European Heart Journal (2010) 31, 472–479 CLINICAL RESEARCH

doi:10.1093/eurheartj/ehp505 Imaging

Impact of contrast-enhanced echocardiography

on the diagnostic algorithm of acute aortic
dissection
Artur Evangelista 1*, Gustavo Avegliano 1, Rio Aguilar 1, Hug Cuellar 2, Albert Igual 3,
Teresa González-Alujas 1, Jose Rodrı́guez-Palomares 1, Patricia Mahia 1,
and David Garcı́a-Dorado 1
1
Servei de Cardiologia, Hospital Universitari Vall d’Hebron, Pº Vall d’Hebron 119, Barcelona 08035, Spain; 2Institut de Diagnòstic per la Imatge, Hospital Vall d’Hebron, Barcelona,

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Spain; and 3Servei de Cirurgia Cardiaca, Barcelona, Spain

Received 21 March 2009; revised 28 June 2009; accepted 2 November 2009; online publish-ahead-of-print 25 December 2009

See page 398 for the editorial comment on this article (doi:10.1093/eurheartj/ehp404)

Aims To determine the usefulness of contrast echocardiography in the diagnosis of aortic dissection (AD) and in the
assessment of findings necessary for adequate patient management.
.....................................................................................................................................................................................
Methods Conventional and contrast-enhanced transthoracic echocardiography (TTE) and transoesophageal echocardiography
and results (TOE) were performed in 128 consecutive patients with clinically suspected acute AD. Results were validated inde-
pendently against intraoperative findings in 45 patients and computed tomography information in 83. Sensitivity and
specificity of conventional TTE increased after contrast enhancement from 73.7 to 86.8% (P , 0.005) and 71.2 to
90.4% (P , 0.05), respectively. Sensitivity and specificity of enhanced TTE were similar to conventional TOE in
ascending aorta (93.3 vs. 95.6% and 97.6 vs. 96.4%, respectively) and in the arch (88.4 vs. 93.0% and 95.3 vs.
98.82%, respectively). Contrast-enhanced TOE permitted the location of non-visualized entry tear in seven cases
(10.6%), helped to correctly identify the true lumen in six (9.1%), and diagnosed retrograde dissection in nine (13.6%).
.....................................................................................................................................................................................
Conclusion Contrast enhancement substantially improves TTE in the diagnosis of AD and should be considered as the initial
imaging modality in the emergency setting. Contrast enhancement also has significant value for obtaining critical mor-
phological and haemokinetic information by TOE useful for adequate patient management.
-----------------------------------------------------------------------------------------------------------------------------------------------------------
Keywords Aortic dissection † Echocardiography † Contrast echocardiography

Aortic dissection (AD) is an acute life-threatening disease that (CT);7 – 12 however, in clinical practice it is only used as the first
requires prompt diagnosis and treatment. Among imaging tech- imaging test in 30 –40% of cases13 owing to its lower availability
niques, echocardiography has the advantage that it can be rapidly compared with CT, particularly in community hospitals, and to
performed at the patient’s bedside.1 Transthoracic echocardiogra- patient discomfort which may cause a rise in arterial blood
phy (TTE) is considered of limited value in the diagnosis of AD, pressure.14,15
with sensitivity ranging from 35 to 80% and specificity 39– In recent years, contrast echocardiography has proved to add
86%.1 – 6 Nevertheless, the studies providing these data were per- useful information in several clinical situations;16 however, to date,
formed when current imaging technology, such as harmonic its value in AD has been described in few case reports.17 – 19 The
imaging or multifrequency transducers, was not yet available. On aim of the present study was to assess the potential of echocardio-
the other hand, transoesophageal echocardiography (TOE), cur- graphy with the use of contrast enhancement in the diagnosis of AD
rently considered one of the reference techniques in this diagnosis, and in the assessment of morphological and haemokinetic features
provides similar sensitivity and specificity to computed tomography necessary for adequate patient management.

