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27/9/2015 Echocardiographic evaluation of the thoracic and proximal abdominal aorta

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Offi cial reprint from UpToDatewww.uptodate.com ©2015 UpToDate

AuthorsNelson B Schiller, MDXiushui Ren, MDBryan Ristow, MD, FACC,

FASE, FACP

Section Editor Warren J Manning, MD

Deputy Editor Susan B Yeon, MD, JD,FACC

Echocardiographic evaluation of the thoracic and proximal abdominal aorta

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Aug 2015. | This topic last updated: Jul 16, 2015.

INTRODUCTION — Echocardiography enables qualitative and quantitative evaluation of the thoracic and proximal

abdominal aorta. Transthoracic echocardiography (TTE) provides views of the proximal ascending aorta, aortic

arch and portions of the descending aorta. However, transesophageal echocardiography (TEE) rather than TTE is

indicated for comprehensive imaging of the aorta, especially in the emergency evaluation of aortic dissection or

traumatic rupture of the aortic isthmus. (See "Clinical manifestations and diagnosis of aortic dissection" and

"Transesophageal echocardiography in traumatic rupture of the aortic isthmus".)

Echocardiographic evaluation of the aorta for atherosclerotic plaque, sinus of Valsalva aneurysms, aortic dilation,and dissection will be reviewed here.

NORMAL AORTIC ROOT AND ASCENDING AORTA — The proximal ascending aorta attaches to the left

ventricle at the annulus (hinge line of the aortic leaflets) and includes the aortic root (comprised of the three

sinuses of Valsalva), the sinotubular junction, and the tubular ascending portion of the aorta. The aortic root is a

direct continuation of the left ventricular outflow tract and is located right and posterior to the pulmonary

infundibulum. The lower portion of the aortic root is connected to the muscular interventricular septum, the

membranous septum, and to the mitral-aortic fibrous continuity (also known as the mitral-aortic intervalvular

fibrosa).

Two-dimensional echocardiography — Transthoracic echocardiography (TTE) examination of the proximal

ascending aorta is generally performed in the left parasternal long-axis view (image 1). Many sonographers limit

their interrogation of the aorta to the proximal sinuses of Valsalva, missing the opportunity to more fully visualize

the aorta. Moving up an intercostal interspace, moving the probe closer to the sternum, or tilting the probe cranially

enables imaging of the more superior ascending aorta.

Right parasternal views, recorded with the patient in a right lateral decubitus position, may also be revealing [1].

This method is especially useful when the aorta dilates to the right of the sternum.

A cr oss sectional image of the aortic root is obtained in the parasternal short-axis view (figure 1). The suprasternal

notch view visualizes the aortic arch.

Transesophageal echocardiography (TEE) provides more highly resolved images of the ascending aorta, aortic

arch, and descending thoracic aorta than TTE, although a small portion of the distal ascending aorta and proximal

arch cannot be seen due to interposition of the left mainstem bronchus and trachea.

All imaged portions of the aorta should be evaluated for the presence of plaque, dilation and dissection (including

intramural hematoma). Views used for measurement should be those that show the maximum diameter of the

aortic root [1]. The aortic root at the level of the sinuses generally has the largest diameter (normal ≤3.7 cm), while

the ascending aortic diameter at the sinotubular junction and above is slightly smaller (normal


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views on adequate TTE or TEE images. The left main artery can often be followed to and beyond its bifurcation

into the anterior descending artery and circumflex artery (image 2A-B); the right coronary artery can usually be

followed for up to 3 cm from its origin. While echocardiography is not a practical method to detect luminal

obstruction, careful gain manipulation makes it possible to detect larger bright densities along the course of the

vessel that probably represent proximal calcification.

In adults, an anomalous origin of the coronary arteries is difficult to establish with an echocardiogram. The best

clue to the presence of a single coronary artery, or one that ends in a coronary cameral fistula, is to observe the

greatly enlarged coronary artery origin often associated with this abnormality. At times, these vessels dilate to the

point that they may be confused with a sinus of Valsalva aneurysm. (See "Congenital and pediatric coronary artery

abnormalities".)

Most cameral fistulae that terminate in one of the ventricles can be detected and localized by observing the

abnormal color flow signal that marks the entrance of the fistula into the chamber. There are several reports from

Japan of success in identifying the proximal aneurysms of Kawasaki's disease by echocardiography. (See

"Cardiovascular sequelae of Kawasaki disease".)

M-mode echocardiography — The motion of the aortic root on the M-mode echocardiogram is an indicator of

global left ventricular systolic and diastolic function [3-5]. Since aortic root motion reflects the events of atrial filling

and emptying, it also provides information about left atrial function (image 3A-C).

