The role of transthoracic echocardiography in the diagnosis and management of acute type A aortic syndrome

Background Transthoracic echocardiography (TTE) has been traditionally considered inadequate for the diagnosis of acute type A aortic syndrome (AAAS). In the last decade, high-resolution probes and harmonic imaging have been implemented in new echocardiographic systems. However, studies assessing the diagnostic accuracy of TTE for the identification of AAAS in large populations using modern ultrasound technology are lacking. Methods The diagnostic value of harmonic imaging TTE was assessed in 270 consecutive patients with suspected AAAS in whom TTE was the initial diagnostic test. Results Acute type A aortic syndrome was diagnosed in 67 patients and excluded in 203 patients (disease prevalence 25%). Sixty-two patients had a classic acute type A aortic dissection, and 5, an acute type A intramural hematoma. Image quality achieved was considered optimal in 244 patients (90%). In the whole study population, TTE had sensitivity, specificity, positive predictive value, and negative predictive value for the diagnosis of AAAS of 87%, 91%, 75%, and 95%, respectively. When evaluating only patients with optimal image quality, these values increased to 97%, 100%, 100%, and 99%, respectively. Forty-seven patients with clear-cut evidence of AAAS were transferred immediately to the operative room, where transesophageal echocardiography confirmed the diagnosis obtained by TTE in all patients. Conclusions Transthoracic echocardiography is a useful imaging modality for the diagnosis of classic acute type A aortic dissection. It cannot be used as the sole screening technique for detecting AAAS, but in the light of the predictive values observed, patients with optimal image quality and clear-cut diagnosis of AAAS should proceed to the operative room, whereas in patients with negative or indeterminate studies, other imaging techniques are needed to refine the diagnosis. (Am Heart J 2012;163:112-8.)