open pdf file in c# : Add text to pdf online control SDK platform web page wpf windows web browser 2015_Thoracic-Aorta0-part736

GUIDELINES AND STANDARDS
Multimodality Imaging of Diseases of the Thoracic
Aorta in Adults: From the American Society
of Echocardiography and the European Association
of Cardiovascular Imaging
Endorsed by the Society of Cardiovascular Computed Tomography
and Society for Cardiovascular Magnetic Resonance
StevenA.Goldstein,MD,Co-Chair,ArturoEvangelista,MD,FESC,Co-Chair,SuhnyAbbara,MD,
AndrewArai,MD,FedericoM.Asch,MD,FASE,Luigi P.Badano,MD,PhD,FESC,Michael A.Bolen,MD,
HeidiM.Connolly,MD,HugCuellar-Calabria,MD,MartinCzerny,MD,RichardB.Devereux,MD,
RaimundA.Erbel,MD,FASE,FESC,RossellaFattori,MD,EricM.Isselbacher,MD,JosephM.Lindsay,MD,
Marti McCulloch,MBA,RDCS,FASE,HectorI.Michelena,MD,FASE,ChristophA.Nienaber,MD,FESC,
JaeK.Oh,MD,FASE,MauroPepi,MD,FESC,AllenJ.Taylor,MD,JonathanW.Weinsaft,MD,
JoseLuisZamorano,MD,FESC,FASE,ContributingEditors:HarryDietz,MD,KimEagle,MD,
JohnElefteriades,MD,GuillaumeJondeau,MD,PhD,FESC,HerveRousseau,MD,PhD,
andMarcSchepens,MD,Washington, District ofColumbia;BarcelonaandMadrid, Spain;DallasandHouston,
Texas;BethesdaandBaltimore,Maryland;Padua,Pesaro,andMilan,Italy;Cleveland,Ohio;Rochester,Minnesota;
Zurich,Switzerland;NewYork, New York; EssenandRostock,Germany; Boston,Massachusetts; AnnArbor,
Michigan;NewHaven,Connecticut;ParisandToulouse, France;andBrugge,Belgium
(JAmSocEchocardiogr 2015;28:119-82.)
TABLEOFCONTENTS
Preamble
121
I. AnatomyandPhysiologyoftheAorta
121
A. TheNormalAortaandReferenceValues
121
1. NormalAorticDimensions
122
B. HowtoMeasuretheAorta
124
1. Interface, Definitions, and Timing of Aortic Measure-
ments
124
FromtheMedstarHeartInstituteattheWashingtonHospitalCenter,Washington,
District of Columbia (S.A.G., F.M.A., J.M.L., A.J.T.); Vall d’Hebron University
Hospital,Barcelona,Spain(A.E.,H.C.-C.);theUniversityofTexasSouthwestern
MedicalCenter,Dallas,Texas(S.A.);theNationalInstitutesofHealth,Bethesda,
Maryland(A.A.); theUniversityofPadua,Padua,Italy(L.P.B.);ClevelandClinic,
Cleveland, Ohio (M.A.B.); Mayo Clinic, Rochester, Minnesota (H.M.C., H.I.M.,
J.K.O.);the UniversityHospitalZurich, Zurich,Switzerland(M.C.);Weill Cornell
Medical College, New York, New York (R.B.D., J.W.W.); West-German Heart
Center, University Duisburg-Essen, Essen, Germany (R.A.E.); San Salvatore
Hospital, Pesaro, Italy (R.F.); Massachusetts General Hospital, Boston,
Massachusetts (E.M.I.); the Methodist DeBakey Heart & Vascular Center,
Houston, Texas;the Universityof Rostock,Rostock,Germany(C.A.N.);Centro
CardiologicoMonzino,IRCCS, Milan, Italy(M.P.);University Hospital Ram
ony
Cajal, Madrid, Spain (J.L.Z.); Johns Hopkins University School of Medicine,
Baltimore, Maryland (H.D.); the University of Michigan, Ann Arbor, Michigan
(K.E.); Yale University School of Medicine, New Haven, Connecticut (J.E.);
Hopital Bichat, Paris, France (G.J.); Hopital de Rangueil, Toulouse, France
(H.R.);andAZStJanBrugge,Brugge,Belgium(M.S.).
Thefollowingauthorsreportednoactualorpotentialconflictsofinterestinrela-
tiontothisdocument:FedericoM.Asch,MD,FASE,MichaelA.Bolen,MD,Heidi
M.Connolly,MD,HugCu
ellar-Cal
abria,MD,MartinCzerny,MD,RichardB.De-
vereux,MDHarryDietz,MD,RaimundA.Erbel,MD,FASE,FESC,ArturoEvan-
gelista, MD, FESC, Rossella Fattori, MD, StevenA. Goldstein,MD, Guillaume
Jondeau, MD,PhD, FESC,Eric M. Isselbacher,MD, JosephM. Lindsay, MD,
MartiMcCulloch,MBA,RDCS,FASE,HectorI.Michelena,MD,FASE,Christoph
Nienaber, MD, FESC, Mauro Pepi, MD, FESC, Marc Schepens, MD, Allen J.
Taylor,MD,andJose LuisZamorano,MD,FESC,FASE.The followingauthors
reported relationships withone or more commercial interests:Suhny Abbara,
MD, serves as a consultant for Perceptive Informatics. Andrew Arai, MD, re-
ceivesresearchsupport fromSiemens.Luigi P.Badano,MD,PhD,FESC,has
receivedsoftware and equipment from GE Healthcare, Siemens, and TomTec
forresearchandtestingpurposesandisonthespeakers’bureauofGEHealth-
care.KimEagle,MD,receivedaresearchgrant fromGORE.JohnElefteriades,
MD, has a bookpublished byCardioText andis a principal investigator on a
grantandclinicaltrialfromMedtronic.JaeK.Oh,MD,receivedaresearchgrant
fromToshibaandcorelaboratorysupportfromMedtronic.Herv
eRousseau,MD,
servesasaconsultantforGORE,Medtronic,andBolton.JonathanW.Weinsaft,
MD,receivedaresearchgrant fromLantheusMedical Imaging.