* Corresponding author. Tel: þ34 93 274 6134, Fax: þ34 93 274 6063, Email: aevangel@vhebron.net
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org.
Contrast echocardiography in the diagnosis of AD 473

Methods Transoesophageal echocardiography study

Patients were placed in the left lateral decubitus position. After control
Patients of blood pressure and moderate sedation by e.v. midazolam (6–
10 mg), TOE with optional colour-coded Doppler was performed
Of 143 consecutive patients with clinically suspected acute AD, 15
using standard planes for the study of ascending aorta, arch, and des-
were excluded from the study: eight Type A dissections with haemo-
cending aorta.1
dynamic shock in which surgical treatment was indicated directly after
conventional or contrast-enhanced TTE, and seven patients with poor
acoustic window secondary to pulmonary emphysema,3 obesity,1 chest
Contrast study
Mechanical index was set between 0.6 and 0.8 in TTE and 0.4 and 0.6
abnormalities,2 or mechanical ventilation.1 Therefore, the study
in TOE. Transducer frequency was reduced to harmonic imaging
included 128 patients. Patient characteristics are described in Table 1.
(2.9 MHz) in TOE studies. Contrast agents, Optisonw (octafluropro-
pane in human albumin microspheres) 0.5 mL or SonoVuew
Study protocol (sulphur hexafluoride) 1 mL bolus, were injected into a peripheral
In all patients, TTE followed by TOE studies was performed in the vein. Several boluses were injected to obtain complete information
acute phase, both with conventional examination (two-dimensional on the variables analysed in the different segments of the aorta using
echocardiography and colour Doppler) and after contrast injection. similar windows to conventional echocardiographic studies.
Transoesophageal echocardiography was performed between 5 and
10 min after completion of the TTE study. The images of these four Echocardiographic variables

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echocardiographic studies were stored separately on VHS video and By conventional TTE or TOE: (i) AD was diagnosed by the presence of
the most demonstrative images in digital cine-loop format for later two vascular lumina separated by an intimal flap,8 and intramural hae-
analysis. Computed tomography was performed in all cases, and MRI matoma when aortic wall thickness was over 5 mm with a crescent or
was considered only when CT and TOE disagreed. Definitive diagnosis circular shape and central displacement of intimal calcification;20 (ii)
was established by surgical anatomical information, diagnostic agree- entry tear was considered to be the widest proximal tear visualized
ment between CT and TOE or MRI. Magnetic resonance imaging by two-dimensional echocardiography or colour Doppler;21 (iii) true
was performed if disagreement between CT and TOE was present. lumen was identified by the systolic expansion of the lumen using
Echo images of each study were analysed in random order in separ- M-mode and the greatest intensity of the flow signal by colour
ate sessions by an observer blinded to the clinical, CT, or anatomical Doppler;21 and (iv) antegrade or retrograde false lumen flow was ana-
data. To assess the reproducibility of AD diagnosis by contrast echo- lysed by colour and pulsed-wave Doppler.21 Finally, pericardial effusion
cardiography, 20 randomly selected studies were analysed by two and tamponade, aortic regurgitation severity and mechanism and aortic
observers with wide and medium experience, respectively. vessel involvement were assessed in the standard criteria by two-
dimensional and colour Doppler echocardiography.8,21 – 23
By contrast enhancement: (i) intimal flap visualization and different
Echocardiographic evaluation
flow patterns in both lumina; (ii) possible location of non-visualized
Echocardiographic studies were performed with GE Vivid I or Vivid 7
entry tear by observing the aortic segment where the maximum con-
Dimension equipment with a 1.5 – 4.3 MHz multifrequency transducer
trast flow appeared the earliest in the false lumen; (iii) true lumen
using harmonic imaging in TTE studies and multiplanar probe with a
identified by the earliest arrival and rapid displacement of contrast in
2.9– 8 MHz multifrequency transducer using harmonic imaging in
the lumina; (iv) antegrade or retrograde false lumen flow defined by
TOE studies.
the direction of systolic displacement of contrast flow through the
false lumen; and (v) involvement of aortic vessels visualized by
Transthoracic echocardiography study echocardiography.
Evaluation of the entire aorta by two-dimensional and colour-coded
Doppler was performed with the patient in the supine, left lateral Reference techniques
and right lateral decubitus positions using multiple views including
Intraoperative inspection of the aorta and adjacent tissues was made
left parasternal, right parasternal, apical, subcostal, suprasternal, and
by experienced surgeons. Findings were documented at the time of
abdominal views.1 Colour-coded Doppler was optimized for assessing
visual examination and recorded on the surgical report.
flow signal and different flow patterns in aortic lumen.
Computed tomography was performed with a multidetector
Siemens sensation, which produced 1 mm slices, each 0.5 mm from
the highest part of the aortic arch to the start of the iliac arteries. In
Table 1 Demographic and clinical characteristics of all cases, a previous non-enhanced CT scan was obtained to assess
the studied population recent haemorrhage. Iodinated contrast material (100 – 120 mL) was
injected at a 3 – 5 mL/s flow rate to obtain a high-quality CT aorto-
Age (years)a 61 (49– 74) graph. Magnetic resonance imaging studies were performed with a
Male/female 92 (72%)/36 (28%) Siemens Magnetom 1.5 T (Erlangen, Germany) device. A standardized
Hypertension 95 (74.2%) protocol including ECG-gated spin-echo, HASTE sequences, and
Diabetes 10 (7.8%) breath-hold gadolinium-enhanced rapid MR angiographic technique
Known thoracic aortic aneurysm 19 (14.8%) were performed in all studies.
Prior cardiac surgery 18 (14.0%)
Marfan syndrome 12 (9.3%) Statistical analysis
Sensitivity, specificity, and predictive values were determined from the
a
Median (IQR). percentage of patients with true-positive and true-negative results with
95% confidence intervals (CIs). The significance of differences in the
474 A. Evangelista et al.