During systole, the aortic root normally moves anteriorly over 7 mm and returns almost completely to its starting

point immediately after the conclusion of ejection. The atrial or presystolic contribution to aortic root motion is

normally minimal.

Abnormal aortic root motion on M-mode echocardiography — If the systolic excursion of the aortic root is

decreased, stroke volume is probably reduced, an effect that is independent of the left ventricular ejection fraction.

As an example, if the left ventricle is hypovolemic but contracts normally, the aortic root motion will be decreased.

Aortic root motion will also be decreased if the ejection fraction is severely reduced and the ventricle is increased

in size (image 4).

AORTIC PLAQUE — Atherosclerotic plaque is visualized as a region of intimal thickening or protrusion. Plaquemay be accompanied by focal calcifications, ulcerations, and/or superimposed thrombi. The presence of thoracic

aortic plaque, even when visualized in the descending aorta, has been associated with an increased risk of

ischemic stroke [6]. Aortic plaque may be a marker of vascular disease and other risk factors for cerebrovascular

disease [7,8]. Care must be taken not to confuse anterior aortic wall thickening with the right coronary artery.

Studies have found increased risk of stroke among patients with protruding aortic atheroma ≥ 4 or 5 mm thick. Our

institution uses the following transesophageal echocardiography (TEE) grading scale for aortic intimal thickness:

grade 0 = normal, grade 1 = mild intimal thickening, grade 2 = moderate intimal thickening less than 5 mm, grade 3

= protruding atheroma ≥ 5 mm thick, and grade 4 = mobile thrombi on atheroma.

On TEE, the presence of large, mobile, or ulcerated plaques is associated with increased risk of stroke [ 9,10]. The

Augmented root motion with full opening of the aortic valve suggests a high cardiac output. High output

states are quite easy to recognize and their appreciation is helpful in clinical management. (See "High-outputheart failure".)

●

Normal or augmented systolic motion of the aortic root in the face of reduced aortic leaflet separation

suggests atrial filling out of proportion to aortic flow and is typical of mitral insufficiency.

●

If the initial diastolic posterior motion of the aortic root is slowed, and the late diastolic posterior motion of the

aorta is exaggerated with atrial systole, reduced LV compliance is suspected.

●

Aortic root motion tends to be flat in restrictive diastolic states, reflecting the reduced cardiac output

generally associated with restrictive cardiomyopathy.

●

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management of aortic plaques is discussed separately. (See "Embolism from aortic plaque: Thromboembolism"

and "Embolism from atherosclerotic plaque: Atheroembolism (cholesterol crystal embolism)".)

Calcification of the aortic valve, aortic root, and sino-tubular junction is associated with reduced survival among

individuals with coronary artery disease [11]. The presence of calcification along these sites may be a marker of

increased vascular disease independent of other medical risk factors.

SINUS OF VALSALVA ANEURYSMS — Sinus of Valsalva aneurysms are occasionally seen on long- and short-

axis views of the two-dimensional echocardiogram. However, quantitative criteria for sinus of Valsalva aneurysm

are lacking. Since asymmetry of the sinuses is occasionally encountered in clinical practice, such a definitionwould be helpful. Lacking a published definition, we propose that a diameter from the widest portion of the

asymmetric sinus to the opposing wall of greater than 4 cm in adults be adopted as a working definition.

The most common location is the right sinus of Valsalva, from which rupture may extend into the right ventricle or,

less frequently, the right atrium or interventricular septum [ 12].

The next most likely location of the aneurysm is the noncoronary sinus, followed by the left sinus. Infrequently, the

aneurysm ruptures into the left ventricle (mimicking aortic regurgitation) or into the left atrium. In a report of 86

patients undergoing sinus of Valsalva aneurysm repair, 44 percent had associated aortic regurgitation [12].

Contrast echocardiography is helpful in delineating the aneurysm and shunt arising from rupture [13]. However,

color flow Doppler imaging is the technique of choice for identifying a ruptured sinus of Valsalva aneurysm.

AORTIC DILATION — The 2011 ACC/AHA practice guidelines for echocardiography recommend

echocardiography for evaluation of suspected dilation of the proximal aorta (movie 1) [14]. Transthoracic

echocardiography (TTE) is recommended as the first choice for this indication with transesophageal

echocardiography (TEE) used only if the TTE examination is incomplete or additional information is needed.

Multimodality imaging guidelines from the American Society of Echocardiography recommend measuring aortic

dimensions from leading edge to leading edge at end diastole, based on reference studies using this technique

[15].

