Differential transesophageal echocardiographic diagnosis between linear artifacts and intraluminal flap of aortic dissection or disruption

Background: The relatively low specificity of transesophageal echocardiogra phy (TEE) for the diagnosis of aortic dissection (AD) or traumatic disrupti on of the aorta (TDA) has been attributed to linear artifacts. We sought to determine the incidence of intra-aortic linear artifacts in a cohort of pa tients with suspected AD or TDA, to establish the differential TEE diagnost ic criteria between these artifacts and true aortic flaps, and to evaluate their impact on TEE diagnostic accuracy. Methods and results: During an 8-year period, patients at high risk of AD ( n = 261) or TDA (n = 90) who underwent a TEE study and had confirmed final diagnoses were studied. In an initial retrospective series, linear artifact s were observed within the ascending and descending aorta in 59 of 230 pati ents (26%) and 17 of 230 patients (7%), respectively. TEE findings associat ed with linear artifacts in the ascending aorta were as follows: displaceme nt parallel to aortic walls; similar blood flow velocities on both sides; a ngle with the aortic wail > 85 degrees; and thickness > 2.5 mm, Diagnostic criteria of reverberant images in the descending aorta were as follows: dis placement parallel to aortic walls, overimposition of blood flow, and simil ar blood flow velocities on both sides of the image. In a subsequent prospe ctive series (n = 121), systematic use of these diagnostic criteria resulte d in improved TEE specificity for the identification of true intra-aortic f laps. Conclusions: Misleading intra-aortic linear artifacts are frequently observ ed in patients undergoing a TEE study for suspected AD or TDA, Routine use of the herein-proposed diagnostic criteria promises to further improve TEE diagnostic accuracy in the setting of severely ill patients with potential need for prompt surgery.