erbelet al. europeanheartjournal 2014tusar-centre-ouest.e-monsite.com › medias › files ›...
TRANSCRIPT
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Anatomie
Erbel et al. European Heart Journal 2014
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ETT
Para-sternale Grand Axe: Racine + Aorte Ascendante
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ETT
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ETT
1 espace intercostal + haut: meilleure visualisation de l’aorte ascendante
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ETT
Supra Sternale: Crosse
Endapex: Segment III Sous-costale: Aorte Abdo
Evangelista et al. European J Echo 2010
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ETO
Ao I
VCS
Coupe 0-30° haute: Aorte ascendante
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ETO
Coupe 30° haute: Sinus de valsalva - coronaires
TCGCD
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ETO
Aorte
OG
VG
Coupe 120°: Racine + Aorte Ascendante
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ETO
Coupe 0° rotation sonde à l’opposé: Segment III
ANT
POST
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ETO
Coupe 90° rotation sonde à l’opposé: Segment III – longitudinal
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ETO
Coupe 0° rotation sonde à l’opposé – haute : Segment II
DISTAL
PROXIMAL
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ETO
SCG
Coupe 0° rotation sonde à l’opposé – haute : Segment II - SCG
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Méthodologie de mesure
Mesures en Diastole
Bord d’attaque à bord d’attaque
En 2D
Evangelista et al. European J Echo 2010
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Méthodologie de mesure
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Méthodologie de mesure
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Valeurs normales
Evangelista et al. European J Echo 2010; Roman et al Am J Cardiol 1989
Ao Asc : Nale < 21 mm/m2
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Influence de la corpulence
Roman MJ – Am J Cardiol 1989
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Influence de l’âge
Vriz et al. Am J cardiol 2014
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Influence du sexe
Vriz et al. Am J cardiol 2014
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Limites de l’échographie
Elefteriades et al. JACC 2010
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Limites de l’échographie
Elefteriades et al. JACC 2010
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Limites de l’échographie
Elefteriades et al. JACC 2010
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Pathologie Aiguë
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SAA: Répartition selon la pathologie
Salvolini et al. Eur J Radiol 2008
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Dissection aortique
• Clivage longitudinal de la paroi aortique au niveau de la média
• Jonction 1/3 ext; 2/3 int
• Porte d’entrée (déchirure intimale)
• Aiguë : ≤ 14 j après symptômes
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Dissection aortique
Erbel et al. European Heart Journal 2014
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DA: Comparaison ETT et ETO
• ETT: • Sensibilité 62%
• Spécificité 85 %
• ETO• Sensibilité 99 %
• Spécificité 98 %
• Mais ETT + rapide et – invasive !
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Comparaison Echo/IRM-CT
ETT/ETO IRM-CT
Flap + +
Vraie/Fausse lumière + +
Porte d’entrée + +/-
IAo + -
Epcht Péric + +
Syndr Malperfusion - +
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DA: Fiabilité des techniques
Nb d’études Sens Spec
ETO 10 98% 95%
AngioScanner 3 100% 98%
IRM 7 98% 98%
Shiga T et al. Arch Int Med 2006
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DA: Diagnostic Echo
• Buts de l’examen:• Confirmer la dissection
• Préciser type (A/B/extension)
• Préciser site(s) de la (des) portes d’entrées
• Préciser l’existence de complications:o Dissection coronaire
o IA (mécanisme/sévérité
o Epanchement péricardique
o Hématome médiastinal
o Epanchement pleural
� Eléments essentiels pour la discussion médico-chirurgicale
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Voile intimal = maître signe
• En TM• Double trait ± mobile• Dédoublement de la paroi aortique
• En 2D• Image linéaire intraluminale ± longue ± mobile
• Faux positifs• Réverbération• Plaque athéromateuse
• Faux négatifs• Forme localisée• Thrombose complète du faux chenal
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DA segment II: voile intimal
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DA type I: ETT PSG transverse
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Flap segment III sous costale ETT
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DA type I: voile intimal/portes d’entrée
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DA: ETT segment II et III
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DA: pièges diagnostics
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Vrai et faux chenal