The ACC/AHA guidelines also recommend echocardiography to evaluate aortic root dilation in Marfan syndrome or

other connective tissue syndromes. In addition, the guidelines recommend TTE to examine first-degree relatives of

patients with Marfan syndrome or other connective tissue disorders. The 2010 ACC/AHA guidelines for the

diagnosis and management of patients with thoracic aortic disease recommend echocardiogram should be

performed at the time of diagnosis of Marfan syndrome, six months thereafter to determine the rate of

enlargement, and annually if stability of the aortic diameter is documented and less than 4.5 cm [16]. The

diagnosis and management of the Marfan syndrome are discussed separately. (See "Genetics, clinical features,

and diagnosis of Marfan syndrome and related disorders" and "Management of Marfan syndrome and related

disorders".)

The 2014 ACC/AHA practice guidelines for valvular disease recommend measuring the diameters of the aortic root

and ascending aorta by TTE for patients with a bicuspid aortic [17]. Magnetic resonance imaging (MRI) or

computed tomography (CT) is recommended if the aortic root or ascending aorta cannot be adequately measured

by echocardiography. Yearly echocardiography, MRI, or CT is recommended for patients with bicuspid aortic

valves and dilation of the aortic root or ascending aorta (diameter greater than 4.0 cm, with consideration of a

lower threshold for patients of small stature). Issues related to bicuspid aortic valve disease are discussed

separately. (See "Clinical manifestations and diagnosis of bicuspid aortic valve in adults" and "Management of

adults with bicuspid aortic valve disease" and "Natural history and management of chronic aortic regurgitation in

adults" and "Pregnancy in women with a bicuspid aortic valve" .)

Limited data are available to compare echocardiography and CT evaluation of thoracic aortic dilation and thoracic

aneurysm. In a small prospective study of 44 patients with known ascending aortic aneurysm, TTE and CT

measurements of aortic diameters correlated well [18]. Ectasia is defined as aortic dilation up to 50 percent greater

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than the normal reference diameter, and aneurysm is defined as greater than 50 percent dilation [16].

Causes of aortic root and ascending aortic dilation and aneurysm formation include hypertension (the most

common cause), atherosclerosis, aortic dissection, aortic stenosis (post-stenotic dilation), bicuspid aortic valve

(associated with aortic dilation even without significant stenosis), aortic regurgitation, and the Marfan syndrome

and other causes of annuloaortic ectasia. Less common etiologies of aortic dilation include inflammatory causes,

such as Takayasu arteritis and infectious causes, such as syphilis. (See "Clinical manifestations and diagnosis of

thoracic aortic aneurysm".)

Various disease processes are associated with different patterns of aortic dilation:

Aortic dissection — TEE is an appropriate initial test to evaluate suspected aortic dissection (image 7) [25].

Choice among TEE, MRI or CT for initial noninvasive imaging of aortic dissection is governed by clinical

considerations and availability (see "Clinical manifestations and diagnosis of aortic dissection").

TEE imaging can help determine the potential for aortic valve-sparing operations [ 26]. The 0-degree high

esophageal view is appropriate for diagnosing ascending aortic dissection. However, TEE evaluation of branch

vessel involvement may be incomplete and additional imaging with other techniques may be required [ 27].

The role of TTE in suspected aortic dissection is primarily for diagnosis of cardiac complications of dissection,including aortic insufficiency, pericardial effusion/tamponade, and regional left ventricular systolic function.

Advances in echocardiography have improved the sensitivity of TTE for aortic dissection to approximately 85

percent or more [15], although TTE remains less sensitive for detection of aortic dissection than TEE, CT, and

MRI. Thus, absence of a dissection flap on TTE should not be used to exclude aortic dissection. In a study of 172

consecutive patients receiving operations for proximal aortic dissection, TTE identified intimal dissection flaps in

159 [28]. TTE may be able to visualize an undulating intimal of a dissection (image 8), but the normal

brachiocephalic vein can often be seen adjacent and superior to the aortic arch in the suprasternal notch view

(image 9), and this should not be mistaken for a dissection.

DESCENDING THORACIC AORTA AND AORTIC ARCH — The descending thoracic aorta can be seen

posterior to the long- and short-axis parasternal views on transthoracic echocardiography (TTE) ( image 10A-D). Inthe parasternal long-axis view, the descending aorta can be seen in cross-section at the posterior atrioventricular

groove, situated outside the pericardium. In the parasternal short-axis plane, an oblique longitudinal section of the

descending aorta can be seen.

