Dr. Raimund Erbel,
The classical features of aortic dissection are well known. Nowadays, new imaging techniques make it possible in nearly all cases to make the correct diagnosis, because the sensitivity and specificity of tranesophageal echocardiography (TEE), computed tomography (CT), and magnetic resonance imaging (MRI) are well beyond 90 %.
In recent years, however, it has become evident that other forms of aortic diseases like intramural hematoma, hemorrhage (IMH), discrete aortic dissection, and penetrating aortic ulcer (PAU) can also be the cause of acute aortic disease. Therefore, the ESC Task Force on Diagnosis and Treatment of Aortic Dissection had used the Svensson classification, which was the topic of the FOCUS Session on Sunday 2 September 2007. The session was well attended and the participants enjoyed the interactive presentations which used a voting system in response to multiple choice questions, which were put forward by A Evangelista, Barcelona, ES, F. Chirillo, Treviso, It, and H Eggebrecht, Essen DE under the chairmen R. Erbel, Essen DE and M Czerny, Vienna, AT.
A Evangelista presented a patient with IMH, class 2 aortic dissection, and differentiated the clinical features from the classical class 1 aortic dissection, pointing out the poor prognosis of these patients, who may develop within few days complete class 1 dissection despite optimal medical treatment with beta blocking agents and blood pressure lowering. As the time course can not be anticipated – we have not the right clinical criteria, he emphasized – regular close follow-up of the patient has to be provided. Progression of the disease can even occur without new onset of symptoms. A first control within one week, and definitely before discharge was recommended.
F Chrillo illustrated that a close look at the aorta by TEE but also other techniques is able to identify patients with class 3 aortic dissection more often than previously anticipated. He has the largest number of patients and went through the patients’ history. A very careful check of the diagnostic tests is important in order to avoid overlooking small, but important disruptions of the intimal layers of the aorta, which are the typical signs of discrete circumscript aortic dissection. Progression to class 1 dissection or rupture were demonstrated, again showing the importance of the need for experienced clinicians.
H Eggebrecht finished the session by demonstrating the time course of 4 cases with penetrating aortic ulcer, the class 4 aortic dissection. Based on published data concerning risk prediction, he followed his patientsand included the audience again for virtual disease making. As the other authors, the available information was not helpful in all cases for predicting prognosis. Despite small size PAUs, progression occurred quite rapidly within a few days and in type B locations, he preferred the graft stent implantation, which particularly in PAU was so successful that a full healing of the aorta was induced in all cases. Multiple close follow-up imaging was suggested with regular visits to the outpatient clinic thereafter. As the other authors, MRI was the method of choice, next to CT, because the whole aorta could be imaged and 3D reconstruction provided.
The knowledge of the different types of aortic dissection is necessary in order to interpret the results of the current imaging techniques. Class 2, 3, and 4 aortic dissections do not present a benign disease, but show a poor prognosis in many patients with acute progression to class 1 dissection or rupture in up to 40% in the long term. But this information is based on a limited number of studies, current clinical features are not well understood in order to differentiate those with a good and those with a malignant history. Therefore, the European Association of Echocardiography is supporting a European Aortic Survey, which can be expected to start in 2008.
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Imaging the aorta for decision making - FOCUS Session
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