New ASE Guidelines: What you must know

1 New ase guidelines : what you must know Federico M Asch MD, FASE, FACC. Chair, ase guidelines and Standards Committee Medstar Washington Hospital center Medstar Health Research Institute Georgetown University Washington, DC. Costa Rica, August 2015. DISCLOSURE. I, Federico Asch, have no relevant financial relationships with pharmaceutical, devices companies or the Educational Committee related to this activity. ase guidelines 2014. Expert Consensus for Multimodality Imaging Evaluation of Adult Patients during and after Cancer Therapy: A Report from the ASE and EACVI, JASE, September 2014.

2 guidelines for the Cardiac Sonographer in the Performance of Contrast Echocardiography: A Focused Update from the ASE, JASE, August 2014. Radiation Safety for the Cardiac Sonographer: Recommendations of the Radiation Safety Writing Group for the Council on Cardiovascular Sonography of the ASE, JASE, August 2014. Multimodality Imaging guidelines for Patients with Repaired Tetralogy of Fallot: A Report from the ASE, JASE, February 2014. ase guidelines 2015. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and the EACVI, JASE, January 2015.

3 guidelines for the Use of Echocardiography as a Monitor for Therapeutic Intervention in Adults: A Report from the ASE, JASE, January 2015. Multimodality Imaging of Diseases of the Thoracic Aorta in Adults: From the ASE and the EACVI. JASE, February 2015. Use of Echo in Adult Hypertension: From EACVI and ASE. JASE July 2015. guidelines for the Evaluation of ASD and PFO: ASE and SCA. JASE August 2015. guidelines for the use echo in the management of patients with Left Ventricular Assist Device. JASE, August 2015.

4 Update from the 2005 ASE Chamber Quantification document (Lang et al). Most referenced article in JASE history (>5500). Need for update given newer technologies newer techniques wealth of normative data available what is new in the Updated CQ document Chamber dimension and function encompass many parameters, including strain and 3D echo. Describes all four chambers, and it is done in a way to avoid discrepancies with other guidelines . (2005 was only LV and LA). The writing group created the data from five databases representing > 3,000 patients.

5 (2005. was expert opinion). The new document only indicates normal/abnormal. It will be left to the individual institutions to determine what they consider mild/moderate/severe. Multiple modalities described M-mode 2D linear 2D Volumes Multiple modalities described 2D Contrast 3D. Strain LV Normal ranges Sources for the normative values RV Function The document by R Lang et al has been published in the Jan 2015 issue of JASE. guidelines AND STANDARDS. J Am Soc Echocardiogr 2015;28:119-82. guidelines Imaging Techniques Chest X-ray Echo (TTE, TEE, 3D-echo, epiaortic).

6 Intravascular echo (IVUS). Intracardiac echo (ICE). CT/MDCT. Magnetic resonance imaging Aortography Diseases of the Thoracic Aorta Acute aortic syndromes - Aortic dissection - Intramural hematoma - Penetrating aortic ulcer - Ruptured aortic aneurysm Thoracic aortic aneurysms - Bicuspid aortic valve-related aortopathy - Marfan syndrome - Other genetic diseases (Ehlers-Danlos; Loeys-Dietz, Turner syndrome,etc). continued .. Diseases of the Thoracic Aorta Traumatic injury of thoracic aorta Aortic coarctation Atherosclerosis Aortitis - Noninfectious - Infectious Measuring the Aorta Measure perpendicular to the long-axis of the aorta Measurement Options Inner edge-inner edge - CT.

7 Outer-outer Leading edge-leading edge- Echo Recommended time to measure the aortic root A. End-systole B. End-diastole - Greater reproducibility (Ao pressure more stable in late diastole). - End-diastole easy to ID by QRS. TTE TEE CT and MRI. Thoracic Aortic Aneurysms what to look for? Normal Aortic size in the adult: Ao root < 40 mm Ascending Ao < 37 mm Descending Aorta < 28 mm These values are, however, very variable. Aortic size to be adjusted by body size and age < 20 yo 20-40 yo >40 yo Roman M et al.

8 Am J Cardiol 1989;64:507. Complications and Asc Ao size Importance of accurate measurements Elefteriades, JACC 2010;55:841. Asc Aortic size at time of Type A Dissection 60% < cm 40% <5 cm Pape et al for IRAD. Circulation 2007;116:1120. You want to explore the ENTIRE Aorta, AT LEAST ONCE. Marfan - Ao Root aneurysm Marfan with prior graft in Asc Aorta Oct 2012 Dec 2012. Dissections post graft ! Need to look at Mostly in arch/Desc ! entire Aorta !! Asch FM, Weinsaft J et al. Manuscript Under Review Marfan MVP.

9 RPA aneurysm Marfan Syndrome - Role of imaging Monitoring aortic enlargement Monitoring every 6/12 months (same method, side by side). Surgical Indication: Aortic diameter > 5cm Rapid progression (2-4 mm/year). Aortic dissection Family Hx of early dissection BAV Aortopathy RL fusion type Most Common 33-60 % Normals Aortic root: 1-25 %. Asc Aorta: 32-35%. Arch: 10 %. Kang JW et al. J Am Coll Cardiol Img 2013; 6:150. Schaefer BM et al. Heart 2008;94:1634. RN fusion type (or RL distribution). RN fusion type 19-32 % Normals Aortic root: 1-15 %.

10 Asc Aorta: 26-54 %. Arch: 41 %. Kang JW et al. J Am Coll Cardiol Img 2013; 6:150. Schaefer BM et al. Heart 2008;94:1634. BAV. Asc Ao/Arch aneurysm Acute Aortic Syndromes Acute Aortic Syndromes Aortic dissection Intramural hematoma Penetrating aortic ulcer Ruptured aortic aneurysm Aortic Dissection - Imaging Primary Objectives Identify entry site Determine type A vs B. Involvement of coronary arteries ? Identify complications: Presence, severity, mechanism of AR. Pericardial or pleural effusion Rupture ?