Le faux chenal est généralement
• externe
• Plus large que le vrai
• Le siège de flux à basse vitesse
• Le siège de contraste spontané et de thrombose
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DA type I: vraie et fausse lumière
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Porte d’entrée
• Solution de continuité dans l’intima
• Présence d’1 flux couleur
• Faux chenal ± perméable
• Parfois borgne sous tension
• Parfois réentrées
Aorte horizontale 10%
Aorte
ascendante
65% Aorte
descendante
20%
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DA: porte d’entrée
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DA: porte d’entrée
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DA: Complications
• Insuffisance aortique : 60 % des types I et II• Mécanisme à préciser
• Quantification en doppler
• Extravasation périaortique
• Épanchement péricardique
• Atteinte coronaire et vx périphériques
• Étude de la fonction VG• HTA
• IDM
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Mécanismes de l’IA dans la DA
n = 12
n = 8
n = 3
Iao modérée/sévère N= 23/50
Ne sont pas réparables
- Marfan- Bicuspidie- “aortite”
Normal = 27/50
Movsowitz et al. JACC 2000
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DA: IA Sévère
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DA: IA sévère
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DA: prolapsus du flap
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L’ETO n’est pas sans risque
• Patient traité médicalement• Beta bloquants
• Antihypertenseurs
• Patient sédaté ++
� Prémédication cruciale +++
Erbel et al. European Heart Journal 2014
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DA : Traitement
Erbel et al. European Heart Journal 2014
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Surveillance d’une dissection
• Dissection non opérée• Persistance des 2 chenaux : 75 % des cas
• Extension antérograde ou rétrograde possible
• Persistance de la porte d’entrée
• Dilatation progressive de l’aorte
• Dissection opérée• Persistance des 2 chenaux : 75 % des cas
• Thrombose autour du tube prothétique
• Faux anévrysme au niveau des sutures
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Ex: Faux-anevrysme après Bentall
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Ex: Faux-anevrysme après Bentall
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Hématome intra-mural
• Etiologie rare de syndrome douloureux thoracique
• Retrouvé dans 10% des DA
• 90 % des patients ont 1 HTA
• Diagnostic écho• Refoulement de l’intima (Ca++) vers la lumière de l’aorte• Élargissement non spécifique du calibre aortique• Épaississement en croissant de la paroi aortique > 5 mm• Absence de rupture intimale• Absence de flux
• Siège : Aorte desc (2/3 cas) ou asc (1/3)
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Hématome paroi
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Hématome paroi
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Hematome paroi segt III
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Hematome intra-mural
Evangelista et al. European J Echo 2010
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HIM: Evolution
• Stabilisation, voire régression (1/3)
• Progression de l’hématome, Dissection aortique (1/3)
• Rupture de la paroi externe (1/3)
• Dilatation anévrysmale ou pseudo-anévrysmale
• Pronostic assez voisin des DA:• Mortalité hospit : 21% (HIA) vs 24% (DA)
• Si type I : 39% (HIA) vs 30% (DA)
• Si type III : 8% (HIA) vs 13% (DA)
Registre IRAD (n=58 pts) – Evangelista A et al. Circulation 2005
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HIM: traitement
• Type A: Chir urgente• Type B: Medical• Type B compliqué: plutôt TEVAR• Contrôle +++ de l’évolutivité : 1, 3,
6, 9, 12 mois si médical
Evangelista A et al. Circulation 2005; Erbel et al. European Heart Journal 2014
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Ulcère pénétrant athéromateux
• D’abord décrit comme cause possible de dissection (Shennan, 1934)
• Plaque athéromateuse, unique ou multiple, dont l’ulcération finit par déchirer la média
• 7 à 10% des aortes douloureuses
• Siège : aorte thoracique descendante ++
• Age moyen 70 ans
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Echographie cardiaque (ETO)
•Cratère à bords irréguliers, sur aorte athéromateuse, souvent dilatée
•Complications : hématome intra-mural, dissection
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Evolution
• Hématome intra-mural
• Pseudo-anévrysme adventiel
• Extension de l’ulcération, à l’origine d’une véritable dissection (17 à 40%), surtout UP localisés sur l’aorte ascendante
• Développement d’un anévrysme, souvent sacculaire
Indications opératoires ≈ HIM
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Evolution
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Rupture Traumatique de l’Aorte (isthme +++)
Guidelines for treatment ot traumatic aortic injuryJ Vasc Surg – 2011
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Quand suspecter 1 RTA ?