frequency ratio of two imaging methods was assessed by the McNemar and proximal arch, and three cases with intraluminal aortic wall
test with continuity correction. In addition, a separate analysis was per- reverberations were mistakenly diagnosed as AD. Contrast TOE
formed to determine the involvement of the ascending aorta, arch, and did not permit the diagnosis of the two dissections located in
descending aorta segments in all 128 cases. A P-value less than 0.05 the upper third of the ascending aorta, which were correctly diag-
was considered statistically significant; however, since this analysis
nosed by TTE, but did adequately identify the three false-positive
involved multiple comparisons, a Bonferroni correction for each
cases of Type A dissection. The sensitivity, specificity, and predic-
block (12 comparisons) was employed, considering a P-value less
tive values of TTE and TOE with and without contrast are shown
than 0.004 statistically significant. Continuous values are expressed
as mean + SD. Kappa test to assess interobserver agreement. in Table 2. The results of TTE in the diagnosis of AD for each
segment analysed are specified in Table 3.
Interobserver agreement on diagnosis showed five (25%) dis-
agreements by unenhanced TTE in the diagnosis of AD between
Results observers: two Type A, two Type B, and in one case without dis-
section (Kappa: 0.38). Using contrast TTE, disagreement occurred
Aortic dissection diagnosis in only one (5%) Type B dissection (Kappa: 0.88). By unenhanced
Of the 128 patients with clinically suspected AD, a definitive diag- TOE and by contrast TOE, agreement was complete between both
nosis of Type A AD was established by surgical findings in 45, Type observers in the diagnosis of AD.
B dissection by CT and TOE agreement in 31, and AD was ruled

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out by CT and TOE agreement in 49 patients and in the remaining
three patients by CT and MRI (Figure 1). Of those with AD, one
Additional morphological and
Type A and five Type B had complete false lumen thrombosis or haemokinetic information on aortic
intramural haematoma. No complications or side effects related dissection
to contrast agent administration were observed. Transoesophageal echocardiography was better than TTE in the
Conventional TTE correctly diagnosed ascending aorta dissec- visualization of false lumen entry tear (59/66; 89.4% vs. 22/50;
tion in 37 of 45 (82.2%) cases, and with contrast enhancement 44.0%; P , 0.001). After contrast enhancement, TTE located the
increased to 42 (93.3%) (P , 0.05) (Figure 2). Of the 43 dissections entry tear in 88% (45/50) of cases (Figure 5) and TOE in all
affecting the aortic arch, unenhanced TTE visualized 34 (79.1%) cases including the seven cases in which the entry tear was non-
and with the use of contrast increased to 38 (88.4.0%) (P , visualized: six in the upper part of the ascending aorta and one
0.05) (Figure 3). Of the 73 cases with descending aorta dissection, in the abdominal aorta.
unenhanced TTE correctly detected 41 (56.2%) and with contrast Conventional TOE failed to correctly identify the true lumen in
increased to 61 (83.6%) (P , 0.001) (Figure 4). None of the six six cases (8.8%), in all of which the intima was immobile by
cases of false lumen thrombosis or intramural haematomas were M-mode, and colour Doppler showed a similar flow pattern in
diagnosed by TTE with or without contrast. both lumina. In all six cases, contrast facilitated easy and rapid
Transoesophageal echocardiography yielded false-negative diag- identification of the true lumen. False lumen flow was retrograde
noses in two ADs located in the upper part of the ascending aorta in seven Type A and two Type B dissections. Conventional TTE