Imaging can identify dilation or an aneurysm and may permit detection of dissection. The descending aorta is a

useful landmark for distinguishing pleural and pericardial effusions, since the pericardium encloses the heart

anterior to the descending aorta.

On TTE, the aortic arch is visualized in the suprasternal notch view. This view is recommended as a routine

component of TTE examination, particularly in cases with bicuspid aortic valve which is frequently associated with

Hypertension appears to have a minor impact on aortic root diameter at the level of the sinuses of Valsalva

[19-21], but is associated with enlargement at the sinotubular junction and tubular ascending aorta [ 19].

●

Congenital aortic stenosis is associated with more significant post-stenotic dilation than degenerative aortic

stenosis with similar valve areas (image 5) [22].

●

Symmetric dilation of the three sinuses is most commonly seen in patients with Marfan syndrome [23,24].

This dilation usually, but not always, terminates abruptly at the sinotubular junction and gives these roots a

distinctive appearance unlike that of other causes of annuloaortic ectasia (image 6A-B). In addition to root

dilation, patients with Marfan syndrome frequently have aortic regurgitation because aortic annulus dilation

causes cusp malcoaptation (image 6A-B). Issues related to echocardiography in Marfan syndrome arediscussed separately. (See "Genetics, clinical features, and diagnosis of Marfan syndrome and related

disorders".)

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coarctation of the aorta. In the suprasternal notch view, color and spectral Doppler interrogation of the proximal

descending aorta may detect accelerated flow characteristic of coarctation. If forward velocity in the descending

aorta by continuous-wave Doppler exceeds 2 m/sec, aortic coarctation should be suspected. If the run-off at the

site of coarctation is delayed, severe coarctation must be considered, and alternate imaging modalities such as

MRI can be helpful in confirming diagnosis and grading severity. (See "Clinical manifestations and diagnosis of

coarctation of the aorta", section on 'Echocardiography'.)

Views of the descending thoracic aorta as it courses along the spine can be obtained in the apical views; posterior

angulation often produces long-axis (in the two chamber view) and short-axis (in the four chamber view) images

(image 10C). Although the aorta is too deep in the far field to be well resolved, the size of the aorta can generally

be measured. A normal caliber aorta is evidence against dissection at that location.

3D echocardiographic imaging provides an intuitive overview of structures and their relation to each other as

illustrated by an example of a mobile aortic mass (movie 2). However, 2D images (movie 3) provide additional

clues to the accurate diagnosis of a vegetation, including thickening of the aortic wall consistent with

inflammation, a fluid-filled collection around the aorta consistent with abscess, and the absence of calcification or

shadowing that would have been more typical of atherosclerotic disease with adjacent thrombus.

When aortic dissection involves the thoracic aorta, especially if there is extravasation of blood around the aorta,

the vessel can be imaged from the left paraspinal window. This strategy can be used to supply additional evidence

about the state of the thoracic aorta. However, transesophageal echocardiography is the method of choice for detecting pathology of the thoracic aorta.

Abdominal aorta — Subcostal imaging of the proximal abdominal aorta is often included in the TTE examination

[29]. The structure can be found to the left of the spine running parallel, but to the left of and deep to, the inferior

vena cava (image 11A-B). Differentiation of the aorta from the vena cava can be made by appreciating the systolic

pulsations of the aorta, which are usually easy to recognize.

Using the subcostal approach, atheromatous irregularities and aneurysms of the proximal abdominal aorta are

readily seen (image 12A-C). Since the descending aorta is closer to the transducer in this view than in other TTE

views, the yield for intimal flaps of aortic dissection is higher from this window. In addition, comparing the

smoothness of the inner layer of the aorta to the vena cava gives some indication of the degree of atheromatous

change that is present in the aorta and, by inference, in the remainder of the vascular tree. Atheromatous change

is typically appreciated as obvious irregularities along the usually smooth interior of the vessel.

Although transesophageal echocardiography (TEE) is the preferred technique for evaluating the aorta, it does not

image the aorta very far below the diaphragm [30]. Ideally, linear arrays should be used for more comprehensive

evaluation of the abdominal aorta.

Transcatheter aortic valve implantation — Echocardiographic evaluation of the aorta is a critical component of

multimodality imaging for transcatheter aortic valve replacement as discussed in detail separately. (See "Imaging

for transcatheter aortic valve replacement".)

OTHER GREAT VESSELS — Transthoracic echocardiography (TTE) is useful in evaluating the other great

vessels.

