Thoracic Aorta Flashcards by Ravi Patel

What does the aortic root entail?

Aortic Valve Annulus

Aortic Cusps

Sinus of Valsalva

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When does the Ascending Aorta begin?

End?

Begins = Sinotubular Junction

Ends = Origin of the Brachicephalic Artery

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When does the aortic arch end?

Isthmus (Origin of Left Subclavian artery) and Ligamentum Arteriosum

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In the midesophageal views, how deep from the incisors should this be?

30 cm from the incisors

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What is a normal diameter of the: Aortic Annulus?

2 - 2.5 cm

Annulus in red in the photo

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What is a normal diameter of the: Sinus of Valsalva?

3 - 3.5 cm

Sinus of Valsalva is in Green

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What is a normal diameter of the: Sinotubular Junction?

2 - 2.5 cm

Junction in Teal

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What is a normal diameter of the: Ascending Aorta?

2.5 - 3.5 cm

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How do you get to a ME Ascending Aorta Long Axis view?

Insert the probe to the ME, sector depth 8-10cm, angle 0°

Find the ME AV LAX (120°)

Withdraw the probe to bring the right pulmonary artery in view

Decrease omniplane angle slightly by 10-20° to make the aortic wall symmetric

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How do you obtain the ME Ascending Aorta in Short Axis?

Insert the probe to the ME, sector depth 10-12cm, angle 0°

From ME AV LAX (120°), withdraw probe (ascending aorta LAX), rotate the omniplane angle back to 0°

From ME AV SAX (30°), withdraw probe (ascending aorta SAX), rotate the omniplane angle back to 0° (Anteflex a little bit)

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Why is the Left Pulmonary Artery not visualized well in the ME Ascending Aorta Short Axis?

Bronchial and Tracheal tree is obstructing the view

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What is the easiest way to obtain a descending aortic short axis view?

Insert the probe to the ME, sector depth 10-12cm, angle 0°

Turn probe to left to find the aorta

Put aorta in middle of display

Decrease depth to 5cm

Advance + withdraw probe

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If you find that you need to constantly adjust the right/left laterality of the TEE probe when scanning the Aorta in the Descending Aortic Short axis, what does this mean?

Tortuous Aorta

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How do you obtain the descending aorta in long axis?

Insert the probe to the ME, sector depth 4-6cm

From Descending Aorta SAX (0°) view

Keep probe tip still, rotate omniplane angle to 90-100°

Aortic walls appear in parallel

Difficult to tell which wall is right from left and anterior from posterior

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What are 4 pathologies you can rule out when evaluataing the aorta in short axis?

Aortic Pathology: Dissection vs. Atheroma Burden

Color flow reversal: Aortic insufficiency (AI severity) Holodiastolic reversal of flow

IABP position

Left Pleural Effusion

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How would you obtain the Upper Esophageal Aortic Arch SAX View?

Insert the probe to the ME, sector depth 10-12cm, angle 0°

Find the ME Descending Aorta SAX (0°) view

Withdraw the probe to obtain the UE Aortic Arch LAX (0°) view

Rotate the omniplane angle to 60-90°

Bring the pulmonic valve and pulmonary artery in view

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How would you obtain the Upper Esophageal Aortic Arch LAX View?

Insert the probe to the ME, sector depth 4-6cm, angle 0°

Find ME Descending Aorta SAX (0°) view

Withdraw probe until aorta changes into oval shape

Turn probe slightly to the right

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What is the significance of the anatomical blind spot of the aorta during cardiac surgery?

Can’t see where they cross clamp or where they cannulate

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What is a Stanford Type A Classification Aortic Dissection?

Type A - Involves any portion of ascending aorta

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What is a Stanford Type B Aortic Dissection Classification?

Type B - Isolated to descending aorta

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What is a DeBakey Type I Class of Aortic Dissection?

It categorizes the dissection based on where the original intimal tear is located and the extent of the dissection (localized to either the ascending aorta or descending aorta or involves both the ascending and descending aorta.

Type I – originates in ascending aorta, and propagates at least to the aortic arch and often beyond it distally.

It is most often seen in patients less than 65 years of age and is the most lethal form of the disease.

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What is a DeBakey Type II Class of Aortic Dissection?

The DeBakey system is an anatomical description of the aortic dissection. It categorizes the dissection based on where the original intimal tear is located and the extent of the dissection (localized to either the ascending aorta or descending aorta or involves both the ascending and descending aorta.

Type II – originates in the ascending aorta and is confined to it.

What is a DeBakey Type IIIa Class of Aortic Dissection?

Type III – originates in the descending aorta and rarely extends proximally, but will extend distally. It most often occurs in elderly patients with atherosclerosis and hypertension.

Type III – originates distal to the subclavian artery in the descending aorta

Further subdivided into IIIa which extends distally to the diaphragm and IIIb which extends beyond the diaphragm into the abdominal aorta

What is the most common case of aortic dissection when doing a case?

50-85% of cases are Type A

What is the non-surgical vs. surgical mortality of Type A dissections?

Non-surgical = 90-95% mortality Surgical = 3.5 - 10% mortality

What is the non-surgical mortality of Type B dissections?

