The Use of EchocardiographicContrast-Enhanced Rapid Diagnosis of

Ruptured Aortic Dissection withTransthoracic Echocardiography

Ameen Abdulmalik, MD, Gerald Cohen, MD, FACC, FASE, Detroit, Michigan

Aortic dissection is an uncommon but often fatalcondition if not promptly managed. Although thediagnosis is generally established by transesopha-geal echocardiography, contrast computed tomogra-phy, or magnetic resonance imaging, clinical andradiologic assessment and transthoracic echocardi-ography represent the first-line approach to pa-tients with sudden onset of severe tearing thoracicpain. Although surface image quality and spatial

doi:10.1016/j.echo.2007.03.014

the presence of aortic dilatation, aortic regurgita-tion, segmental ventricular dysfunction, and effu-sions indicate a greater likelihood of a lethal out-come and hasten urgent management. Because anaortic rupture may be the cause of an effusion, rapiddiagnosis is crucial. We report an unusual case ofStanford type B aortic dissection with rupture thatwas diagnosed by transthoracic echocardiographyand confirmed with an ultrasound contrast injec-

resolution may prevent detection of an intimal flap, tion. (J Am Soc Echocardiogr 2007;20:1317.e5-e7.)

CASE REPORT

A 58-year-old man with a history of hypertensionand nephrolithiasis presented to the emergencydepartment with severe lower back pain thatstarted abruptly after dinner. The pain radiated tothe abdomen and was associated with vomitingbut no chest pain. He presented in moderatedistress and was afebrile, diaphoretic, and tachy-pneic with a blood pressure of 204/102 mm Hg,heart rate of 75 beats/min, and oxygen saturationof 98% on room air. The jugular veins were notdistended, heart sounds were normal, and lungswere clear. The abdomen was benign except formild epigastric tenderness. Pulses were palpableand symmetric but diminished.

Transthoracic echocardiography showed a largeleft pleural effusion with a collapsed lung, organiza-tion, possible hematoma, and a dissection of thenormal-sized abdominal aorta with a clear intimalflap (Fig. 1A and B). Suboptimal image qualityprevented evaluation of left ventricular function,prompting administration of an ultrasound contrastagent, Definity (Activated Perflutren Lipid Micro-spheres; Bristol-Myers Squibb Medical Imaging,

From the Department of Cardiology, St. John Hospital and Med-ical Center, Detroit, Michigan.Reprint requests: Ameen Abdulmalik, MD, St. John Hospital andMedical Center, Cardiology, 22101 Moross, Detroit, MI 48236(E-mail: ameen.abdulmalik@stjohn.org).0894-7317/$32.00Copyright 2007 by the American Society of Echocardiography.

North Billerica, Mass). Enhanced images showednormal left ventricular function and opacification ofthe true lumen, but not the false lumen, of thedissected abdominal aorta (Fig. 1C and D). Ruptureof the thoracic descending aorta was indicated byvisualization of the Definity contrast bleeding fromthe aorta into the pleural cavity (Fig. 1C and Video1C). Emergency transesophageal echocardiographyconfirmed Stanford type B aortic dissection. Thesefindings prompted urgent insertion of a 26-mm �10-cm TAG endograft stent (W. L Gore & Associates,Inc., Flagstaff, Ariz) into the descending thoracicaorta. Hospitalization was complicated by loculatedpleural effusion with entrapment of the left lungrequiring thoracotomy and decortications. The pa-tient underwent physical rehabilitation and wasdischarged after 4 weeks. He continues to do well.

DISCUSSION

Acute aortic dissection is associated with earlymortality as high as 1% per hour if untreated andcarries greater than 50% mortality if ruptured.1-3

Despite our greater understanding of the disease,clinical presentation is diverse and outcome iscatastrophic if not promptly managed.4,5 Contrastcomputed tomography, magnetic resonance imag-ing, and transesophageal echocardiography arehighly accurate in establishing the diagnosis6 butare not as expeditiously doable as bedside trans-thoracic imaging. Although transthoracic echocar-diography has a low sensitivity for the diagnosis of

aortic dissection,6 use of intravenous echocardio-

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Journal of the American Society of Echocardiography1317.e6 Abdulmalik and Cohen November 2007

graphic contrast agent can decrease artifact andhelp delineate the true and false lumen of aorticdissection.7,8 Furthermore, our case report showshow intravenous ultrasound contrast can be use-ful in the diagnosis of aortic rupture.

Pleural effusion is a common finding in aorticdissection, especially Stanford type B, and may bethe dissection’s only presenting feature.9,10 Typi-cally, pleural effusion becomes evident 4.5 � 3.9with a range of 1 to 15 days after presentation.11

Whether the pleural effusion is reactive or hemor-rhagic secondarily to rupture should be promptlyinvestigated because rupture has a poor outcome.Intravenous ultrasound contrast has also been usedto diagnose rupture as the cause of pericardialeffusion.12

Transthoracic echocardiography with contrastcan effectively diagnose a ruptured aortic dissec-tion that is actively bleeding while stabilizing thepatient medically and awaiting a definitive diag-nostic modality to be performed. The diagnosis ofruptured aortic dissection will expedite the ar-rangement for surgical or percutaneous interven-tion. If there is clinical concern that a pericardialor pleural effusion is the result of aortic rupture,

Figure 1 A and C: Apical four chambers withouaorta without and with contrast, respectively. Siteinto left pleural cavity (arrowheads). Contrast in lflap (dotted arrow). EFF, Left pleural effusion; HEventricle; LA, left atrium; TL, true lumen; FL, fal

bedside confirmation may be quickly achieved by

the administration of ultrasound contrast duringtransthoracic echocardiography.

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Journal of the American Society of EchocardiographyVolume 20 Number 11 Abdulmalik and Cohen 1317.e7

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