AttentionASEMembers:
TheASEhasgonegreen!Visitwww.aseuniversity.orgtoearnfreecontinuing
medical education credit through anonline activity related to this article.
Certificatesareavailableforimmediateaccessuponsuccessfulcompletion
of theactivity. Nonmembers willneedtojointhe ASEtoaccessthisgreat
memberbenefit!
Reprintrequests:AmericanSocietyofEchocardiography,2100GatewayCentre
Boulevard,Suite310,Morrisville,NC27560(E-mail:ase@asecho.org).
0894-7317/$36.00
Copyright2015bytheAmericanSocietyofEchocardiography.
http://dx.doi.org/10.1016/j.echo.2014.11.015
119
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2. Geometry of Different
AorticSegments:
ImpactonMeasure-
ments
126
a. Aortic
Annulus
126
b. Sinuses of Valsalva
andSTJ
126
c. Ascending Aorta and
MoreDistalSeg-
ments
126
C. Aortic Physiology and
Function
127
1. Local Indices of Aortic
Function
127
2. Regional Indices of
AorticStiffness:Pulse-
waveVelocity
(PWV)
128
II. ImagingTechniques
129
A. Chest X-Ray (CXR)
129
B. TTE
129
C. TEE
130
1. Imaging
of
the
Aorta
130
D. Three-Dimensional Echo-
cardiography
131
E. Intravascular Ultrasound
(IVUS)
131
1. Limitations
131
F. CT
131
1. Methodology
132
a. CTA
132
i. Noncontrast
CT
beforeAortog-
raphy
133
ii. Electrocardiograph-
icallyGated
CTA
133
iii. Thoracoabdominal
CTafterAortog-
raphy
133
iv. Exposure
to
IonizingRadia-
tion
134
v. Measure-
ments
134
G. MRI
135
1. Black-Blood
Se-
quences
135
2. Cine
MRI
Se-
quences
135
3. FlowMapping
135
4. Contrast-EnhancedMR
Angiography
(MRA)
135
5. Artifacts
136
H. Invasive
Aortog-
raphy
136
I. ComparisonofImagingTechniques
137
III. Acute AorticSyndromes
138
A. Introduction
138
B. AorticDissection
138
1. ClassificationofAorticDissection
138
2. Echocardiography(TTEandTEE)
139
a. EchocardiographicFindings
140
b. DetectionofComplications
141
c. LimitationsofTEE
141
3. CT
141
4. MRIofAorticDissection
143
5. ImagingAlgorithm
144
6. UseofTEEtoGuideSurgeryforTypeAAorticDissection
144
7. Use of Imaging Procedures to Guide Endovascular Ther-
apy
146
8. SerialFollow-UpofAorticDissection(ChoiceofTests)
147
9. PredictorsofComplicationsbyImagingTechniques
148
a. MaximumAorticDiameter
148
b. PatentFalse Lumen
148
c. PartialFalseLuminalThrombosis
149
d. EntryTearSize
149
e. TrueLuminalCompression
149
10. Follow-UpStrategy
149
C. IMH
149
1. Introduction
149
2. ImagingHallmarksandFeatures
149
3. ImagingAlgorithm
151
4. SerialFollow-UpofIMH(ChoiceofTests)
151
5. PredictorsofComplications
151
D. PAU
151
1. Introduction
151
2. ImagingFeatures
151
3. ImagingModalities
152
a. CT
152
b. MRI 152
c. TEE
152
d. Aortography
152
4. ImagingAlgorithm
153
5. SerialFollow-UpofPAU(ChoiceofTests)
153
IV. ThoracicAorticAneurysm
153
A. DefinitionsandTerminology
153
B. ClassificationofAneurysms
154
C. Morphology
154
D. SerialFollow-UpofAorticAneurysms(ChoiceofTests)
154
1. AlgorithmforFollow-Up
155
E. UseofTEEtoGuideSurgeryforTAAs
155
F. SpecificConditions
156
1. MarfanSyndrome
156
a. Aortic Imaging in Unoperated Patients with Marfan Syn-
drome
156
b. PostoperativeAorticImaginginMarfanSyndrome
157
c. PostdissectionAorticImaginginMarfanSyndrome
157
d. FamilyScreening
157
2. OtherGeneticDiseasesoftheAortainAdults
157
a. TurnerSyndrome
157
b. Loeys-DietzSyndrome
157
c. FamilialTAAs
157
d. Ehlers-DanlosSyndrome
157
3. BAV-RelatedAortopathy
157
a. BicuspidValve–RelatedAortopathy
157
b. ImagingoftheAortainPatientswithUnoperatedBAVs
158
c. Follow-Up Imaging of the Aorta in PatientswithUnoperated
BAVs
158
d. Postoperative Aortic Imaging in Patients with BAV-Related
Aortopathy
158
e. FamilyScreening
159
V. TraumaticInjurytotheThoracicAorta
159
A. Pathology
159
B. ImagingModalities
160
1. CXR
160
2. Aortography
160
3. CT
160
Abbreviations
AAS
=Acuteaorticsyndrome
AR
=Aorticregurgitation
ASE
=AmericanSocietyof
Echocardiography
BAI
=Bluntaorticinjury
BSA
=Bodysurfacearea
CT
=Computedtomography
CTA
=Computed
tomographicaortography
CXR
=Chestx-ray
EACVI
=European
AssociationofCardiovascular
Imaging
EAU
=Epiaorticultrasound
GCA
=Giant-cell(temporal)
arteritis
ICM
=Iodinatedcontrast
media
IMH
=Intramuralhematoma
IRAD
=InternationalRegistry
ofAcuteAorticDissection
MDCT
=Multidetector
computedtomography
MIP
=Maximum-intensity
projection
MR
=Magneticresonance
MRI
=Magneticresonance
imaging
PWV
=Pulsewavevelocity
STJ
=Sinotubularjunction
TA
=Takayasuarteritis
TEE
=Transesophageal
echocardiography
TEVAR
=Transthoracic
endovascularaorticrepair
3D
=Three-dimensional
TTE
=Transthoracic
echocardiography
2D
=Two-dimensional
ULP
=Ulcerlikeprojection
120 Goldsteinetal
JournaloftheAmericanSocietyofEchocardiography
