorta can be appreciated. The intimal
flap is denoted by arrowheads. External
to the posterior wall of the aorta is a
space bounded by the true wall of the
aorta (upward-pointing arrows) and the
left atrium (LA), which represents a
pseudoaneurysm (PA). B: Short-axis
view representing the same anatomy
in which the relatively circular aorta
(Ao) can be noted. Lateral to this is a
large complex space partially filled with
hematoma representing the
pseudoaneurysm. RA, right Atrium.
FIGURE 20.54. Transesophageal
echocardiogram recorded in a patient
with a complex dissection and
subsequent pseudoaneurysm of the
ascending aorta. A: Longitudinal view
of the ascending aorta in which the
true (TL) and false lumens (FL) of the
aorta can be appreciated. The intimal
flap is denoted by arrowheads. External
to the posterior wall of the aorta is a
space bounded by the true wall of the
aorta (upward-pointing arrows) and the
left atrium (LA), which represents a
pseudoaneurysm (PA). B: Short-axis
view representing the same anatomy
in which the relatively circular aorta
(Ao) can be noted. Lateral to this is a
large complex space partially filled with
hematoma representing the
pseudoaneurysm. RA, right Atrium.
FIGURE 20.55. Longitudinal transesophageal echocardiogram recorded in the
same patient as depicted in Figure 20.54. The shorter arrows denote the intimal
flap. The pseudoaneurysm (PA) is denoted by the longer arrow. Distinct color flow
(horizontal arrow) can be seen through a communication point between the aorta
and pseudoaneurysm. LA, left atrium.
FIGURE 20.55. Longitudinal transesophageal echocardiogram recorded in the
same patient as depicted in Figure 20.54. The shorter arrows denote the intimal
flap. The pseudoaneurysm (PA) is denoted by the longer arrow. Distinct color flow
(horizontal arrow) can be seen through a communication point between the aorta
and pseudoaneurysm. LA, left atrium.
FIGURE 20.56. Intravascular ultrasound (IVUS)
recorded in a patient with traumatic aortic injury. A:
Recorded in the same patient depicted in Figure
20.10 who is a 38-year-old man involved in a motor
vehicle accident and suspected of having aortic
trauma. For comparison, refer to Figure 20.10, which
was recorded in a noninvolved area of the lower
thoracic aorta. A: Note the central position of the
imaging catheter (C) and the relatively circular aortic
geometry. From roughly the 6 o'clock to 12 o'clock
position (black arrows) there is a distinct area of
crescentic thickening in the wall, the maximal
dimension of which is denoted by the double-headed
white arrow. This represents intramural thrombus
formation as a result of aortic trauma. This image
was recorded at the level of the ligamentum
arteriosum. B: Recorded in a 23-year-old patient
after a motor vehicle accident. Note the noncircular
shape of the overall aorta with marked irregularity of
the inner wall from approximately the 7 o'clock to 12
o'clock position (black arrows). There is also a limited
dissection flap (white arrows) within the lumen.
FIGURE 20.57. Transesophageal
echocardiogram recorded in a patient
2 weeks after a high-speed motor
vehicle accident in whom an aortic
pseudoaneurysm formed at the site of
rupture. A: Recorded in the short-axis
view in which the true aortic lumen
(TL) can be seen. There is additional
space that represents the
pseudoaneurysm posterior to the aorta
(PA). The nature of the
pseudoaneurysm is better appreciated
in B, which is a longitudinal view
recorded in the same area. The lumen
of the aorta is noted (Ao) as well as 1-
cm long break in its continuity
(arrowheads) communicating to the
pseudoaneurysm (PA).
FIGURE 20.57. Transesophageal
echocardiogram recorded in a patient
2 weeks after a high-speed motor
vehicle accident in whom an aortic
pseudoaneurysm formed at the site of
rupture. A: Recorded in the short-axis
view in which the true aortic lumen
(TL) can be seen. There is additional
space that represents the
pseudoaneurysm posterior to the aorta
(PA). The nature of the
pseudoaneurysm is better appreciated
in B, which is a longitudinal view
recorded in the same area. The lumen
of the aorta is noted (Ao) as well as 1-
cm long break in its continuity
(arrowheads) communicating to the
pseudoaneurysm (PA).
Infections of the Aorta
FIGURE 20.58. Longitudinal axis transesophageal echocardiogram recorded in an
immunocompromised patient with a fungal infection. In this instance, there has
been involvement of the lung by aspergillosis, which has subsequently invaded
both the pulmonary artery (PA) and aorta (Ao). Note the irregular intraluminal
echos in both the pulmonary artery and aorta, which represent direct extension of
the infection into the vascular structures. The long leftwardpointing arrow denotes
a area of pulmonary consolidation due to this infection.
Aortic Thrombus
FIGURE 20.59. Transesophageal
echocardiogram recorded in a patient
with a recent embolic event to the
kidney. A: Longitudinal view of the
aorta in which there is focal protruding
atheroma and/or a thrombus (vertical
arrow) protruding into the lumen.
Additionally, there is an elongated soft
tissue density mass within the lumen of
the aorta (horizontal arrow) that in real
time is highly mobile. B: The same
patient at the same level of the aorta
recorded in the short axis in which the
elongated, highly mobile soft thrombus
can again be Appreciated.
FIGURE 20.59. Transesophageal
echocardiogram recorded in a patient
with a recent embolic event to the
kidney. A: Longitudinal view of the
aorta in which there is focal protruding
atheroma and/or a thrombus (vertical
arrow) protruding into the lumen.
Additionally, there is an elongated soft
tissue density mass within the lumen of
the aorta (horizontal arrow) that in real
time is highly mobile. B: The same
patient at the same level of the aorta
recorded in the short axis in which the
elongated, highly mobile soft thrombus
can again be Appreciated.
FIGURE 20.60. Transesophageal echocardiogram recorded in a patient with an
embolic event to the lower extremity. Note the relatively normal appearing
circular aorta in which there were two highly mobile echo densities consistent
with a mobile thrombus that arose from the surface of a complex atheroma (not
in view in this image).
FIGURE 20.61. Parasternal long-axis transthoracic echocardiogram recorded in a
patient with Takayasu arteritis. Note the abnormally bright echo within the anterior
and posterior wall of the aorta in the young female patient in whom
atherosclerotic disease would not be expected. Ao, aorta; LA, left atrium; LV, left
ventricle.
FIGURE 20.61. Parasternal long-axis transthoracic echocardiogram recorded in a
patient with Takayasu arteritis. Note the abnormally bright echo within the anterior
and posterior wall of the aorta in the young female patient in whom
atherosclerotic disease would not be expected. Ao, aorta; LA, left atrium; LV, left
ventricle.