PENETRATING ATHEROSCLEROTIC AORTIC ULCER - DOCUMENTATION BY TRANSESOPHAGEAL ECHOCARDIOGRAPHY

Objectives. This study sought to describe the ability of transesophage al echocardiography (TEE) to document the presence of penetrating athe rosclerotic aortic ulcers and their complications. Background. TEE has greatly enhanced our ability to assess patients with suspected aortic disease. However, the utility of this technique in the diagnosis of p enetrating atherosclerotic aortic ulcers is still undefined. Methods. TEE was performed prospectively in 194 patients to evaluate aortic dis ease. Twelve patients with the diagnosis of aortic ulcers or their com plications were specifically studied. The diagnosis was confirmed by p athologic studies in six patients and by an additional diagnostic tech nique (angiography, computed tomography or magnetic resonance imaging) in the other six. All 12 patients were hypertensive and presented wit h chest or back pain; the mean age was 65 years (range 56 to 79). The initial working diagnosis was acute aortic dissection in nine patients . Aortic ulcers were located in the descending thoracic aorta in eight patients, the aortic arch in two and the ascending aorta in two. Resu lts. TEE could detect aortic ulcers or their complications in 10 patie nts but failed to detect these lesions in the remaining 2 (1 with aort ic ulcers in the distal ascending aorta and 1 with aortic ulcers in th e aortic arch). In four patients, aortic ulcers were detected as a cal cified focal outpouching of the aortic wall and were associated with c oncomitant aneurysmal dilation of the aorta in two patients and with a small localized intramural hematoma in one. TEE visualized a partiall y thrombosed pseudoaneurysm complicating an aortic ulcer in the descen ding thoracic aorta of two patients. Four patients had an aortic ulcer complicated by a ''limited aortic dissection'' in the descending aort a that could be detected by TEE. Five patients underwent operation, ho because of aneurysmal dilation of the aorta and three because of aort ic dissection; two patients died of aortic rupture; the remaining five did well (11-month follow-up) without operation. Conclusions. Aortic ulcers should be included in the differential diagnosis of chest or ba ck pain, especially in elderly hypertensive patients. These ulcers and their complications may be recognized by TEE. (C) 1998 by the America n College of Cardiology.