February2015
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4. TEE
161
5. IVUS
161
6. MRI
162
C. ImagingAlgorithm
162
D. ImaginginEndovascularRepair
162
VI. AorticCoarctation
162
A. Aortic Imaging in Patients with Unoperated Aortic Coarcta-
tion
163
B. PostoperativeAorticImaginginCoarctation
164
VII.Atherosclerosis
164
A. PlaqueMorphologyandClassification
164
B. ImagingModalities
165
1. Echocardiography
165
2. EpiaorticUltrasound(EAU)
165
3. CT
166
4. MRI
166
C. ImagingAlgorithm
166
D. SerialFollow-UpofAtherosclerosis(ChoiceofTests)
167
VIII.Aortitis
167
A. MycoticAneurysmsoftheAorta
167
B. NoninfectiousAortitis
168
IX. PostsurgicalImagingoftheAorticRootandAorta
169
A. WhattheImagerNeedstoKnow
169
B. CommonAorticSurgicalTechniques
169
1. InterpositionTechnique
169
2. InclusionTechnique
169
3. CompositeGrafts
169
4. AorticArchGrafts
169
5. ElephantTrunkProcedure
169
6. CabrolShuntProcedure
170
7. TechnicalAdjuncts
170
C. NormalPostoperativeFeatures
170
D. ComplicationsafterAorticRepair
170
1. Pseudoaneurysm
170
2. FalseLuminalDilatation
170
3. InvolvementofAorticBranches
171
4. Infection
171
E. RecommendationsforSerialImagingTechniquesand
Schedules
171
X. Summary
171
NoticeandDisclaimer
171
References
171
PREAMBLE
Aorticpathologiesarenumerous,presentingmanifestationsarevaried,
andaorticdiseasespresenttomanyclinicalservices,includingprimary
physicians,emergencydepartmentphysicians,cardiologists,cardiacsur-
geons, vascular surgeons, echocardiographers, radiologists, computed
tomography (CT) and magnetic resonance (MR) imaging (MRI) im-
agers, andintensivists. Many aorticdiseasesmanifestemergently and
are potentially catastrophic unless suspected and detected promptly
andaccurately.Optimalmanagementoftheseconditionsdependson
thereported findingsfrom ahandfulofimagingmodalities, including
echocardiography,CT,MRI,andtoalesserextentinvasiveaortography.
Inthepastdecade,therehavebeenremarkableadvancesinnonin-
vasiveimagingofaorticdiseases.Thisdocumentisintendedtoprovidea
comprehensivereviewoftheapplicationsofthesenoninvasiveimaging
modalitiestoaorticdisease.Emphasisisontheadvantagesanddisad-
vantagesofeachmodalitywhenappliedtoeachofthevariousaortic
diseases. Presently, there isa lack of consensus on the relative role
(comparative effectiveness) of these imagingmodalities. Anattempt
has been made to determine first-line and second-line choices for
some ofthesespecific conditions. Importantly, wehaveemphasized
the need for uniform terminology and measurement techniques.
Whenever possible, these recommendations are evidence based,
followingacriticalreviewoftheliterature.Insomeinstances,therecom-
mendationsreflectaconsensusoftheexpertwritinggroupandinclude
‘‘vetting’’byadditionalexpertsfromthesupportingimagingsocieties.
Becauseoftheimportanceofpromptrecognitiontotheirsuccessful
treatment,thisreviewemphasizesacuteaorticsyndromes(AAS),such
asaorticdissectionanditsvariants(e.g.,intramuralhematoma[IMH]),
rupture ofascendingaorticaneurysm,aortictrauma, andpenetrating
ulcer.Otherentities,suchasTakayasuaortitis(TA),giant-cell(temporal)
arteritis(GCA),andmycoticaneurysm,arediscussedbriefly.Lesscom-
monaorticdiseasessuchasaortictumors(becauseoftheirrarity)and
congenitalanomaliesofthecoronaryarteries,aorticarch,andsinusof
Valsalva aneurysms are not addressed. Several other topics are also
beyondthescopeofthisreview,includingtheimportantandemerging
roleofgeneticsintheevaluationandmanagementofaorticdiseases.
Moreover,thisdocumentisnotintendedtoreplaceorextendtherec-
ommendationsof prior excellent guidelines in decision making and
managementfortheseconditions.
1
Tosummarize,thefocusofthisdocumentisthefundamentalrole
of themajor noninvasive imagingtechniques. Inaddition toclinical
acumen and suspicion, knowledge of these imaging modalities is
crucial for the assessment and management of the often life-
threateningdiseasesoftheaorta.
I.ANATOMYANDPHYSIOLOGYOFTHEAORTA
A.The NormalAortaandReference Values
Theaortaisthelargestandstrongestarteryinthebody;itswallconsists
ofthreelayers:thethininnerlayerorintima,athickmiddlelayerorme-
dia,andaratherthinouterlayer,oradventitia.Theendothelium-lined
aorticintimaisathin,delicatelayerandiseasilytraumatized.Themedia
is composed of smooth muscle cells and multiple layers of elastic
laminae that provide not only tensile strength but also distensibility
andelasticity,propertiesvitaltotheaorta’scirculatoryrole.Theadven-
titia contains mainly collagen as well as the vasa vasorum, which
nourishtheouterhalfoftheaorticwallandamajorpartofthemedia.
