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AORTIC DISSECTION

Like PE, bedside echo is only a rule in test for aortic dissection with a sensitivity of 77-80%  (1,2). A type B dissection may not even be seen unless you look at the abdominal aorta and dissection extends that far. Whenever you see an echogenic pericardial effusion or ischaemic changes on the ECG which don't have reciprocal changes or don't fit an arterial territory, go looking for a dissection flap. 

Features suggestive of a type A dissection are (3,4):

1. Dilated ascending aorta (>3cm or >1:1 with RV and LA)

2. Acute aortic regurgitation

3. hyperechoic undulating dissection flap

4. echogenic pericardial effusion

5. RWMA 

DILATED ASCENDING AORTA

The ascending aorta in PLAx is normally 1:1 with the RV and LA. Sometimes with dissection, the ascending aorta can become dilated. Always look for AR and a dissection flap if you see this, 

PLAx: dilated ascending aorta -  1:1:1 RV:Ao:LA ratio not met. If you look closely you can see the dissection flap. Also the pericardial effusion has echogenic material: likely clot.

DISSECTION FLAP

A dissection flap is hyperechoic and undulating. It seems to float like a flag in the breeze. You can see it in PLAx or in the supraclavicular view.  Sometimes, artefacts (especially reverberation) can look like a dissection flap. So ensure you see the flap in multiple views and that it has motion independent to the aortic walls. 

The supraclavicular view can sometimes be helpful in showing the flap. 

AORTIC REGURGITATION

Sometimes, the dissection or the dilation of the ascending aorta causes AR. Putting colour on the valves will show a regurgitant jet.

RWMA

Typically aortic dissection causes RV RWMA due to dissection into the right coronary artery.

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REFERENCES

1. Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A, Rakowski H, Struyven J, Radegran K, Sechtem U, Taylor J, Zollikofer C, Klein WW, Mulder B, Providencia LA; Task Force on Aortic Dissection, European Society of Cardiology. Diagnosis and management of aortic dissection. Eur Heart J. 2001 Sep;22(18):1642-81. doi: 10.1053/euhj.2001.2782. PMID: 11511117.

2. Evangelista A, Flachskampf FA, Erbel R, Antonini-Canterin F, Vlachopoulos C, Rocchi G, Sicari R, Nihoyannopoulos P, Zamorano J; European Association of Echocardiography; Document Reviewers:, Pepi M, Breithardt OA, Plonska-Gosciniak E. Echocardiography in aortic diseases: EAE recommendations for clinical practice. Eur J Echocardiogr. 2010 Sep;11(8):645-58. doi: 10.1093/ejechocard/jeq056. Erratum in: Eur J Echocardiogr. 2011 Aug;12(8):642. PMID: 20823280.

3. Nishigami K. Update on Cardiovascular Echo in Aortic Aneurysm and Dissection. Ann Vasc Dis. 2018 Dec 25;11(4):437-442

4. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM; 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; Society for Vascular Medicine. Circulation. 2010 Apr 6;121(13):e266-369.