Figure 1 Subjects’ flow chart. *With and without contrast echocardiography.

Contrast echocardiography in the diagnosis of AD 475

in 13, and left subclavian artery in 19). Transthoracic

echocardiography was useful in the diagnosis of supraaortic
vessel involvement (49/60; 82%), mainly after contrast enhance-
ment (55/60; 91%). However, TOE with or without contrast per-
mitted a correct diagnosis in only 29 cases (48%), but in all 19 with
subclavian artery involvement. Transthoracic echocardiography
was limited for diagnosing coronary artery and coeliac trunk invol-
vement; however, TOE with and without contrast enhancement
correctly diagnosed the four coronary dissections shown by
surgery and 19 coeliac trunk dissections diagnosed by CT. Both
echocardiographic techniques failed to diagnose lower vessel
involvement.

Discussion
The present study shows the usefulness of contrast echocardiogra-

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phy in the assessment of AD. The use of contrast in TTE substan-
tially improved the diagnosis of AD, yielding similar results to
conventional TOE in ascending aorta and aortic arch. In addition,
contrast facilitated the diagnosis of reverberations in ascending
aorta, easily identified the true lumen and improved the location
of the entry tear and false lumen flow direction by TTE and
TOE. These results may imply a changing role of TTE and TOE
in the acute phase of AD.

Role of transthoracic echocardiography

Transthoracic echocardiography, despite the use of colour
Doppler, has commonly been considered of limited diagnostic
value in the diagnosis of AD, with sensitivity and specificity
ranging from 35 to 80% and from 39 to 86%, respectively.1 – 6
However, recent advances in echocardiography, including harmo-
nic and contrast imaging, have greatly improved image quality
and, consequently, have modified the role of TTE in AD diagnosis.
By contrast enhancement, different flow patterns in the two lumina
Figure 2 Right parasternal view of transthoracic echocardio- are easy identified, and when the density decreases over time, the
graphy. (A) No intimal flap is visualized in the ascending aorta intimal flap becomes more evident. In the present study, the use of
by two-dimensional echocardiography. (B) Colour Doppler
contrast was safe and significantly improved the diagnosis of AD by
does not identify two different flow patterns. (C) After
TTE, with similar results to TOE in ascending aorta and aortic arch,
contrast-enhancement, the intimal flap (arrow) and the different
density of contrast in true lumen (TL) and false lumen (FL) are and sensitivity increasing from 56.2 to 83.6% in descending aorta
clearly visualized. owing to better definition of both lumen flows. Contrast enhance-
ment also facilitated the assessment of supraaortic vessel
involvement.
Contrast TTE is of limited value in cases with poor imaging
and TOE using colour-coded Doppler did not identify false lumen quality, in the diagnosis of intramural haematoma and in non-
flow direction; however, with the use of contrast, TTE correctly extended thoracic aorta dissection. Obesity, emphysema, mechan-
diagnosed the seven cases (six Type A and one Type B) and ical ventilation, or chest wall deformities may adversely affect the
TOE all nine cases. reliability of TTE, but this represented only 5% of patients in our
Significant aortic regurgitation was diagnosed in 28 patients by series. These limitations imply that TTE is by no means a definitive
TTE and TOE. In 22 cases (78.6%), TTE identified the mechanism test for ruling out the possibility of acute aortic syndrome.
of regurgitation defined by TOE. Although CT was not useful for However, even in negative studies, TTE frequently establishes an
this information, surgery confirmed aortic regurgitation mechan- alternative diagnosis of chest pain in 40% of cases.24 It is well
isms diagnosed by TOE in all cases. Pericardial effusion was diag- established that conventional TTE is very useful for evaluating
nosed in 20 patients by CT, TTE, and TOE. Arch branch vessel aortic regurgitation severity, pericardial tamponade, and left ventri-
involvement was diagnosed by CT in 32 ADs, 28 of which were cular function, providing complementary information to that
Type A (brachiocephalic artery in 28, left common carotid artery obtained by CT in the evaluation of AD.25,26
476 A. Evangelista et al.

