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It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced in the detection, management,

/pdf/acc-aha-2006-guidelines-for-the-management-of-patients-with-27qfh9fc7i.pdf

ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

https://www.medpagetoday.com/upload/2014/3/3/02536-1.pdf

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease

ContextAcute aortic dissection is a life-threatening medical emergency associated
with high rates of morbidity and mortality. Data are limited regarding the
effect of recent imaging and therapeutic advances on patient care and outcomes
in this setting.ObjectiveTo assess the presentation, management, and outcomes of acute aortic
dissection.DesignCase series with patients enrolled between January 1996 and December
1998. Data were collected at presentation and by physician review of hospital
records.SettingThe International Registry of Acute Aortic Dissection, consisting of
12 international referral centers.ParticipantsA total of 464 patients (mean age, 63 years; 65.3% male), 62.3% of whom
had type A dissection.Main Outcome MeasuresPresenting history, physical findings, management, and mortality, as
assessed by history and physician review of hospital records.ResultsWhile sudden onset of severe sharp pain was the single most common presenting
complaint, the clinical presentation was diverse. Classic physical findings
such as aortic regurgitation and pulse deficit were noted in only 31.6% and
15.1% of patients, respectively, and initial chest radiograph and electrocardiogram
were frequently not helpful (no abnormalities were noted in 12.4% and 31.3%
of patients, respectively). Computed tomography was the initial imaging modality
used in 61.1%. Overall in-hospital mortality was 27.4%. Mortality of patients
with type A dissection managed surgically was 26%; among those not receiving
surgery (typically because of advanced age and comorbidity), mortality was
58%. Mortality of patients with type B dissection treated medically was 10.7%.
Surgery was performed in 20% of patients with type B dissection; mortality
in this group was 31.4%.ConclusionsAcute aortic dissection presents with a wide range of manifestations,
and classic findings are often absent. A high clinical index of suspicion
is necessary. Despite recent advances, in-hospital mortality rates remain
high. Our data support the need for continued improvement in prevention, diagnosis,
and management of acute aortic dissection.

https://jamanetwork.com/journals/jama/articlepdf/192401/JOC90321.pdf

The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease.

2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC).

Jeffrey L. Anderson, MD, FACC, FAHA, Chair , Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect , Nancy M. Albert, PhD, CCNS, CCRN, FAHA, Biykem Bozkurt, MD, PhD, FACC, FAHA, Ralph G. Brindis, MD, MPH, MACC, Mark A. Creager, MD, FACC, FAHA[§§][1], Lesley H. Curtis, PhD, FAHA, David DeMets, PhD,

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Background The treatment of thoracic aortic dissection is guided by prognostic and anatomical information. Proximal dissection requires surgery, but the appropriate treatment of distal thoracic aortic dissection has not been determined, because surgery has failed to improve the prognosis. Methods We prospectively evaluated the safety and efficacy of elective transluminal endovascular stent–graft insertion in 12 consecutive patients with descending (type B) aortic dissection and compared the results with surgery in 12 matched controls. In all 24 patients, aortic dissection was diagnosed by magnetic resonance angiography. In each group, the dissection involved the aortic arch in 3 patients and the descending thoracic aorta in all 12 patients. With the patient under general anesthesia, either surgical resection was undertaken or a custom-designed endovascular stent–graft was placed by unilateral arteriotomy. Results Stent–graft placement resulted in no morbidity or mortality, whereas surgery for type B disse...

https://www.nejm.org/doi/pdf/10.1056/NEJM199905203402003

Nonsurgical Reconstruction of Thoracic Aortic Dissection by Stent–Graft Placement

Background and Methods This study was designed to assess the safety and reliability of new noninvasive imaging methods as compared with aortography in the diagnosis of dissection of the thoracic aorta. One hundred ten patients with clinically suspected aortic dissection followed a diagnostic protocol that included transthoracic and transesophageal color-flow Doppler echocardiography (TTE and TEE), contrast-enhanced x-ray computed tomography (CT), and magnetic resonance imaging (MRI). Imaging results were compared in a blinded fashion and validated independently against intraoperative findings in 62 patients, autopsy findings in 7, and the results of contrast angiography in 64. Results The sensitivities of MRI, TEE and x-ray CT for detecting dissection were similar, at 98.3, 97.7, and 93.8 percent, respectively; TTE had a sensitivity of only 59.3 percent (P<0.005). The specificities of both TTE (83.0 percent) and TEE (76.9 percent) were lower than those of x-ray CT (87.1 percent) and MRI (97.8 percent; P<0...

The diagnosis of thoracic aortic dissection by noninvasive imaging procedures.

BACKGROUNDAortic dissection requires prompt and reliable diagnosis to reduce the high mortality. The purpose of this study was to assess the reliability of both ECG-triggered magnetic resonance imaging (MRI) and transesophageal two-dimensional echocardiography combined with color-coded Doppler flow imaging (TEE) for the diagnosis of thoracic aortic dissection and associated epiphenomena.METHODS AND RESULTSFifty-three consecutive patients with clinically suspected aortic dissection were subjected to a dual noninvasive imaging protocol in random order; imaging results were compared and validated against the independent morphological "gold standard" of intraoperative findings (n = 27), necropsy (n = 7), and/or contrast angiography (n = 53). No serious side effects were encountered with either imaging method. In contrast to a precursory screening transthoracic echogram, the sensitivities of both MRI and TEE were 100% for detecting a dissection of the thoracic aorta irrespective of its location. The specificit...

Diagnosis of thoracic aortic dissection. Magnetic resonance imaging versus transesophageal echocardiography.

Chest radiography for the diagnosis of acute aortic syndrome.

The goal of this study was to prospectively compare the accuracy of transthoracic and transesophageal B-mode and Doppler echocardiography with helical CT for detecting acute pulmonary embolism.Thirty-five consecutive patients underwent transthoracic and transesophageal echocardiography and contrast-enhanced helical CT. Echocardiographic examinations were analyzed for indirect criteria, including increased main pulmonary artery diameter, tricuspid regurgitation, and dilatation of the right ventricular cavity, as well as for direct thrombus visualization. Sensitivity, specificity, and negative and positive predictive values were calculated.Pulmonary embolism was revealed by helical CT in 22 of 35 patients; in 11 of these 22 cases, central pulmonary embolism was seen. Transthoracic and transesophageal B-mode echocardiography failed to reveal pulmonary embolism in nine patients, two of whom had central pulmonary embolism. The sensitivity and specificity of the combination of both echocardiographic investigati...

https://www.ajronline.org/doi/pdfplus/10.2214/ajr.167.4.8819386

V. Nicolas

Papers

Nonsurgical Reconstruction of Thoracic Aortic Dissection by Stent–Graft Placement

The diagnosis of thoracic aortic dissection by noninvasive imaging procedures.

Diagnosis of thoracic aortic dissection. Magnetic resonance imaging versus transesophageal echocardiography.

Chest radiography for the diagnosis of acute aortic syndrome.

Acute pulmonary embolism: value of transthoracic and transesophageal echocardiography in comparison with helical CT.