Theelasticpropertiesoftheaortaareimportanttoitsnormalfunc-
tion.Theelasticityofthewallallowstheaortatoacceptthepulsatile
output of the left ventricle in systole and to modulate continued
forward flow during diastole. With aging the medial elastic fibers
undergo thinning and fragmentation. The ordinary concentric
arrangementofthelaminaeisdisturbed.Thesedegenerativechanges
areaccompaniedbyincreasesincollagenandgroundsubstance.The
lossofelasticityandcomplianceoftheaorticwallcontributestothe
increase in pulse pressure commonly seen in the elderly and may
beaccompaniedbyprogressivedilatationoftheaorta.
A geometrically complex organ, the aorta begins at the
bulb-shapedroot (level 1inFigure1) andthen coursesthroughthe
chestandabdomeninacandycane–shapedconfiguration,withavar-
iableorientationtothelongaxisofthebody,untilitterminatesinthe
iliacbifurcation. Theaortaconsistsof fivemainanatomicsegments:
theaorticroot,thetubular portionofthe ascendingaorta,theaortic
arch, the descending thoracic aorta, and the abdominal aorta. The
mostproximalpart ofthe ascendingaorta,the aorticroot(segment
IinFigure 1), includesthe aortic valve annulus, aortic valve cusps,
JournaloftheAmericanSocietyofEchocardiography
Volume28Number2
Goldsteinetal 121
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coronary ostia, and sinuses of Valsalva. Distally the root joins the
tubularportionoftheascendingaorta(segmentII)ataneasilyrecog-
nized landmark termed the sinotubular junction (STJ). The tubular
portionofthe ascending aortaextendsfromtheSTJ tothe originof
thebrachiocephalicartery.Thisrelativelylongsegmentissubdivided
intosegmentIIa,whichextendsfromtheSTJtothepulmonaryartery
level,andsegmentIIb,fromthepulmonaryarteryleveltothebrachio-
cephalic artery.The aortic arch (segment III) extendsfrom the bra-
chiocephalic artery to the left subclavian artery. The descending
thoracic aorta (segment IV) may be subdivided into the proximal
part(segmentIVa),whichextendsfromthe leftsubclavianarteryto
the level ofthepulmonary artery,andthedistalpart(segmentIVb),
which extends from the level of the pulmonary artery to the dia-
phragm. The abdominal aorta (segmentV)maybesubdivided into
the proximalpart(segmentVa),whichextendsfromthediaphragm
to the ostia of the renal arteries, and the distal part (segment Vb),
fromtherenalarteriestotheiliacbifurcation.
1.Normal AorticDimensions. Becauseoftheeasewithwhichit
can be visualized and its clinical relevance,
2,3
the aortic root is the
segment for which the greatest amount of data are available.
Severallarge studieshave reportednormal aorticroot diametersin
theparasternallong-axisviewbytwo-dimensional(2D)transthoracic
echocardiography (TTE).
4-10
Measurement of the aortic root
diametershouldbe madeperpendicular tothe axisof theproximal
aorta, recorded from several slightly differently oriented long-axis
views. The standard measurement is taken as the largest diameter
fromtherightcoronarysinusofValsalvatotheposterior(usuallynon-
coronary) sinus. Most studiesreport aortic root diameter measure-
ments at end-diastole using the leading edge–to–leading edge
technique(Figure2).
Inadults,aorticdimensionsarestronglypositivelycorrelatedwith
age
5-8,10,11
and body size.
4-6,8,10,11
They are larger in men than in
women of the same age and body size.
6,12,13
Although in several
reports, aortic diameters have been normalized to body surface
area (BSA),
10,13,14
this approach has not been entirely satisfactory
because it is systematically lower in smaller than in larger normal
adults. Fortunately, among children, the regression line of aortic
diameterand height (ratherthanBSA)hasa near-zerointercept,so
thatnormalizationtoheighthasprovedtobe asimpleandaccurate
alternative in growing children.
15
Benchmark values from which
the guidelines have been taken
1,16
come from the work of
Roman et al.,
9
whoreported normal root dimensionsfor three age
groups(Figure3).
Theupper limitofnormal aorticdiameterhasbeen defined as2
SDsgreaterthanthemeanpredicteddiameter.TheZscore(thenum-
berofSDsaboveorbelowthepredictedmeannormaldiameter)isa
useful way to quantify aortic dilatation. Among normal subjects,
95.4%haveZscoresbetween2and2.Therefore,anaorticdiam-
eter canbeconsidereddilatedwhen theZscoreis$2.Usingthe Z
score allows comparison of a given patient’saortic size at different
timepoints,accountingfortheeffectsofadvancingageandincreasing
Figure 2 Transthoracic echocardiogram m in n the parasternal
long-axisview(zoomedonaorticrootandascendingaorta)illus-
trating measurement of the aortic root diameter at sinus of
Valsalvalevelatend-diastoleusingtheleadingedge–to–leadin-
g-edgemethod.ascAo,Ascendingaorta;LVOT,leftventricular
outflow tract.
Figure 1 CT reconstruction of f a normal l aorta a illustrating g its
segmentation as follows:segment I=aorticroot;segment II =
tubular ascending aorta(subdivided intoIIa[STJto thepulmo-
nary artery level]and IIb [fromthepulmonary artery leveltothe
brachiocephalic artery]); segment III = aortic arch; segment
IV = descending thoracic aorta (subdivided into IVa [from the
left subclavian artery to thelevel ofthepulmonary artery] and
IVb [from thelevel of the pulmonary artery to thediaphragm]);
and segment V =abdominal aorta (subdivided into Va [upper
abdominalaorta fromthediaphragm to the renal arteries] and
Vb[fromtherenalarteries totheiliacbifurcation]).
122 Goldsteinetal
JournaloftheAmericanSocietyofEchocardiography
February2015
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bodysize,thusdistinguishingnormalfrompathologicgrowth.TheZ
scoreisthereforeparticularlyusefulfor evaluatinggrowingchildren.
It should be mentioned that aortic root dimensions may be
increased by the hemodynamic effects of both endurance and
strength exercise training in competitive athletes.
17-19
This aortic
root enlargement appears to be greater at the sinuses of Valsalva
than at the aortic annulus or STJ. However, it should be
emphasized that theeffectsof exercise training on aorticdiameters
are relatively small and that marked enlargement should suggest a
pathologicprocess.