Pulmonary artery — In the parasternal long-axis view, imaging just superior to the left atrium usually

demonstrates the left pulmonary artery as it crosses under the ascending aorta. Inspecting the bifurcation of the

pulmonary artery in its long-axis (in the parasternal short-axis view) may reveal the relationship between the left

pulmonary artery and the descending aorta (image 13A-B). Color Doppler near the pulmonary artery bifurcation in

this view can detect the retrograde continuous flow characteristic of a patent ductus arteriosus.

Carotid arteries and subclavian vessels — The innominate, left common carotid, and left subclavian vessel

origins can be imaged by TTE from the suprasternal notch. From the neck, the carotid and vertebral arteries can

be studied effectively by trained vascular sonographers using dedicated linear array transducers. Skill in

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performing this examination is helpful when evaluating a patient for dissection of the aorta because detection of

extension of the dissection into the carotid arteries has important clinical implications.

SUMMARY AND RECOMMENDATIONS

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Transthoracic echocardiography (TTE) provides views of the proximal ascending aorta, aortic arch, and

portions of the descending aorta. However, transesophageal echocardiography (TEE) is superior to TTE for

comprehensive imaging of the aorta, especially in the emergency evaluation of aortic dissection or traumatic

rupture of the aortic isthmus. (See "Clinical manifestations and diagnosis of aortic dissection" and

"Transesophageal echocardiography in traumatic rupture of the aortic isthmus".)

●

TEE provides more highly resolved images of the ascending aorta, aortic arch, and descending thoracic aorta

than TTE, although a small portion of the distal ascending aorta and proximal arch cannot be seen by TEE

due to interposition of the left mainstem bronchus and trachea. (See 'Two-dimensional echocardiography'

above.)

●

The presence of large, mobile, or ulcerated plaques in the thoracic aorta on TEE is associated with an

increased risk of stroke. (See 'Aortic plaque' above.)

●

Echocardiography is the primary modality for identification of sinus of Valsalva aneurysms and any

associated shunt arising from rupture. (See 'Sinus of Valsalva aneurysms' above.)

●

Echocardiography enables identification of aortic dilation and is indicated for monitoring of individuals at risk

for progressive aortic dilation, particularly those with Marfan syndrome or a bicuspid aortic valve. (See 'Aortic

dilation' above.)

●

TEE is an appropriate initial test to evaluate suspected aortic dissection. Choice among TEE, MRI, or CT for

initial noninvasive imaging of aortic dissection is governed by clinical considerations and availability. (See

"Clinical manifestations and diagnosis of aortic dissection".)

●

http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-aortic-dissection?source=see_linkhttp://-/?-http://-/?-http://-/?-http://www.uptodate.com/contents/transesophageal-echocardiography-in-traumatic-rupture-of-the-aortic-isthmus?source=see_linkhttp://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-aortic-dissection?source=see_linkhttp://www.uptodate.com/contents/echocardiographic-evaluation-of-the-thoracic-and-proximal-abdominal-aorta/abstract/9http://www.uptodate.com/contents/echocardiographic-evaluation-of-the-thoracic-and-proximal-abdominal-aorta/abstract/8http://www.uptodate.com/contents/echocardiographic-evaluation-of-the-thoracic-and-proximal-abdominal-aorta/abstract/7http://www.uptodate.com/contents/echocardiographic-evaluation-of-the-thoracic-and-proximal-abdominal-aorta/abstract/6http://www.uptodate.com/contents/echocardiographic-evaluation-of-the-thoracic-and-proximal-abdominal-aorta/abstract/5http://www.uptodate.com/contents/echocardiographic-evaluation-of-the-thoracic-and-proximal-abdominal-aorta/abstract/4http://www.uptodate.com/contents/echocardiographic-evaluation-of-the-thoracic-and-proximal-abdominal-aorta/abstract/3http://www.uptodate.com/contents/echocardiographic-evaluation-of-the-thoracic-and-proximal-abdominal-aorta/abstract/2http://www.uptodate.com/contents/echocardiographic-evaluation-of-the-thoracic-and-proximal-abdominal-aorta/abstract/1http://www.uptodate.com/contents/license


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27/9/2015 Echocardiographic evaluation of the thoracic and proximal abdomi nal aorta


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11. Saha SA, Beatty AL, Mishra RK, et al. Usefulness of an Echocardiographic Composite Cardiac CalciumScore to Predict Death in Patients With Stable Coronary Artery Disease (from the Heart and Soul Study).

Am J Cardiol 2015; 116:50.

12. Moustafa S, Mookadam F, Cooper L, et al. Sinus of Valsalva aneurysms--47 years of a single center experience and systematic overview of published reports. Am J Cardiol 2007; 99:1159.