- polytraumatisé ou trauma thoracique sévère
- décélération horizontale- décéleration verticale
- et/ou élargissement du médiastin supérieur (8 cm)
- Flap intimal épais (intima + média), mobile à l ’intérieur de la lumière
- Dilatation localisée et déformation des contours de l ’aorte sous tension (paroi réduite à l ’adventice)
Diagnostic Echographique (ETO) :
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Rupture totale
- Présence d'1 écho intraluminal circulaire, épais,battant localisé- Déformation aortique localisée- Flux de part et d'autre de la déchirure avec présence d'1 aliasing- Hématome mediastinal
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Rupture subtotale
- Présence d'1 écho intraluminal linéaire, épais, battant localisé- Déformation aortique localisée- Flux de part et d'autre de la déchirure avec aliasing couleur- Hématome médiastinal
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RTA : rupture partielle
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RTA isthmique: faux anévrysme
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Rupture partielle
- Présence d'1 écho intraluminal linéaire, épais, battant, localisé- Déformation aortique localisée inconstante- Présence d'1 aliasing- Hématome médiastinal
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Hématome mediastinal
Vignon Chest 1998; Slama Arch mal cœur 1997
- D1 > 5.5 ou D2 > 6.6 a 1 sens de 80 % et 1 specif de 92 % pour 1 RTA- Evolution : diminution ou disparition ds 80 % des cas,- Pas de surmortalite si pas de RTA
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RTA : prise en charge
TEVAR (tt endovasc) (mort 9%) > open aortic repair (19%) > tt med (46%)
Erbel et al. European Heart Journal 2014
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Conclusion
• L ’ETT et surtout l ’ETO demeurent des techniques difficilement contournables dans l’exploration de l’aorte thoracique
• L’exploration ultrosonore intervient cependant en complément des autres techniques d’imagerie (angioscanner, IRM), notamment pour la crosse aortique et l’aorte descendante
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Bibliographie
2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. Erbel et al. Eur Heart J. 2014 Nov 1;35(41):2873-926
Echocardiography in aortic diseases : EAE recommandations for clinical practice. Evangelista A et al – Eur J Echocardiogr 2010;11:645-58
2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic AorticDisease J Am Coll Cardiol. 2010 Apr 6;55(14):e27-e129
Two-dimensional echocardiographic aortic root dimensions in normal children and adults . Roman MJ et al – Am J Cardiol 1989;64:507-12
Diagnosis and management of aortic dissections . Recommandations of the task force on aortic dissection. ESC. Erbel R et al . Eur Heart J 2001;22:1642-81
Echocardiography in the emergency assessment of acute aortic syndromes . Meredith EL et al . Eur J Echocardiogr 2009;10:121-9
Diagnostic accuracy of TEE, helical CT and magnetic resonance imaging for suspected thoracic aortic dissection. Systematic review and meta-analysis. Shiga T et al. Arch Int Med 2006;166:1350-6
The French Study of Aortic Plaques in stroke group : atherosclerotic disease as a risk factor for recurrent ischemic stroke . N Engl J Med 1996;334:1216-21