17,18
Recently,makinguseofadatabaseconsistingofamultiethnicpop-
ulationof1,207apparentlynormaladolescentsandadults$15years
ofage,investigatorsdevisedequationstopredictmeannormalaortic
root diameter anditsupper limitbyage,body size(BSAorheight),
andgender
6
(Table1formenandTable2forwomen).Theseequa-
tionshavebeenusedgraphicallytodepicttheupperlimitsofthe95%
confidenceintervalfor normalaorticrootdiameterusingsurfacesto
depictthe interactingeffectsof age andbody size (seeFigure4 for
menandFigure5 forwomen).
A noncontrast gated cardiac computed tomographic study,
20
including4,039adultpatients,showedage,BSA,gender,andhyper-
tension to be directly associated with thoracic aortic diameters
perpendicular to the long axis of the aorta. These associations are
concordant with those from echocardiographic studies. In another
recentlargestudyusingsimilarmethodology,themeanvalueofthe
diametersoftheascendingaortawas1.860.2cm/m
2
andofthede-
scendingthoracicaortawas1.460.2cm/m
2
,withtheupperlimitsof
normalbeing2.1and1.8cm/m
2
,respectively.
21
However,moreac-
curatenormalvaluesofthoracicaorticdiametersmaybeobtainedby
anatomically correct double-oblique short-axisimagesusingelectro-
cardiographically gated multidetector CTor by MRI of axially ori-
ented aortic segments. The upper limits of normal are 3.7 cm for
the aortic root at the sinuses, 3.6 cm for the ascending aorta and
2.5 cm for the descending thoracic aorta by CT,
8
and 2.5 cm for
the descending thoracicaorta and2.0 cm for theupper abdominal
aortabyMRI.
22
Aswithechocardiography,aorticrootandascending
aorticdiametersincreasesignificantlywith ageand BSAon CTand
MRI. Aortic root diameters increase 0.9 mm per decade in men
and0.7mmperdecadeinwomen.
4
Theestablishmentofnormative valuesandreferenceranges, tak-
ing intoaccount aging andgender, isofgreat importance for diag-
nosis, prognosis, serial monitoring, and determining the optimal
timingforsurgicalintervention.Normalvaluesandproximalaorticdi-
ametershavebeenreportedusingdifferentimagingtechniques,from
thepioneerstudiesbasedonM-modeand2Dechocardiography
9,10
to more recent studies obtained using CT
7,8,20,23-25
and MRI.
5,26
Despite differences in image acquisition methods, temporal and
spatialresolution,andsignal-to-noiseratios,CT,MRI,TTE,andtrans-
esophagealechocardiography(TEE)haveevolvedasnearequalstan-
dards for assessing aortic root size. Each of these modalities has
Table2 Normalaorticrootdiameterbyageforwomenwith
BSAof1.7m
2
Age(y)
15–29 30–39 40–49 50–59 60–69 $70
Meannormal(cm)
2.9
3.0
3.2
3.2
3.3
3.4
Upperlimitofnormal
(cm)
3.3
3.4
3.6
3.6
3.7
3.9
Add0.5mmper0.1m
2
BSA above1.7m
2
orsubtract0.5 mmper
0.1m
2
BSAbelow1.7m
2
.
6
Figure3 Aorticrootdiameter(verticalaxis)inrelationtoBSA(horizontalaxis)inapparentlynormalindividualsaged1to15(leftpanel,
blue),20to39(centerpanel,green),and$40(rightpanel,pink)years.Forexample,anindividualbetweentheagesof20and39years
(centerpanel,green)whohasaBSAof2.0m
2
(verticalgreenline)hasanormalrootdiameterrange(2SDs)between2.75and3.65cm,
asindicated bytheintersections ofthetwo horizontalgreenlineswiththegreen-shaded parallelogram.
Table1 NormalaorticrootdiameterbyageformenwithBSA
of2.0m
2
Age(y)
15–29
30–39
40–49
50–59
60–69
$70
Meannormal(cm)
3.3
3.4
3.5
3.6
3.7
3.8
Upperlimitofnormal
(cm)(95%CI)
3.7
3.8
3.9
4.0
4.1
4.2
Add0.5mm per0.1m
2
BSAabove 2.0 m
2
orsubtract0.5mm per
0.1m
2
BSAbelow2.0m
2
.
6
CI,Confidenceinterval.
JournaloftheAmericanSocietyofEchocardiography
Volume28Number2
Goldsteinetal 123
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advantagesanddisadvantages,whichhave beendiscussed.Itshould
be emphasized that normal aorticdiametersvary systematically by
age,gender,andbodysize,andreferencevaluesindexedtothosepa-
rametershavebeenprovided.Last,itiscriticallyimportanttoempha-
sizenotonlymethodologicvariancebutalsointer-andintraobserver
variability.Inseveralstudies,variability ofmeasurementofproximal
aortic diameters ranges from 1.6 to 5 mm.
8,23,24,27,28
Given this
degree of variability, apparent small changes in proximal aortic
diameters on serial computed tomographic examinations may be
withintherangeofmeasurementerror.Accordingly,for all imaging
techniques, we recommend that changes of #3 mm
by
electrocardiographically gated
CT and #5
mm
without
electrocardiographicgatingbeviewedwithcautionandskepticism.
B.HowtoMeasure theAorta
Accurate andreproducible measurements of aortic dimensions are
necessary for the detection and classification of aortic disease and
forguidingtherapeuticdecisions.Modernimagingmodalitiesenable
one to make measurements far more accurately than did invasive
contrastangiography,theonlytooloriginallyavailable.
Echocardiography,CT,andMRIeachhasparticularstrengthsand
limitationsbutcanbeadaptedfortheacquisitionofviewsthatallow
measurementofthediameterorcross-sectionalareaofdifferentseg-
mentsoftheaorta(Figure1).