13. Terdjman M, Bourdarias JP, Farcot JC, et al. Aneurysms of sinus of Valsalva: two-dimensional

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15. Goldstein SA, Evangelista A, Abbara S, et al. Multimodality imaging of diseases of the thoracic aorta in

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American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,American Stroke Association,Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions,Society of Interventional Radiology, Society of Thoracic Surgeons,and Society for Vascular Medicine. J AmColl Cardiol 2010; 55:e27.

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Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.18. Tamborini G, Galli CA, Maltagliati A, et al. Comparison of feasibility and accuracy of transthoracic

echocardiography versus computed tomography in patients with known ascending aortic aneurysm. Am JCardiol 2006; 98:966.

19. Kim M, Roman MJ, Cavallini MC, et al. Effect of hypertension on aortic root size and prevalence of aorticregurgitation. Hypertension 1996; 28:47.

20. Palmieri V, Bella JN, Arnett DK, et al. Aortic root dilatation at sinuses of valsalva and aortic regurgitation inhypertensive and normotensive subjects: The Hypertension Genetic Epidemiology Network Study .Hypertension 2001; 37:1229.

21. Vasan RS, Larson MG, Levy D. Determinants of echocardiographic aortic root size. The Framingham HeartStudy. Circulation 1995; 91:734.

22. Ben-Dor I, Sagie A, Weisenberg D, et al. Comparison of diameter of ascending aorta in patients with severeaortic stenosis secondary to congenital versus degenerative versus rheumatic etiologies. Am J Cardiol 2005;96:1549.

23. Eisenberg MJ, Rice SA, Paraschos A, et al. The clinical spectrum of patients with aneurysms of theascending aorta. Am Heart J 1993; 125:1380.

24. Dev V, Goswami KC, Shrivastava S, et al. Echocardiographic diagnosis of aneurysm of the sinus of Valsalva. Am Heart J 1993; 126:930.

25. Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007appropriateness criteria for transthoracic and transesophageal echocardiography: a report of the AmericanCollege of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria WorkingGroup, American Society of Echocardiography, American College of Emergency Physicians, American

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26. David TE, Feindel CM, Webb GD, et al. Long-term results of aortic valve-sparing operations for aortic rootaneurysm. J Thorac Cardiovasc Surg 2006; 132:347.

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Topic 5293 Version 12.0

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GRAPHICS

Two-dimensional transthoracic echocardiogram

(2D TTE) parasternal long axis view

This parasternal long axis echocardiogram was obtained in systole;

the aortic valve is open and the mitral is closed.

RV: right ventricle; IL: inferolateral left ventricular wall; IVS: interventricular

septum; NCC: noncoronary cusp of the aortic valve; RCC: right coronary cusp

of the aortic valve; aML: anterior mitral valve leaflet; pML: posterior mitral

valve leaftlet; dAo: descending aorta.

Graphic 77446 Version 4.0


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Two-dimensional transthoracic echocardiogram (2D TTE) parasternal

short axis view of the aortic root

(A) A diagram of the transducer position for obtaining a short axis two dimensional image; the

short axis is obtained by a 70° to 110° clockwise rotation of the transducer from the parasternal

long axis, with superior and inferior transducer manipulations and the plane is oriented at the

base of the heart (left panel).

(B and C) The parasternal short axis view from a transthoracic echocardiogram shows the

noncoronary (NCC), right coronary (RCC) and left coronary (LCC) leaflets of the aortic valve.

Also seen are the left atrium (LA), right atrium (RA), tricuspid valve (TV), right ventricle (RV)

and pulmonic valve (PV).



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Short axis view of left main coronary artery

The short axis view, with the imaging plane through the aortic root

(AO) just above the aortic valve, demonstrates the left main coronary

artery (LMCA). Panel B shows the M-mode echocardiogram of the

LMCA.

PV: pulmonary valve.



12/34




(2D TTE) from the parasternal short axis view at

the level of the coronary arteries

The origins of the right (RCA) and left (LCA) coronary arteries can be

seen on the short axis precordial view, obtained through the aortic

root (Ao) just above the valves; there is a vague "pinwheel"

relationship of the sweep of the arteries. Additionally, the left atrial

appendage (LAA) is seen just inferior to the LCA and the pulmonary

valve (PV) just superior.

LA: left atrium.