Non-surgical = 40% mortality

When you get a crash aortic dissection, what are 4 aspects of the echo you need to evaluate?

1. Origin of intimal tear 2. Determine extent of dissection 3. Confirm presence of dissection flap separating true and false lumens 4. Assess associated collateral damage

Which lumen (True or False) has a *_higher systolic velocity_*?

**True lumen** has a higher systolic velocity

Which lumen (True or False) has evidence of stasis/thrombus?

False Lumen

Which lumen (True or False) does the intimal flap shift toward? Is this shift in systole or diastole?

Intimal flap moves toward **False Lumen** in systole

Which lumen (True or False) does high velocity jet flow? Is this during systole or diastole?

high velocity jet flows from True to False Lumen during systole

List in order from most to least **sensitive** for Aortic Dissection.

#1 MRI (98%) CT Scan (94%) TEE (88-98%) #4 TTE (77-80%)

List in order from most to least **specific** for Aortic Dissection.

#1 = MRI (98%) #2 TEE (90-95%) ``` #3 TTE (93%) #4 CT Scan (87%) ```

What is a **Type I** Crawford Classification for TAAA: thoracoabdominal aortic aneurysm?

The Crawford classification of TAAA is based upon the extent of aortic involvement. ## Footnote **Type I** arises from **above** the sixth intercostal space, usually near the left subclavian artery, and extends to include the origins of the celiac axis and superior mesenteric arteries. Although the renal arteries can also be involved, the aneurysm does not extend into the infrarenal aortic segment.

What is a **Type II** Crawford Classification for TAAA: thoracoabdominal aortic aneurysm?

The Crawford classification of TAAA is based upon the extent of aortic involvement. Type II aneurysm also arises **above the sixth intercostal space** and may include the ascending aorta, but extends distal to include the infrarenal aortic segment, often to the **level of the aortic bifurcation**.

What is a Type III Crawford Classification for TAAA: thoracoabdominal aortic aneurysm?

Type III aneurysm arises in the distal half of the descending thoracic aorta, **below** the sixth intercostal space, and extends into the **abdominal aorta.**

What is a **Type IV** Crawford Classification for TAAA: thoracoabdominal aortic aneurysm?

The Crawford classification of TAAA is based upon the extent of aortic involvement. ## Footnote Type IV aneurysm generally involves the **entire abdominal aorta from the level of the diaphragm to the aortic bifurcation.**

What is a Type V Crawford Classification for TAAA: thoracoabdominal aortic aneurysm?

The Crawford classification of TAAA is based upon the extent of aortic involvement. Type V aneurysm arises in the distal half of the descending thoracic aorta, **below** the sixth intercostal space, and extends into the abdominal aorta, but is limited to the visceral segment.

What is the difference between measuring aortic aneurysms with a TEE vs. CT/MRI?

TEE = Internal Diameter CT/MRI = External Diameter

What is a **normal size** of the **ascending aorta**?

2.2 - 3.7 cm

What is a **normal** size of the **Aortic Arch**?

**2.5 - 3.0 cm**

What is a **normal** size of the **descending aorta**?

**2.0 - 2.5 cm**

What is **Grade I** of Aortic Atheroma?

Normal aorta without burden

What is **Grade II** of Aortic Atheroma?

\<3 mm plaque burden Minimal intimal thickening

What is Grade III of Aortic Atheroma?

3-5 mm plaque burden Minimal intimal thickening

What is **Grade IV** of Aortic Atheroma?

\>5 mm plaque burden

What is Grade V of Aortic Atheroma?

Any **mobile** component of the plaque

Why are Beta Blockers beneficial for managing a patient with Aortic dissection?

**Aortic Wall Stress** is decreased by: 1. Velocity of ventricular contraction (dP/dt) 2. Rate of Ventricular Contraction 3. Blood Pressure

What is your HR goal and dosing recommended for **Esmolol** when you have a Type A dissection?

Control heart rate before blood pressure (Goal to **keep HR \<60 bpm** and SBP 100-120) Esmolol Advantage of short half life, easily titratable **Bolus 0.5mg/kg over 1min** **infuse 0.05mg/kg/min** (titrate upward in 0.05mg/kg/min increments to a maximum of **0.3 mg/kg/min**)

What is your HR goal and dosing recommended for Labetalol when you have a Type A dissection?

**HR \< 60 bpm** Labetalol - has both α and beta effects **Push dose - 10-20mg** with repeat doses of **20-40mg q10min** up to 300mg Drip - Load 15-20mg IV, followed by 5mg/hr

What is your dose of Metoprolol when using it for aortic dissections?

Metoprolol ## Footnote **5mg IV x 3** **I**nfuse at **2-5mg/hr**

What is your dose of Diltiazem when using it for an acute aortic dissection?

Diltiazem - Use if contraindications to beta-blockers ## Footnote **Loading 0.25mg/kg over 2–5 min,** followed by a drip of 5mg/h

What is your dose of Nicardipine when using it for an aortic dissection?

Nicardipine/Clevidipine - consider following regimen for nicardipine: ## Footnote **5mg/hr start, then titrate up by 2.5mg/hr every 10 min until goal** Once at goal, **drop to 3mg/hr** and re-titrate from there **May initially bolus 2mg IV**