1. Interface, Definitions, and
Timing
of
Aortic
Measurements. The American Society of Echocardiography
(ASE) proposed standards for measurement of the aortic root in
1978.
29
The ASErecommendedmeasurementatend-diastolefrom
the leadingedgeoftheanterior rootwalltotheleadingedge ofthe
posterior aorticroot wall.This technique wasbelieved to minimize
the impact of ‘‘blooming’’ofbright reflectorsonthismeasurement.
The ASE-recommended method wasfollowed in many important
clinical and epidemiologic studies
10,13
that have reported normal
limits for individuals of differing body size and age, and these
normal limits have been incorporated into multiple guidelines for
imaging in adults (Figures4 and5).
1,9,16
As a consequence, much
of the available data on normal aortic root size as well as on the
prevalence andprognostic significance of aorticdilatation in adults
haveemergedfrom echocardiography.
6,10,13
Societal guidelines for measurement by CT or MRI are not
currently available. Consequently, uniformity in measurement
methodsislacking.Manyresearchandclinicalstudiesusingthesemo-
dalitieshavereportedaorticmeasurementsmadefrominneredgeto
inneredgeonelectrocardiographicallygatedornongatedimages.The
2010guidelinesforthediagnosisandmanagementofthoracicaortic
diseasetooktheoppositeapproach,recommendingmeasurementof
aorticdiameter betweenexternal surfacesto avoid confounding by
intraaortic thrombus or atheroma, as is commonly found in the
abdominal butnotintheascendingaorta.
1
Furthermore,thereisno
standardized ‘‘trigger time’’ (end-systole vs end-diastole) for image
acquisition. Thus, the use of multiple imaging modalities such as
CT, MRI, and 2D and three-dimensional (3D) echocardiography
has led to nonuniformity in measurement techniques. Moreover,
there is currently no standardized approach for reconciling aortic
measurements across imaging modalities (echocardiography, CT,
MRI, aortography) by trigger time (end-systole vs end-diastole) or
byedgeselection(leadingedge,inner-inner,outer-outer).Thiswriting
committeehadhopedtorecommendauniformandconsistentmea-
surementtechniquetominimizedifferencesamongthesevariousim-
aging modalities. However, after much consideration, the group
recommendsthat echocardiographic measurementscontinue to be
madein the standardfashionfrom leading edgetoleadingedge, at
end-diastole, and perpendicular to the long axis of the aorta. The
advantagesofend-diastolicmeasurementsincludegreater reproduc-
ibility(becauseaorticpressureismoststableinlatediastole)andthe
ease of identification of end-diastole by the onset of the QRS
Figure 5 Surfacesrepresentingaorticdiameters1.96Zscore
(95% confidence interval) above the predicted mean value of
aorticdiameter for ageand BSA in femalesubjects $15 years
ofage.(AdaptedfromDevereuxetal.
6
)
Figure 4 Surfaces representing g aortic diameters s at t a 1.96 Z
score(95% confidenceinterval) above thepredicted mean for
age and BSA in male subjects $15 years of age. (Adapted
fromDevereuxetal.
6
)
124 Goldsteinetal
JournaloftheAmericanSocietyofEchocardiography
February2015
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Figure6 Modelsofthethoracicaortashowingthecutplanesoftheaorticannulusforeachappliedimagingmodality.(A)Angiog-
raphy inthe90 leftanterioroblique(LAO)projectionwith anorangearrow indicating thesagittalannulusdiameter (left) andinthe
0
posteroanterior(p.a.)projectionwithabluearrowindicatingthecoronalannulusdiameter (right).(B)TTE(left) and2DTEE(right)
leftventricularoutflowtract(LVOT)viewoftheaorticannulus.Thecutplanesslightlydifferbecauseparasternalandmidesophageal
acoustic are not quite comparable. Both the transthoracic and 2D transesophageal echocardiographic LVOT views resemble a
sagittalview (brightanddarkyellow arrows,respectively).Thedirectionofthearrowsintheaorticarchmodelandtheechocardio-
graphic images indicate the scanning direction. Individual adjustments in scan plane direction are shown in the model. (C)
Three-dimensionaltransesophageal echocardiographic cropped images of asagittal(left) and coronal (right) view with thecorre-
sponding diameters (orangeand bluearrows). The sagittal and coronalcut planes aredepicted in the aortic archmodel and the
anatomicshort-axisview(middle).(D)Dual-sourcecomputedtomographic(DSCT)reconstructed imagesofasagittal(left)andcor-
onal(right)viewwiththecorrespondingdiameters(orangeandbluearrows).Thesagittalandcoronalcutplanesaredepicted inthe
aorticarchmodeland theanatomicshort-axisview (middle).AO,Ascendingaorta;LA,leftatrium.(FromAltioketal.
418
)
JournaloftheAmericanSocietyofEchocardiography
Volume28Number2
Goldsteinetal 125
complex. Although other techniques use the inner edge–to–inner
edge approach, there are currently insufficient data to warrant a
changeforechocardiography.Availabledatasuggestthattheechocar-
diographicleadingedge–to–leadingedge approachproducesvalues
comparable with thoseproduced by the inner edge–to–inner edge
approachonCTandMRI,isreproducible,andlinkstoalargebody
ofhistoricalandprognosticdatathathavelongguidedclinical deci-
sionmaking.
Forallmodalities,itisdesirable,wheneverpossible,tospecifythe
locationsofmeasurements,byreferencingthemtoagivenlandmark.
Forexample,withTEE,ameasurementofthemaximaldiameterof
the ascending aorta may be reported by its distance from the STJ.
Inthe descendingthoracicaorta,referencetothelocationofamea-
surementor abnormalityisusuallymadebyitsdistancefrom thein-
cisors. Similar attempts should be made for measurements and
findingswithCTandMRI.
