Aortic Dissection 16 th Annual Toronto Perioperative TEE Symposium - - PowerPoint PPT Presentation

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Aortic Dissection 16 th Annual Toronto Perioperative TEE Symposium - - PowerPoint PPT Presentation

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Echocardiography for Aortic Dissection 16 th Annual Toronto Perioperative TEE Symposium 2018.11.10 Azad Mashari MD FRCPC Department of Anesthesia & Pain Management Advanced Perioperative Imaging Lab Toronto General Hospital This work is

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16th Annual Toronto Perioperative TEE Symposium 2018.11.10 Azad Mashari MD FRCPC

Department of Anesthesia & Pain Management Advanced Perioperative Imaging Lab Toronto General Hospital

Echocardiography for

Aortic Dissection

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Competing Interests

No fjnancial disclosures :( Work supported by the Peter Munk Cardiac Center Foundation

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Objectives

At the completion of this presentation participants will be able to

  • 1. Visualize & describe the anatomi

mical cal relationships between thoracic aortic segments, tracheobronchial tree & esophagus to identify imaging windows and blind spots for TEE

  • 2. Describe primary complications of acute TAD and

corresponding clinica cal object bjectives es of f intraoper erative TEE during emergency repair surgery

  • 3. Describe the ba

basic c ec echoca cardiogr graphic c asses essmen ment of aortic dissection.

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Intraoperative Echocardiography for

Aortic Dissection

Acute Type A Dissection for emergency repair

Iatrogenic Type A Dissection Subacute Type A Dissection Traumatic Aortic Dissection Type B Dissection

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Outline

  • 1. Pathophysiology
  • 2. Anatomy

3.TEE for emergency repair

  • f ATAD
  • Diagnosis
  • Surgical planning
  • Procedural guidance
  • Post operative assessment
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Pathophysiology of Aortic Diseases

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Anatomy

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https://i.pinimg.com/originals/d7/9e/2f/ d79e2f7c895d8ea328c9714acd3b4929.jpg

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TEE TEE

in Emergency Repair of Acute Type A Dissection

“The primary purpose of intraoperative TEE is to detail ail the anat atomy my o

  • f

the dis dissectio ion an and t d to be better de defj fjne i its ph physio iolo logic gic co consequence ce” - Goldstein et

al JASE 2015 Feb;28(2):119–82

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Goals of TEE in Emergency Repair of ATAD

1. . Dia Diagnosis sis: Defjne anatomy & physiologic consequences of ATAD 2. . Procedura ral l pl plannin ing: Provide information relevant to key surgical decisions 3. . Mo Monit itori ring & gui uidance 4. . Post st-ope perative ive asse ssessm ssment

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Goals: Diagnosis

  • Assess presence of pe

peric ricardial o dial or ple r pleura ural e efg fgus usio ion suggestive of aortic rupture

  • Identify location of in

intimal t imal tears

  • Identify false &

& t true rue lume lumens

  • Defjne extent of dissection
  • Asses ao

aortic ic in insuffj ffjcie ciency

  • Assess ventricul

ricular r fun unctio ion

  • Assess perf

rfus usio ion of branching vessels

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Goals: Diagnosis

  • Assess presence of pe

peric ricardial o dial or ple r pleura ural efg fgus usio ion suggestive of aortic rupture

  • Identify location of in

intimal t imal tears

  • Identify false &

& t true rue lume lumens

  • Defjne extent of dissection
  • Asses ao

aortic ic in insuffj ffjcie ciency

  • Assess ventricul

ricular r fun unctio ion

  • Assess perf

rfus usio ion of branching vessels

70% 70%

~30%

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Goals: Diagnosis – Luminal Truth

Evangelista et al. Echocardiography in aortic diseases. Eur J Echocardiography. 2010 Sep;11(8):645–58

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Question

In what situation does the intimal fmap move towards ds the t true rue l lum umen in in systole? Which other typical fjndings of TL vs FL do not apply in this situation?