Figure 3 Suprasternal view of transthoracic echocardiography in a patient with Type B dissection. Left panel: with non-enhanced study,
intimal flap is not visualized. Right panel: intimal flap (white arrow) and two lumina are visualized in aortic arch.

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not seem justified. However, TOE is the only diagnostic modality
that can be used in the operating room and has the potential to
provide accurate information on some anatomical features that
are important for surgical treatment.11 Transoesophageal echocar-
diography is better than CT in location of the entry tear28,30,31 and
identification of aortic regurgitation mechanisms23 and dynamic
false lumen flow.21 Entry tear exclusion is one of the main objec-
tives of surgical or endovascular therapy in AD. The entry tear is
visualized by TOE in 77 –97% of ADs.21,28,30 – 32 When the entry
tear is not visualized, it is frequently located in the blind aorta seg-
ments on TOE, the upper part of the ascending aorta or the
abdominal aorta. In these cases, the use of contrast permits
location of a non-visualized entry tear by showing the early
arrival of contrast into the false lumen in the dissected aorta.
Some studies have pointed out the different prognoses of ante-
Figure 4 Suprasternal view by transthoracic echocardiography
grade vs. retrograde dissections.33 Although conventional colour
in a patient with Type B dissection. The entry tear is located in
Doppler TOE is often limited for diagnosing the direction of
the upper part of descending aorta (arrow). The absence of con-
trast in the proximal part of the false lumen indicates that no
false lumen flow,32,34 contrast enhancement allows easy differen-
other proximal tear is present. tiation of antegrade vs. retrograde false lumen flow by TTE or
TOE.
Identification of the true lumen is fundamental for correct surgi-
cal or endovascular treatment of the dissection.1,35 Systolic expan-
Role of transoesophageal sion of the true lumen is a useful finding to differentiate true and
echocardiography false lumina.1 Nevertheless, in some cases the intima remains
Transoesophageal echocardiography has been considered a first-line immobile and the use of contrast easily permits identification of
imaging modality in AD diagnosis,9,21,27,28 mainly in patients with the true lumen and significant complications during therapeutic
haemodynamic compromise, owing to its accuracy, rapidity, and procedures can thus be avoided.
portability.7 – 10 However, TOE is limited in visualizing the distal In the present series, TTE was better than TOE for visualizing
part of the ascending aorta and the abdominal aorta, and tends to supraaortic vessels. However, a recent study established a tech-
be observer- and experience-dependent.7 The use of contrast nique for visualizing these arteries in nearly all cases in anaesthe-
improved the diagnosis of Type A AD by TOE by correctly identify- tised patients in intraoperative TOE.36 Finally, TOE was very
ing intraluminal reverberations. We reported that M-mode analysis useful for diagnosing coronary artery and coeliac trunk involve-
of the location and mobility of intraluminal images was better than ment. Although TOE failed to diagnose lower vessel involvement,
assessing different flow patterns by colour Doppler in the correct this information is less important in the first few hours.
diagnosis of these artefacts.29 However, in some difficult cases, con-
trast may add rapid, valuable information.18 Clinical implications
When the diagnosis of Type A dissection is clearly established Transthoracic echocardiography constitutes a routine non-invasive
by contrast TTE, with or without CT, a confirmatory TOE does diagnostic option widely available in almost any community
Contrast echocardiography in the diagnosis of AD 477