2. Geometry of Different Aortic Segments: Impact on
Measurements. Accurateandreproduciblemeasurementofaortic
diameter or cross-sectional area in a given segment requires three
measurements of its diameter perpendicular to the long axis. In
mostcases,thelargestcorrectlyorientedmeasurementisreported.
a.AorticAnnulus.–Althoughtheaorticannulusisapproximatelycir-
cular inchildrenandyoungadults,itmay becomeelliptical inolder
adults.Thus,3DimagingbyCTorechocardiographyor2Dimaging
in multiple planes (e.g., long-axis or sagittal and coronal planes) is
requiredtomeasurea diameter thatisaccurate enoughtobe used
when selecting patients for transcatheter aortic valve replacement
(Figure6).
b. Sinuses of Valsalva and STJ.–Aortic root diameter can be
measuredperpendiculartoitslongaxisby2Dechocardiographyor
inanalogousnontrue coronaland sagittalplaneby MRIor CT. The
variability inthismeasurement resulting fromthe orientationofthe
aorticroot isovercome bychoosing the largest diameter measured
fromtherightcoronarysinusofValsalvatotheposterior(usuallynon-
coronary)sinus,paralleltotheaorticannulusandperpendiculartothe
longaxisoftheproximalaortainseveralslightlydifferently oriented
long-axis views. Failure to search for the largest correctly oriented
measurement can lead to underestimation of aortic root diameter.
AorticrootdiameteriscommonlymeasuredbyCTorMRIbetween
the inner edges from commissure to opposite sinus (Figure 7).
Diametersmeasuredusingthesinus-to-sinusmethodaregenerallya
mean of 2 mm larger than those measured by the sinus-to-
commissure method
4,7
(Figure8).However,usingthesinus-to-sinus
methodhasseveral advantages,includingtheease ofdetectingcusp
margins incomputed tomographic or MRI transverse planes, close
agreementwithechocardiographicmeasurements,andgreaterfeasi-
bility in bicuspid valves. Thus,for aortic measurements by CTand
MRI,itisrecommendedtoaveragethethreesinus-to-sinusmeasure-
mentsinend-diastoleinthesinus-of-Valsalvaplane.Whenthesinuses
are unusually asymmetric, it may be preferable to report the three
measurementsindividually.
c. Ascending Aortaand MoreDistalSegments.–Thesame basic
principlesapplytoobtainingcorrectmeasurementsoftheotheraortic
segments.Conventionalimagingbyallmodalitiesandtechniquescan
beusedtomeasurethediameterofaorticsegmentsthatareoriented
alongthelongaxisofthebody.However,thenecessitytoavoidob-
liqueimagingthatcanoverestimatetheaorticdiameterappliestothe
Figure 7 AorticrootmeasurementsbyCT.Theaorticrootdiameteriscommonlymeasuredbetween theinneredgesfromone
commissuretooppositesinus(yellowline)orfromonesinustoanothersinus(redline),as showninthelargeimage(left),whichis
azoomed cross-sectionalview oftheaorticrootatthesinus ofValsalvalevelusing adoubleobliqueimagefororientation(shown
intherightpanel).
126 Goldsteinetal
JournaloftheAmericanSocietyofEchocardiography
February2015
aorticarchandtoportionsofthedescendingthoracicandabdominal
aortathatmaytakeatortuouscourse(Figure9).
Weemphasizethatthereisnostandardizedmethodformeasuring
the aorta across imaging modalities (echocardiography, CT, MRI,
aortography).Althoughoneofthemajorgoalsofthiswritingcommit-
tee was to provide a uniform and universally accepted method to
minimize differences among these various imaging modalities, no
consensuscouldbe reached.After muchconsideration,it isrecom-
mended that echocardiographic measurements continue to be
madefromleadingedgetoleadingedge.Althoughothertechniques
use inner edge–to–inner edge or outer edge–to–outer edge
approaches,therearecurrentlyinsufficientdatatowarrantachange
for echocardiography. Available data suggest that the echocardio-
graphicleadingedge–to–leadingedgeapproachgiveslargermeasure-
mentscomparedwiththeinneredge–to–inneredgeapproachonCT
(average difference, 2 mm), and the leading edge–to–leading edge
methodlinkstoalargebodyofhistoricaland,moreimportant,prog-
nosticdatathatinfluencedecisionmaking.
8
Outofconcernthatpa-
tient management might be adversely affected (i.e., intervention
might be delayed, leading to a catastrophic complication such as
rupture or dissection) by switching to a new protocol that would
leadtoasmallermeasurement,itwasdecidedtocontinuetorecom-
mendtheleadingedge–to–leadingedgeapproach.
C.Aortic PhysiologyandFunction
Theaortafunctionsasbothaconduitandareservoir.Itselasticprop-
ertiesallow it to expandin systoleand recoil during diastole. Thus,
under normal conditions,alargeproportion(upto50%) ofthe left
ventricular stroke volume is stored in the aorta (mainly in the
ascendingaorta)atend-systole,andthestoredbloodisthenpropelled
forwardduringdiastoleintotheperipheralcirculation.Thisreservoir
functionisimportantformaintainingbloodflowandarterialpressure
throughoutthe cardiaccycle. The thoracic aortaismoredistensible
than the abdominal aorta because its media contains more elastin.
Aortic distensibility declines with age and as a result of premature
degeneration in elastin and collagen associated with some disease
states.
30
Duringleftventricularsystole,thislossofaorticwallcompli-
anceresultsinincreasedsystolicpressureandpulsepressureand,in
turn,aorticdilatationandlengthening.Thecompliance oftheaortic
wallmaybeestimatedbyassessingchangeinaorticvolumeinrelation
to the simultaneouschangeinaorticpressure.Thismay beassessed
locally bydiameteror areachangethroughthe cardiaccycleinrela-
tiontopressurechange(e.g.,distensibility)orregionallybydetermina-
tionofthevelocityofthepulsewave.
1. Local Indices of Aortic Function. Techniques that provide
accurate definitionoftheaorticdiameteror volumeinsystoleand
diastole canbeusedtoevaluatetheelasticpropertiesofthe aorta.
