THE DIAGNOSIS OF THORACIC AORTIC DISSECTION BY NONINVASIVE IMAGING PROCEDURES

Background and Methods. This study was designed to assess the safety and reliability of new noninvasive imaging methods as compared with aortography in the diagnosis of dissection of the thoracic aorta. One hundred ten patients with clinically suspected aortic dissection followed a diagnostic protocol that included transthoracic and transesophageal color-flow Doppler echocardiography (TTE and TEE), contrast-enhanced x-ray computed tomography (CT), and magnetic resonance imaging (MRI). Imaging results were compared in a blinded fashion and validated independently against intraoperative findings in 62 patients, autopsy findings in 7, and the results of contrast angiography in 64. Results. The sensitivities of MRI, TEE and x-ray CT for detecting dissection were similar, at 98.3, 97.7, and 93.8 percent, respectively; TTE had a sensitivity of only 59.3 percent (P<0.005). The specificities of both TTE (83.0 percent) and TEE (76.9 percent) were lower than those of x-ray CT (87.1 percent) and MRI (97.8 percent; P<0.05), mainly as a result of false positive findings in the ascending aorta. MRI and x-ray CT were more sensitive than TTE in detecting the formation of thrombus in the entire thoracic aorta (P<0.05), but were not superior to TEE in this regard. CT was not effective in detecting an entry site or aortic regurgitation, but MRI and TEE accurately identified both. Two patients died during or soon after CT and TEE, and three died between retrograde angiography and surgery. Conclusions. A noninvasive diagnostic strategy using MRI in all hemodynamically stable patients and TEE in patients who are too unstable to be moved should be considered the optimal approach to detecting dissection of the thoracic aorta. Comprehensive and detailed evaluation can thus be reduced to a single noninvasive diagnostic test in the investigation of suspected dissection of the thoracic aorta.