13/34



2D and M mode echocardiographic images of the

normal aortic root from the parasternal short axis

position

The M-mode beam is directed through the two dimensional image of the

aortic root at the base of the heart (panel A). The resulting M-mode

echocardiogram (panel B) demonstrates normal systolic and diastolicmotion patterns; the anterior excursion is over 14 mm and the diastolic

posterior excursion mainly occurs early in diastole. The aortic (Ao) valve

leaflets open as widely as the internal dimensions of the root permit and

remain open throughout systole, creating a box-like configuration. The

anterior motion of the root and the behavior of the valve are typical

findings when the stroke volume is normal.

PA: main pulmonary artery; LA: left atrium; RVOT: right ventricular outflow tract.



14/34



M-mode echocardiogram of normal aorta and left

atrium

The M-mode echocardiogram is obtained from the long axisparasternal two dimensional view (panel A); the dotted line represents

the M-mode beam passing through the aortic root, the right (R) and

noncoronary (N) cusps of the aortic valve, and the left atrium (LA).

The atrium is measured at end systole (arrows) when the descent of

the left ventricle base has resulted in maximal filling.



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Two-dimensional transthoracic echocardiogram (2D TTE) and

M mode echocardiographic images along with a

phonocardiogram of the normal aortic root from the

parasternal short axis position

Panel A shows the short axis view from a two-dimensional echocardiogram recorded

at the base of the heart at the level of the aortic valve; the line (M) bisecting the

aortic valve represents the plane of the M-mode beam used to generate the M-

mode echocardiogram in panel B. The aortic valve opens nearly to the aortic (Ao)

walls (panel B) and while opened it has a box-like configuration. The line marks the

peak of the R wave on the ECG. There is a brisk anterior systolic motion of the

entire Ao root and even faster earlier diastolic relaxation (posterior motion); the

posterior movement of the aortic root occurs predominantly in early diastole with

very little movement in late diastole. This pattern occurs in young healthy hearts

that rely predominantly on early relaxation for filling rather than atrial contraction.

The M-mode echocardiogram with simultaneous phonocardiogram is seen in panel

C. The vibrations on the posterior moving non-coronary aortic leaflet (down arrows)

are similar in timing and frequency with the low intensity, early systolic "innocent"

murmur recorded on the phonocardiogram (up arrows). These vibrations are

common in normal valves with normal or elevated cardiac output.



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M-mode echocardiogram of aortic root in

cardiomyopathy

In cardiomyopathy with reduced stroke volume the systolic anterior

excursion of the aortic (Ao) root is greatly reduced in comparison to

the normal pattern. Additionally, the aortic valve (AoV) opening is

greatly reduced and its duration abbreviated. Just after achieving their

maximum separation, the AoV leaflets immediately begin drifting

closed, with a loss of the normal box-like configuration.



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Aortic dilation in aortic stenosis

Aortic pathology can be better seen by imaging the ascending aorta

one interspace above the usual long axis precordial window. The

normal appearance of the sinuses and ascending aorta (Asc Ao) is

seen in panel A. For comparison, panel B shows poststenotic dilatation

which is quite typical and almost always found in aortic stenosis.

AV: aortic valve; LA: left atrium; LV: left ventricle.



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M-mode echocardiogram of aortic regurgitation

The M-mode echocardiographic findings in aortic regurgitation, due to

the Marfan syndrome in this case, include fluttering of the mitral

valve (MV) (panel A) and a greatly dilated aortic root (Ao), measuring

48 mm, in relationship to a small appearing left atrium (LA) (panel B),

which measures 27 mm. The aortic to atrial diameter ratio has been

used as a sign of the Marfan syndrome.



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Aortic root enlargement

The normal aortic root (RT) and ascending aorta (AAo) are seen in

panel A; slight prominence of the sinuses of Valsalva (SinV) can be

appreciated. Panel B is the aortic RT and AAo from a patient with the

Marfan syndrome; the SinV are large while the AAo is relatively

normal, a pattern that seems unique to the Marfan syndrome. In panel

C, a greatly enlarged aortic (Ao) RT is also seen, but the pattern

differs from that seen in the Marfan patient; the dilatation begins at

the aortic ring and continues beyond the sinotubular junction well into

the AAo, considered to represent aortoannular ectasia.



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TEE descending aortic dissection

Aortic dissection is characterized by the formation of an "intimal flap" seen as a hyperechoic line

extending across the vessel delimiting two distinct lumens (A). Color flow Doppler (B) depicts

higher (orange) blood flow velocity and intraluminal velocity in the inferior of the two lumens,

but does not provide definitive information regarding which is the true lumen and false lumen.

Courtesy of W Manning, MD.