Themostcommonlyappliedindicesfor clinicalpurposesareaortic
distensibility and the stiffness index, which is less dependent on
blood pressure. Aortic distensibility andthe stiffness index can be
determined from the changesin the aortic diameter from systole
to diastole and from changes in the arterial pressure using the
followingformula:
Distensibility
103$mmHg
1
¼
Area
systole
Area
diastole
Area
diastole
$Pulsepressure
$1;000:
For these calculations, the pulse pressure should be measured
ideallyatthesamelevel ofthe aortaatwhichthe aorticdiameter is
Figure9 Diagramillustratingthepotentialpitfallofobtainingan
obliquecutresultinginan‘‘ellipsoid’’cross-sectionthatoveres-
timatesthetruediameter.Thisisespeciallyaproblemwhenthe
descending aortaistortuous.
Figure8 Computedtomographicscanimageofaorticrootillus-
trates that the mean difference of the aortic root diameter is
about 2 mmlarger measured by the anteroposterior diameter
(sinus-sinus) shown by red arrow
than by the sinus-
commissurediameter(blackarrow).
JournaloftheAmericanSocietyofEchocardiography
Volume28Number2
Goldsteinetal 127
measured.Inclinicalpractice,however,brachialarterypressure can
beused,eventhoughthepulsepressureobtainedfrom thebrachial
artery may be slightly higher than that obtained from the aorta
because ofthe amplificationphenomenon,whichis moreapparent
inyoungindividuals.
31
2.Regional Indices ofAortic Stiffness:Pulsewave Velocity
(PWV). PWVisdefinedasthelongitudinalspeedofthepulsewave
in the aorta. PWVisinversely relatedtoaorticelasticity.Hence, a
stiffer aorta will conduct the pulsewave faster than a more
compliant aorta. Central pressure, at the level of the ascending
aorta, is produced asa combination of the antegrade wave from
theleftventricleandtheretrograde‘‘reflective’’wavesfromthepe-
riphery.Inyoungindividuals,becausetheaortaismoreelastic,the
pulsewave speedislow,sotheretrogradeflow arrivesintheprox-
imalaortaduringdiastole.Asaresult ofaorticstiffening,thePWV
increases, and the retrograde flow arrives in the proximal aorta
earlier in systole, leading to a greater LVafterload and decreased
diastolicpressure.
ReportednormalvaluesforinvasivelydeterminedPWVmeasure-
mentsinmiddle-agedhumansare4.460.4m/secintheaorticroot,
5.3 6 0.2 m/sec in the proximal descending thoracic aorta,
5.7 6 0.4 m/sec in the distal thoracic descending aorta,
5.7 6 0.4 m/sec in the suprarenal abdominal aorta, and
9.260.5m/secintheinfrarenalaorta.
32
Carotid-femoral PWV is considered to be the gold-standard
measureofarterialstiffness, especiallybecauseitissimpletoobtain
and because multiple epidemiologic studies have demonstrated its
predictivevaluefor cardiovascularevents.However,theabilityofa
givenindividual’sPWV value to predictaorticeventshas notbeen
previously evaluated.
33
A recent expert consensus adjusted this
thresholdvalueto10m/secbyusingthedirectcarotid-to-femoraldis-
tance.
34
ThemainlimitationofPWVinterpretationisthatitissignif-
icantly influencedby arterialbloodpressure.Multimodalityimaging
techniques provide a unique opportunity to assess aortic PWV by
theformula:
AorticPWVðm=secÞ¼
DistanceðmmÞ
TransittimeðmsecÞ
:
Echocardiography can accurately estimate the transit time be-
tween aorticlevelsby the subtractionofthetimebetweena fixed
reference in the QRS complex and the beginning of the flow at
thetwolevelsstudied.Distancecanbegrosslyestimatedexternally
withatape.
MRIcanmeasurethePWVusingthetransittimeoftheflowcurves
from aphase-contrastacquisition.Transit time can be calculated by
theupslopeapproach,whichhasbeendescribedpreviouslyandcor-
relatesmore withageandaorticstiffnessindicesthanpoint-to-point
approaches such as foot-to-foot and half-maximum methods.
35
Distance can accurately be measuredatthe centerline of the aorta
betweenaorticlevelsstudied.
Anormal-sizeaortamaybefunctionallyabnormal.Thus,determi-
nationofaorticfunctionmayhelpdefinethenatureoftheunderly-
ing disease and give prognosticinformation insome diseases.This
wasemphasizedbyVrizetal.,
4
whostatedthataorticstiffnessshould
be taken into account when increases in aortic diameter are de-
tected.
Insummary, aortic biophysical properties canbeeasilyandreli-
ablyassessedbyimagingtechniques,particularlyDopplerechocardi-
ography and phase-contrast MRI. This evaluation may provide
Table3 PlainCXRfindingsinaorticdissection
1. Mediastinalwidening
2. Abnormalitiesinregionofaorticknob
1. Enlargement(expansionofaorticdiameter)
2. Presenceofdoubledensity(duetoenlargementoffalse
lumen)
3. Irregularcontour
4. Blurredaorticknob(indistinctaorticmargin)
3. Displacementofintimalcalcium
4. Discrepancyindiametersofascendinganddescendingaorta
5. Displacementoftrachea,leftmainbronchus,oresophagus
6. Pleuraleffusion(morecommonontheleft)
Figure 10 Sites for measurements s of f the aortic c root and
ascendingaorta.Thisdiagramillustrates thefoursitesatwhich
measurements are recommended: 1 = aortic valve annulus
(hingepoint ofaorticleaflets), 2=aorticrootatsinuses ofVal-
salva (maximaldiameter, usuallymidpoint),3 =STJ,4=prox-
imaltubular portionof theascending aorta.Ao, Aorta; LA, left
atrium;LV,leftventricle.
Figure11 Transthoracicechocardiographicsuprasternalnotch
view ofthedistalascendingaorta(AscAo),aorticarch,supra-
aorticvessels(arrows),andproximaldescendingthoracicaorta
(DescAo).
128 Goldsteinetal
JournaloftheAmericanSocietyofEchocardiography
February2015
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