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Goals: Diagnosis

  • Assess presence of pe

peric ricard ardial l or p

  • r pleural

ral e efg fgusion

  • n suggestive of

aortic rupture

  • Identify location of inti

timal mal te tears ars

  • Identify false &

& tru rue lu lume mens

  • Defjne extent of dissection
  • Asses aort
  • rtic i

insuffjc uffjciency

  • Assess ve

ventri ricular f ar fun uncti tion

  • n
  • Assess pe

perf rfus usio ion of branching vessels

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Goals: Diagnosis – Aortic Insufficiency

A: Tear dilates Ao root & annulus – failure of coaptation B: : Asymmetric dissection depressed one leafmet below coaptation line C: Annular support disrupted, resulting in fmail leafmet D: Prolapse of intimal fmap through aortic valve in diastole, preventing coaptation

Yas asmin S. Ham amiran ani et al

  • al. Circulat
  • ation. 2012;126:1121-1126
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Goals: Diagnosis – Ventricular Function

Generalized dysfunction associated with Acute AI Regional dysfunction associated Coronary artery injury/obstruction

Coronary involvement: R > L

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Right Coronary Artery

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Right Coronary Artery

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Left Main Coronary Artery

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Left Main Coronary Artery

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Goals: Diagnosis – Perfusion of Branches

Arch & Visceral vessels

  • Dynamic obstruction: Compression of TL by FL
  • Static obstruction: Extension of dissection into or

avulsion of branch

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Caused by interposition of air-fjlled structures

(tracheobronchial tree, lung)

Often includes brac acheocephal alic & L common caro aroti tid Very rare for dissections to start or be limited to this area Dealing with the blindspot

  • TTE suprasternal notch view
  • Epiaortic imaging
  • Bronchial balloon (“A-view” catheter)
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Left subclavian artery

http://pie.med.utoronto.ca/TEE/

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Left common carotid

http://pie.med.utoronto.ca/TEE/

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Inominate artery

http://pie.med.utoronto.ca/TEE/

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Supresternal Notch View (TTE)

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Goals: Diagnosis

  • Assess presence of pe

peric ricardial o dial or ple r pleura ural e efg fgus usio ion suggestive of aortic rupture

  • Identify location of in

intimal t imal tears

  • Identify false &

& t true rue lume lumens

  • Defjne extent of dissection
  • Asses ao

aortic ic in insuffj ffjcie ciency

  • Assess ventricul

ricular r fun unctio ion

  • Assess perf

rfus usio ion of branching vessels

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Goals: Procedur ural l Plann lanning ing

Assist with Key Surgical Decisions

  • Cannulation:

– Venous: Central or femoral? – Arterial: Axillary or femoral?

  • Arch repair?
  • Aortic root repair/replacement?
  • Aortic valve?
  • Coronary bypass?
  • Should pathology in descending aorta be addressed acutely?
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Goals: Monit nitoring ring & & Pr Proce cedur ural al Guid uidance ance

Dynamic process: extent & physiologic consequences can evolve Femoral cannulation: confjrmation of wire and cannula position Retrograde cardioplegia cannula EVAR guidance

  • TEE can distinguish false &true lumens
  • Avoid protruding plaques in landing zone
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Two stage femoral venous cannula placement: guidewire

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Two stage femoral venous cannula placement: guidewire

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Two stage femoral venous cannula placement

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Two stage femoral venous cannula placement

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Goals: Post Operative Assessment

  • Confjrm exclusion of entry tear and any proximal
  • Ventricular function
  • Aortic valve function
  • Adequacy of fmow in descending thoracic aorta
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References

  • Goldstein et al. Mu

Multi timod modality I ty Ima maging o

  • f Di

Disea seases o es of the the T Thoracic Ao Aorta ta i in Ad

  • Adults. JASE 2015 Feb;28(2):119–82.
  • Evangelista et al. Echo

hocard rdiograph phy y in a n aorti tic d disea sease

  • ses. Eur J
  • Echocardiography. 2010 Sep;11(8):645–58.
  • Erbel R et al. 2014 ESC G

Guidel elines nes o

  • n the

the di diagnosi sis s and nd trea treatmen ment o t of a aorti tic disea seases es: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873–926.

  • David TE. Surg

rgery f y for

  • r a

acute t type A a e A aor

  • rti

tic d disse ssecti

  • tion. J Thorac Cardiovasc
  • Surg. 2015 Aug;150(2):279–83.
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azad.mashari@uhn.ca APIL.ca

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Thank you!

Acknowledgements

  • Jo Carroll, Sarah Russell & the Organizing Team
  • Max Meineri, Joshua Hiansen, Jacobo Moreno, Annette Vegas, Jackie Cade, Patricia

Murphy & the PMCC Foundation

  • UHN Department of Anesthesia & Pain Management
  • Anesthesia Associates