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Ascending aortic dissection on echocardiogram

Modified long axis view shows a proximal dissection of the aortic root

(Ao), with a flap extending to the aortic valve (V). This aortic

pathology is seen by imaging the ascending aorta one interspace

above the usual long axis precordial window.

LA: left atrium; LV: left ventricle.



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Suprasternal notch view of aortic arch and brachiocephalic vein

In this view, taken with the neck extended and the probe positioned at the suprasternal notch and

caudally, the aortic arch is visualized centrally. The aortic vessel wall is a linear structure that se

the aorta from the brachiocephalic vein; this should not be confused with a dissection. The

brachiocephalic vein has continuous flow in both systole and diastole when visualized by color Do

and this further differentiates the structure from the aorta or branch arteries.



23/34



Mildly dilated thoracic aorta

The long axis precordial view shows slight dilation of the thoracic

aorta (Th Ao).

CS: coronary sinus.



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(2D TTE) from the parasternal long and short axis

views showing the descending thoracic aorta

The descending thoracic aorta can be seen from the parasternal long

axis view. Both the long (panel A) and short axis (panel B) precordial

views show the descending thoracic aorta (TAo). Note that the short

axis imaging plane demonstrates the long axis of the TAo.

LV: left ventricle; RA: right atrium; LA: left atrium; Ao R: aortic root.



25/34




(2D TTE) from a modified two-chamber view

showing the descending thoracic aorta

The descending thoracic aorta (T Ao) can be imaged from the apical

two- and four-chamber view. Posterior angulation of the transducer

(panel A) often opens the T Ao such that it can be seen in its longaxis. Major pathology such as aneurysms can often be detected in this

way. Anterior angulation in the apical two chamber view (panel B)

demonstrates the proximal aortic arch (Ao).

LA: left atrium; LV: left ventricle; rpa: right pulmonary artery.



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(2D TTE) from a modified four-chamber view

showing the descending thoracic aorta

The thoracic or descending aorta (T Ao) can be imaged from the

apical two- and four-chamber view. Posterior angulation (panel B)

shows the T Ao in its short axis, located below the left atrium (LA).Anterior angulation in four-chamber view (panel A) shows the origin of

aortic root (Ao).

RA: right atrium; LA: left atrium.



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(2D TTE) from the subcostal view showing the

abdominal aorta

The abdominal aorta (Ab Ao) can be seen in subcostal long (panel A)

and short axis (panel B) views. The neural canal (NC) is seen through

the intervertegral disc in this thin patient.



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Echocardiographic image of the abdominal aorta

The abdominal (Ab) aorta (Ao) is seen from the subcostal long axis(panel A) and short axis views (panel B). In this thin patient the

neural canal (NC) is seen through the intervertegral disc in the short

axis view.

RA: right atrium.



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Abdominal aortic aneurysm long and short axis

(A) The long axis view shows an aneurysm of the abdominal aorta (A

Ao An) as the aorta crosses the diaphragm. Prominent plaques just

beyond the aneurysm can be appreciated.

(B) The short axis through the aneurysm (An) also shows the inferiorvena cava (IVC).



30/34



Dissection of the abdominal aorta on longitudinal

ultrasound

The long axis view shows a dissection of the abdominal aorta (AAo)

and the presence of a spiral flap (f).



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Dissection of the abdominal aorta on transverse

ultrasound

The short axis view shows a dissection (Dis) of the abdominal aorta(AoAb) and a spiral flap (arrows).



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(2D TTE) from the right ventricular (RV) outflow

tract view showing the pulmonic valve and the

pulmonary artery bifurcation

Pulmonary artery (PA) bifurcation into the right (RPA) and left (LPA)

pulmonary arteries can be seen in the short axis precordial view. Note

that in this view the LPA is proximal to the descending aorta (dAo).

Ao: aorta; RVOT: right ventricular outflow tract; pv: pulmonic valve.



33/34



Pulmonary artery

The right pulmonary artery (RPA) can be seen in the precordial long

axis view as it crosses under the transverse aorta (Ao), superior to

the left atrium (LA).



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Disclosures: Nelson B Schiller, MD Nothing to disclose. Xiushui Ren, MD Nothing to disclose. Bryan

Ristow, MD, FACC, FASE, FACP Nothing to disclose. Warren J Manning, MD Equity Ownership/Stock

Options: Pfizer (Pharmaceuticals). Equity Ownership/Stock Options (Spouse): General Electric (Imaging

equipment). Susan B Yeon, MD, JD, FACC Nothing to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are

addressed by vetting through a multi-level review process, and through requirements for references to be

provided to support the content. Appropriately referenced content is required of all authors and mustconform to UpToDate standards of evidence.

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