Table 2 Diagnosis of aortic dissection

Global TTE Contrast TTE TOE Contrast TOE

...............................................................................................................................................................................
Sensitivity (%) 73.7* (63.1– 84,2) 86.8† (78.6– 95.1) 97.3 (93.1–100) 97.3 (93.1–100)
Specificity (%) 71.2* (57.9– 84.4) 90.4 (81.3– 100) 94.2 (86.9–100) 100 (99.0–100)
PPV (%) 78.9 (68.7– 89.1) 93.0 (85.0– 100) 96.1 (91.1–100) 100 (99.3–100)
NPV (%) 64.9 (51.7– 78.2) 82.5 (71.0– 94.0) 96.1 (89.8–100) 96.3 (90.3–100)

TTE, transthoracic echocardiography; TOE, transoesophageal echocardiography. Numbers in parentheses are 95% CIs.
*P , 0.005 TTE vs. contrast TTE, TOE, and contrast TOE after Bonferroni correction for multiple post hoc comparisons.
†
P , 0.05 contrast TTE vs. TOE and contrast TOE.

Table 3 Diagnosis of aortic dissection in relation to aortic segments

Ascending aorta dissection TTE Contrast TTE TOE Contrast TOE

...............................................................................................................................................................................
Sensitivity (%) 82.2* (69.9–94.5) 93.3 (84.9–100) 95.6 (88.4– 100) 95.6 (88.4–100)

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Specificity (%) 89.2* (81.9–96.5) 97.6 (93.7–100) 96.4 (91.8– 100) 100 (99.4–100)
PPV (%) 80.4 (67.9–93.0) 95.5 (88.2–100) 93.5 (85.3– 100) 100 (98.8–100)
NPV (%) 90.2 (83.2–97.3) 96.4 (91.9–100) 97.6 (93.6– 100) 97.6 (93.8–100)
...............................................................................................................................................................................
Aortic arch dissection
Sensitivity (%) 79.1* (65.8–92.4) 88.4 (77.6–99.1) 90.7 (80.9– 100) 95.4 (87.9–100)
Specificity (%) 88.2†‡ (80.8–95.7) 95.3 (90.2–100) 98.8 (95.9– 100) 100 (99.4–100)
PPV (%) 77.3 (63.8–90.8) 90.5 (80.4–100) 97.5 (91.4– 100) 100 (98.8–100)
NPV (%) 89.3 (82.1–96.5) 94.2 (88.7–99.7) 95.5 (90.5– 100) 97.7 (93.9–100)
...............................................................................................................................................................................
Descending aorta dissection
Sensitivity (%) 56.2} (44.1–68.2) 83.6§ (74.4–92.8) 100 (99.3– 100) 100 (99.3–100)
Specificity (%) 81.8* (70.7–92.9) 94.5 (86.0–100) 100 (99.1– 100) 100 (99.1–100)
PPV (%) 80.4 (68.5–92.3) 95.3 (87.2–100) 100 (99.3– 100) 100 (99.3–100)
NPV (%) 58.4 (46.8–70.1) 81.3 (70.7–91.9) 100 (99.1– 100) 100 (99.1–100)

TTE, transthoracic echocardiography; TOE, transoesophageal echocardiography.

*P , 0.05 TTE vs. contrast TTE, TOE, and contrast TOE.
†
P , 0.05 TTE vs. contrast TTE.
‡
P , 0.01 TTE vs. TOE and contrast TOE.
}
P , 0.001 TTE vs. contrast TTE, TOE, and contrast TOE after Bonferroni correction for multiple post hoc comparison.
§
P , 0.001 contrast TTE vs. TOE and contrast TOE after Bonferroni correction for multiple post hoc comparison.

Figure 5 Contrast-enhanced TTE. Left panel: retrograde Type A dissection. Arrival of contrast in false lumen is observed from the aortic arch
(large arrow). Antegrade flow (small arrow) is visualized in true lumen (TL). Right panel: retrograde Type B dissection. Antegrade contrast flow
in TL (black arrow). Retrograde progression of false lumen contrast from distal abdominal aorta (white arrow) located the distal entry tear.
478 A. Evangelista et al.

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